Congress 2023 Podium Abstracts

Abdus S. Burahee¹, Liron S. Duraku², Caroline A. Hundepool³, Kyle R. Eberlin⁴, Amy Moore⁵, Christopher J. Dy⁶, Shalimar Abdullah⁷, Vaikunthan Rajaratnam⁸, J. Michiel Zuidam³, Dominic M. Power¹

¹Queen Elizabeth Hospital, Birmingham, United Kingdom. ²Amsterdam UMC, Amsterdam, Netherlands. ³University Medical Center, Rotterdam, Netherlands. ⁴Massachusetts General Hospital, Harvard Medical School, Boston, USA. ⁵The Ohio State University Wexner Medical Center, Ohio, USA. ⁶Washington University School of Medicine, St Louis, USA. ⁷University Kebangsaan Malaysia, Kuala Lumpur, Malaysia. ⁸Khoo Teck Puat Hospital, Yishun, Singapore

Abstract

Background: This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance.

Methods: A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites, in tandem. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants’ knowledge and skills were assessed using pre- and postcourse questionnaires.

Results: A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives.

Conclusion: This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.

Implications: The study has several learning points that extend beyond the realm of academic research into the actionable aspects of surgical training. These include curriculum design, technological scalability, interdisciplinary collaboration, participant engagement, time management, feedback mechanisms, standard operating procedures, patient safety and quality of care, and cost-efficiency.

James Murray^1,2, Emma Howie^3,4, Rory Clarke⁵, Nikki Totton⁶, Adam Peckham-Cooper^7,8, Helen Church⁹, Steven Yule^3,4, James Tomlinson^1,2

¹Sheffield Teaching Hospitals, Sheffield, United Kingdom. ²University of Sheffield, Sheffield, United Kingdom. ³Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. ⁴Edinburgh Surgical Sabermetrics Group, University of Edinburgh, Edinburgh, United Kingdom. ⁵NHS England, -, United Kingdom. ⁶Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom. ⁷Leeds Institute of Emergency General Surgery, St James’s University Hospital, Leeds, United Kingdom. ⁸University of Leeds, Leeds, United Kingdom. ⁹Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom

Abstract

Background: Surgical training is focussed towards the teaching and evaluation of technical skills. However, quantification of other factors that influence surgical performance (e.g. mental skills, environmental context) are poorly understood. The aim of this study was to discern whether multi-modal surgical sabermetric evaluation of trainees is a feasible method of identifying novel factors that influence technical performance.

Methods: Surgically-interested trainees from a single deanery were invited to take part in a range of supervised laparoscopic tasks on a standardised laparoscopic box trainer. Participants wore physiological sensors (Shimmer 3 GSR+) to measure objective cognitive load during simulations, and completed the NASA-TLX, a validated measure of subjective cognitive, post-simulation. Technical performance was assessed by blinded assessors from video using the Global Objective Assessment of Laparoscopic Skills framework.

Results: A total of 29 trainees participated (M/F 11/18, CST/FY 16/13). Total levels of subjective cognitive load were found to be significantly correlated with mental fatigue (r=0.73,p=<0.001), time-pressure (r=0.7,p=<0.001), and anxiousness (r=0.8,p=<0.001). Objective levels of cognitive load were not correlated with either subjective load or overall technical performance. Overall technical performance was found to be significantly correlated with depth perception (r=0.93,p=<0.001), dexterity (r=0.87,p=<0.001), efficiency (r=0.9,p=<0.001), tissue handling (r=0.82,p=<0.001) and autonomy (r=0.93,p=<0.001). Quality of tissue handling was found to be negatively affected by perceived time-pressure (r=-0.4,p=0.033), subjective anxiousness (r=-0.37,p=0.049) and a distracting environment (r=-0.41,p=0.029). Furthermore, in addition to poor tissue handling, a distracting environment was negatively associated with dexterity (r=-0.4,p=0.03) subjective cognitive load (r=0.61,p=<0.001) and overall technical performance (r=-0.41,p=0.03).

Conclusion: This is one of the first studies to demonstrate that trainees’ cognitive load is associated with technical performance. We found it feasible to gather multimodal surgical sabermetrics data (video, sensor, subjective). Further work is required to assess if strategies can be implemented to improve cognitive load and improve performance.

Sherif Ahmed Kamel^1,2, Katie Lee¹, Sunil Dhar¹, Martin Raglan¹

¹Nottingham University Hospitals NHS, Nottingham, United Kingdom. ²Ain Shams University, Cairo, Egypt

Abstract

Background: Total Ankle Replacement (TAR) is increasingly established as the first-line surgical management for end-stage ankle arthritis. Infinity TAR is fixed-bearing implant that has market share in England, according to the NJR. We report the mid-term outcomes of prospectively-collected data with a minimum 5-year follow-up. Primary aim was to assess survivorship and complications. Secondary aims were to assess functional and radiological outcomes.  

Methods: Data was collected preoperatively and annually from October 2014 to November 2018. Implant survivorship, complications, reoperations, and patient-reported outcome scores (PROMS; Manchester-Oxford-Foot-and-Ankle-Score (MOXFQ) and European-Quality-of-Life -5-Dimensions (ED-5L)) were collected and analysed. A radiological review was conducted, and implants were assessed for lucencies and subsidence.

Results: 68 Infinity TARs were performed on 68 patients between 23/10/2014 and 13/11/2018. 63 were primaries, 2 were conversion arthrodesis, and 3 were revisions TARs. Age at index surgery was 34-88 years (mean 67, SD 11). 52 (76 %) patients had additional balancing procedures to TAR during index surgery. 10 (14.7%) patients were lost to follow-up, 6 of them because of death not related to surgery or implant. There was a statistically and clinically significant improvement in all the domains and index of MOXFQ and 3 domains from the ED-5L score. (P<0.05). Implant survivorship was 93.1% at 5 years. The 4 revisions were due to aseptic loosening and subsequent pain.  Non-revision reoperations were 8 cases (13.8%). No cases of prosthetic joint infection were recorded. 3(5%) had a nerve injury, 4 (6.9%) cases had wound problems, which settled with dressings only. 2 (3.4%) cases had non-fatal pulmonary embolism. 2 cases (3.4%) had radiolucency. 4 (6.9%) cases had stiffness necessitating open debridement.

Conclusion: We conclude that Infinity® total ankle replacement has good mid-term performance and patient satisfaction. It is a viable option for the treatment of end-stage ankle arthritis.

Vinesh Sandhu¹, Vivek Ajit Singh², Tze Yong Choo², Nor Faissal Yasin²

¹UCL Medical School, University College London (UCL), London, United Kingdom. ²Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia

Abstract

Background: The foot is a complex structure which can be the origin of development of tumours. Most lesions of the foot are reactive or inflammatory, but some are true neoplasms. This study aimed to identify the patterns of tumours affecting the foot.

Methods: This is a retrospective analysis of 195 patients with foot tumours treated at the Orthopaedic Oncology Unit of University Malaya Medical Centre, Malaysia, between 1 January 2010 to 31 December 2020. This data was extracted from a larger cohort comprising 4997 patients with orthopaedic tumours. 

Results: There were 195 cases of foot tumours: 148 benign and 47 malignant. Of these, 47 were bone tumours, 4 metastases, and 144 soft tissue tumours. Six patients succumbed to the disease. Two cases of giant cell tumour (GCT) and one patient with synovial sarcoma had a recurrence. In general, the treatment of foot tumours was wide resection. However, in metastasis cases, amputation was done. Most tumours involved the toes and dorsum of the foot. Soft tissue tumors of the foot were more common amongst the elderly patients, while bone tumours, occurred predominantly during the second decade of life. The gender distribution was almost equal for foot tumours. Ganglion and GCT of the bone were the commonest benign soft tissue and bone tumours. The most common malignant soft tissue and bone tumours were malignant melanoma and chondrosarcoma. Overall, the amputation rate was 5.64%, the recurrence rate 1.54% and mortality rate 3.08%. The MSTS score was 79%, and the TESS score was 76.23%. 

Conclusions: Foot tumours are relatively rare, mostly originating from soft tissue, and the majority are benign. Nonetheless, a noteworthy proportion, approximately a quarter of these tumours, demonstrate malignancy. The surgical interventions undertaken in managing these tumours and associated functional outcomes generally yield acceptable results. 

ZIYI CHEN, Xicheng Gu, Xiaoao Xue, Run Pan, Yinghui Hua
Department of Sports Medicine, Shanghai, China

Abstract

Background: Arthroscopic anterior talofibular ligament repair (AATFLR) is a surgical strategy to treat   chronic ankle instability (CAI) patients.  This study identified risk factors that influenced the functional outcomes of AATFLR for CAI and developed prognostic nomogram for predicting functional outcomes in future AATFLR cases.

Methods: Patients undergoing AATFLR from January 2016 to June 2022 with at least 10 months of follow-up were included in the study. The Karlsson ankle functional score (KAFS) was evaluated pre-operatively and at last follow-up visit. A total of 15 potential predictors including age, sex, body mass index, side affected, time from injury to surgery, sports-related injury, osteophyte, loose bodies, distal tibiofibular syndesmosis, ATFL avulsion fracture, Outerbridge classification of osteochondral lesions, post-operative immobilization method, ambulation time, walking time, and follow-up time, were recorded. We first used univariate binary logistic regression analysis to select the potential significant prognostic features, which were then subjected to the least absolute shrinkage and selection operator (LASSO) regression algorithm for final feature selection. A nomogram based on the regression model was developed to estimate the functional outcomes of patients. Models were validated internally using bootstrapping and externally by calculating their performance on a validation cohort.

Results: Overall, 200 ankles fit inclusion criteria. Of these 200, 185 (92.5%) ankles were eligible and divided into development (n = 121) and validation (n = 64) cohorts. Four predictors were ultimately included in the prognostic nomogram model: age, sex, sports-related injury, and post-operative immobilization method. 

Conclusion: We found in our cohort the significant predictors of poorer functional outcomes of AATFLR were post-operative immobilization with lower-leg cast, female sex, non-sports-related ankle sprain, and increasing age. Prognostic nomograms were created. 

ZIYI CHEN, Xicheng Gu, Xiaoao Xue, Yinghui Hua

Department of Sports Medicine, Shanghai, China

Abstract

Purpose: The aim of this study was to compare the clinical outcomes between patients with chronic ankle instability (CAI) undergoing arthroscopic anterior talofibular ligament (ATFL) repair who received elastic bandage treatment and those who received lower-leg cast immobilization.

Methods: CAI patients with isolated ATFL injury undergoing arthroscopic ATFL repair from January 2017 and August 2019 were included in the study. The visual analogue scale (VAS) at rest and during activities, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score), and time of returning to walk, walk normally, work and sports were evaluated preoperatively, and at 6 months and 12 months follow-up. 

Results: A total of 41 patients were included in this study. Among them, 24 patients accepted lower-leg cast fixation, and the other 17 patients were immobilized with elastic bandage. Compared to patients with lower-leg immobilization, patients with elastic bandage fixation had significantly lower VAS during activities (P = 0.021) and higher AOFAS score (P = 0.015) at 12 months follow-up. The Karlsson score at 6 months follow-up were significantly higher in elastic bandage group than those in lower-leg group (P = 0.011). However, no significant difference was observed in time of returning to walk, work and sports between the two groups. 

Conclusion: Elastic bandage treatment was better than lower-leg cast immobilization in terms of eliminating pain symptom at 12 months follow-up, and improving ankle functional outcome at 6 months follow-up. Moreover, the present study emphasized that lower-leg cast immobilization offered no advantages in arthroscopic ATFL repair postoperative immobilization.

Firas Raheman^1,2, Kerementi Othieno-P'Otonya², Ines Reichert², Raju Ahluwalia²

¹Broomfield Hospital, Mid & South Essex NHS Trust, Chelmsford, United Kingdom. ²King's College Hospital, London, United Kingdom

Abstract

Background: Diabetes complicates prognostic considerations post-acute ankle fractures. Surgeons may delay necessary surgery due to anticipated complications. Our study compares complication rates in diabetic versus non-diabetic patients and assesses the effectiveness of long-segment fixation methods for optimal outcomes.

Methods: We conducted a retrospective review of ankle fractures from 2014-2019, cross-referencing records with departmental databases. Patients were then observed prospectively for a minimum 5-year follow-up. We identified patients with diabetes and recorded HbA1c levels, utilizing the Charlson Comorbidity Index (CCI) to profile patient comorbidity. Our study included age, gender, and follow-up matched non-diabetic controls, as well as conservatively managed diabetic and surgically treated groups, focusing on rigid long-segment fixation. Multivariate logistic regression assessed predictors of negative outcomes (fixation failure, early wound complications, fracture-related infections, and Charcot arthropathy), and Cox-proportional hazards modelling analysed predictors of five-year morbidity and mortality.

Results: We compared 152 diabetic ankle fracture patients with a control group. 74 received conservative treatment, and 78 underwent operative fixation, including 31 with rigid-fixation. Both diabetic groups had higher complication risks than control (n=180), with relative-risks ranging from 3.1-3.4(P< 0.002). Forty-five-patients had CCI>5(6.03±1.86), with increased diabetes complications: neuropathy (RR=5.9,p< 0.003), higher HbA1c levels (RR=4.6,p< 0.004). Risks post-surgery decreased with prolonged-immobilization (RR=0.86) and/or rigid-fixation (RR=0.65).  CCI>5 score correlated with morbidity(r=0.43, p=0.03). Multivariate-logistic-regression showed increased morbidity with standard-fixation (OR=1.48,95%CI= 0.97–3.26, p=0.033). Comparing rigid-long-segment fixation, each unit increase in CCI within the non-rigid fixation group raised morbidity risk by 29.5% (HR=1.295,95%CI=0.937–1.789,p=0.033). The area under the receiver operating characteristic curve was 0.764, validating the index's use in our prediction model.

Conclusion: Diabetics face higher complication risks, though less than once believed. Treatment methods show minimal variance, but evidence favors rigid long-segment fixation and extended immobilization for better risk-benefit ratios over non-operative management.

Meraj Akhtar¹, Paul Lee²

¹ULHT, Lincoln, United Kingdom. ²ulht, Lincoln, United Kingdom

Abstract

Abstract Background: The current trend for surgical management of acute mid-substance Achilles tendon ruptures has been towards minimally invasive techniques to reduce soft tissue complications. With the global healthcare service moving towards a costeffective model with improve operating room efficiencies and reduce reprocessing needs, the authors have described a novel technique using commercial readily available, single use, disposable suture passer instrument and vicryl-tape to repair the Achilles tendon. 

Objectives: The purpose of this study was to report our percutaneous Achilles tendon technique and present the clinical results. 

Patients and Methods: Twenty-one patients (18 males, 3 females) with a confirmed diagnosis of acute mid-substance achilles tendon rupture were treated with the above technique over a year period. There was at least a minimum of one year follow up in our study (range: 12 to 25 months).

Results: There were no wound infections, re-rupture or sural nerve damage in our series. Mean time to return to work was 40 days (range: 30–92). 21 patients (84%) were able to return to their previous sport at an average of 6.5 months (range: 4 – 12). The Achilles Tendon Rupture Score was 83.1 (range: 70 -95) at their one-year follow-up. 

Conclusions: This new technique is safe and exhibit excellent clinical results. This makes it an attractive alternative repair method for acute Achilles tendon ruptures where surgeon are looking to use disposable instrument. Keywords: acute Achilles tendon ruptures, surgery, percutaneous, functional rehabilitation

Karan Malhotra^1,2, Shelain Patel^1,2, Nicholas Cullen¹, Matthew Welck^1,2

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

Abstract

Background: The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to classify the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. 

Methods: We included 20 cavovarus feet from adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, 14 males). Patients included had flexible deformities, with no previous surgery. Previous work established that the majority of rotational deformity in cavovarus feet occurs at the talonavicular joint, which is often reduced during surgery. Using specialized software (Bonelogic® 2.1, Disior™) a 3-dimensional, virtual model was created. Using data from normal feet as a guide, the talonavicular joint of the cavovarus foot was digitally reduced to a ‘normal’ position. Models of the corrected position were exported and geometrically analyzed using Blender 3.64 to identify anatomical trends. 

Results: We identified 4 types of cavovarus forefoot morphotypes. Type 0 was defined as a balanced forefoot (2 cases, 10%). Type 1 was defined as a forefoot where the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular joint correction (12 cases, 60%). Type 2 was defined as a forefoot where the second and first metatarsals were progressively plantarflexed, with no significant adduction (4 cases, 20%). Type 3 was defined as a forefoot where the metatarsals were adducted after talonavicular de-rotation (2 cases, 10%). 

Conclusion: We classify 4 forefoot morphotypes in cavovarus feet. It is important to recognize and anticipate the residual forefoot deformities after hindfoot correction as different treatment strategies may be required for different morphotypes to achieve balanced correction. 

Bakur Jamjoom¹, Karan Malhotra², Shelain Patel², Nick Cullen², Matthew Welck², Tim Clough³

¹The Princess Alexandra Hospital, Harlow, United Kingdom. ²The Royal National Orthopaedic Hospital, London, United Kingdom. ³Wrightington Hospital, Wrightington, United Kingdom

Abstract

Background: Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. 

Methods: A 2 centre retrospective review of consecutive series of 32 patients undergoing ankle and hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed.  Union was assessed clinically and with either plain radiography or weight-bearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. 

Results: Mean age was 57 years (19-76 years).  Mean follow-up of 22.8 ±8.3 months.  22% were smokers.  There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic.  10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic.  The combined symptomatic non-union rate was 12.5%.  Mean time to union was 9.6 ±5.9 months.  One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork.  Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures.  There was no bone graft collapse with all patients maintaining bone length.

Conclusion: Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages.  

Alexander Carver¹, Marc Choong¹, Robert Fawdry², Conor Boylan², Nikhil Nanavati¹

¹1. Rotherham NHS Foundation Trust, Rotherham, United Kingdom. ²2. Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Abstract

Background: Ankle fractures comprise 10% of fractures seen in ED. Despite this, debate remains regarding their optimal management. There is no clear consensus whether delaying ankle ORIF leads to better outcomes. There is also debate whether early post-operative weight bearing (WB) before 6 weeks impacts post-operative outcomes. The aim of this study was to investigate whether a delay in operation or a prolonged post-operative weight-bearing plan led to (1) increased complications and (2) poorer outcomes in patient-recorded outcome measures (PROMs). 

Methods: 160 patients who underwent ankle ORIF between 2021-2023 were analysed. Primary outcomes were post-operative complications. Secondary outcomes were PROMs, using EQ-5D and MOxFQ questionnaires. Data was analysed using SPSS26 software. Analysis used independent two-tailed Mann-Whitney U tests for continuous data with nominal independent variables, and Kruskal-Wallace tests for ordinal independent variables. Fisher-exact tests were used for categorical variables. 

Results: Of 160 ORIFs performed, 100 were on trimalleolar fractures, 43 on bimalleolar fractures, and 17 on unimalleolar fractures. 84 complications were recorded. 75 patients provided PROMs. Delay in operation did not have a statistically significant impact on overall complication rate (p=0.482). There was no statistically significant difference in EQ-5D (p=0.433) and MOxFQ (p=0.325) scores regardless of delay in operation. Additionally, time spent until WB post-operatively did not have a statistically significant impact on overall complication rate (p=0.634). There was also no statistically significant difference in EQ-5D (p=0.358) and MOxFQ (p=0.089) scores regardless of post-operative WB plan.

Conclusions/Findings: Our results suggest that a delay in ankle ORIF operation does not lead to an increase in complications or poorer PROMs post-operatively, potentially giving clinicians more time to plan procedures. Early post-operative WB also had no impact on complication rate or PROMs, meaning early mobilisation may accelerate patient rehabilitation, facilitate independence, and reduce prolonged inpatient hospital stay.

Junaid Aamir¹, Thomas Huxley², Maya Clarke², Neel Dalal¹, Annabelle ohnston McCarter¹, Dimitrios Rigkos¹, Junaid Kutty¹, Christopher Gunn¹, Codrin Ioan Condurache¹, Donal McKeever¹, Abdul Gomaa^1,2, Lyndon Mason^1,2

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

Abstract

Introduction: Deltoid ligament reconstruction (DLR) is an important factor in the consideration of pes planus deformity. There is little evidence in the literature determining whether DLR could mitigate the risk of patients acquiring flat foot postoperatively following deltoid ligament injury

Aim: Our objective was to establish if there was a difference in pes planus deformity in patients who underwent DLR during their ankle fracture fixation compared to those who did not.

Methods:  A retrospective analysis of post-operative weight bearing radiographs was performed of patients who underwent ankle fracture fixation. Inclusion criteria were confirmed deltoid instability presurgery without medial malleolar fracture and post operative weightbearing radiographs at least 6 weeks post-fixation. Patients were categorised into no deltoid ligament reconstruction (nDLR) and having DLR. Radiographic pes planus parameters involved Meary’s Angle assessment. Other fracture morphology was classified.

Results: A total 723 ankle fractures were screened. 122 patients were included for further analysis. There were 94 patients in the nDLR group and 28 patients in DLR group. The mean Meary’s Angle was 15.81 (95% CI 14.06, 17.56) degrees in the nDLR group and -.2 (95% CI -3.86, 3.82) in the DLR group. This was statistically significant (p<.001). There was no significant difference in medial clear space measurements (2.90mm v 3.19mm, p = 0.145). There were significantly more pes planus patients in the nDLR than the DLR group (p<.001, 90.5% vs 25%).

Conclusion: In this study there was significantly greater pes planus parameters in patients not undergoing DLR. Patients undergoing DLR had on average normal parameters, whilst those not undergoing DLR had on average severe pes planus. The benefits of DLR are not only maintaining ankle stability but maintaining medial arch integrity, and this should be taken into account in a future study on DLR.

a 25 year national population study using hospital episode statistics data

Conor Hennessy^1,2, Rick Brown², Constantinos Loizou², Bob Sharp², Simon Abram¹, Adrian Kendal^1,2

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

Abstract

Background: Urgent below knee amputation (BKA) remains a last resort surgical treatment for intractable diabetic foot disease. There is no consensus on mortality in diabetic patients undergoing BKA in the UK, and what risk factors predispose patients to poor outcomes.

Methods: Hospital episode statistics (HES) admitted patient care (APC) data was obtained from NHS digital and combined with ONS mortality data from 1998-2022. Data was cleaned using HES data dictionaries in STATA 18. Operations and complications were identified according to the OPCS-4 and ICD-10 codes.

Results: We identified 28045 BKAs undertaken in diabetic patients in the 25-year period. The rates of BKA decreased from 2002 (5.9/100,000) to 2012 (4.4/100,000) and plateaued between 2012-2022 (4.3/100,000 in 2022). The current rates are significantly higher in males (7/100,000) compared to females (1.9 /100,000). Mortality at 30, 90 days, 1 and 5 years were 7.1%, 12.7%, 24.6% and 61.2%, respectively. Female sex was associated with higher mortality at all time points (OR 1.07, 1.12, 1.15, 1.16 respectively). Increasing age was associated with significantly worse mortality at all time-points. A lower deprivation status was associated with better longer-term outcomes. British-Asians had significantly higher mortality risk at all timepoints (OR 1.99, 1.86, 1.63, 1.05 respectively). The 90-day re-operation rate for any cause was 20.68%. The ipsilateral re-amputation rate at any time was 10.37% (n=2909), and the contralateral amputation rate was 8.22% (n=2304).  Additional 90 day complications included PE (0.75%,n=211), MI (3.63%, n=1019) and Stroke (1.12%, n=316).

Conclusions: This landmark 25-year study in an English population reveals BKA in diabetics is associated with high mortality rates peri-operative morbidity and high incidence of significant complications. Multivariate analysis identified that being of female sex, over 60 years old, of British-Asian heritage or from a lower socio-economic group predicted worse outcomes.

Max Little¹, Charlotte Binnie², Iris Kwok¹, Jonathan Super³, Derek Effiom¹, Peter Rosenfeld^1,4

¹Imperial College Healthcare NHS Trust, London, United Kingdom. ²ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST, London, United Kingdom. ³Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. ⁴Fortius Clinic, London, United Kingdom

Abstract

Background:Total ankle arthroplasty (TAA) remains an excellent treatment option for end stage ankle osteoarthritis. We present the longer-term results of a mobile-bearing TAA.

Methods: TAA was performed in 100 consecutive ankles (94 patients) in an independent, prospective, single-surgeon series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of 10.8 years (range 5-15 years).

Results: A total of twelve ankles (ten patients) died without having any radiological or clinical outcomes recorded at the minimum follow-up set at five years. Nine ankles (nine patients) were lost to follow-up or were unable to comply. Seventy-nine ankles (75 patients) were included at an average age of 69 at the time of their operation. Four of 79 ankles (5%) underwent major revisions to a fusion or revision TAA – one due to infection, one due to unexplained pain, and two due to migration of the talar component – all within five years of the index operation. Four other ankles (5%) underwent other revision operations – one had subtalar fusion and grafting for a cyst-related talar fracture at three years post-op, one required curettage and grafting for tibial bone cysts at four years, one had a liner exchange with a minimally-invasive heel-shift osteotomy for varus wear of the liner at six years and the final patient’s fractured liner was exchanged at eight years post-op. With all-cause revision as an endpoint, implant survival was calculated using Kaplan-Meier curves as 92.4% at 5 years and 89.9% at 10 years. If a TAA survived to five years without revision, survival at ten years was 96.1%.

Conclusion/findings: This series demonstrates excellent survivorship as well as radiographic and patient-reported outcomes for a mobile-bearing TAA at 10 years with a revision rate similar to those previously published in the literature.

Muhammad Maaz Gul Kaka Khel¹, Syed Naveed Mohsin², Hafiz Faisal Shahzad³, Phillip Purcell⁴, Amir Siddique⁵, Mahmood Ahmad⁶, Shahab Khan⁷

¹Liverpool University Hospitals Foundation Trust, Liverpool, United Kingdom. ²Trauma and Orthopaedics, Saint James's Hospital, Dublin, IRL, Dublin, Ireland. ³Orthopaedic Unit-1, Mayo Hospital, Lahore, Lahore, PAK, Lahore, Pakistan. ⁴Centre of Applied Science for Health, Technological University Dublin, Dublin, IRL, Dublin, Ireland. ⁵Our Lady of Lourdes Hospital Drogheda, Drogheda, Ireland. ⁶Trauma & Orthopaedics, Shifa International Hospital Islamabad,, Islamabad, Pakistan. ⁷Trauma and Orthopedics, Royal Bolton Hospital, Bolton, GBR, Bolton, United Kingdom

Abstract

Introduction : Lower limb fractures frequently require immobilization with backslabs to promote healing. This study investigates a novel approach involving the incorporation of a single ridge to enhance backslab strength while maintaining cost-effectiveness.

Objective: To assess the mechanical performance of ridged backslabs in comparison to traditional nonridged backslabs, specifically focusing on their load-bearing capacity and cost-effectiveness when used in lower limb fractures.

Methods: This experimental study, conducted between January 2023 and June 2023, compares three groups backslabs with varying layers(eight,ten and twelve) were fabricated, each consisting of four ridged and four non-ridged specimens. These backslabs, constructed from six-inch plaster of Paris rolls, were 190 cm in length. A three-point bending test was conducted on both groups using a Hounsfield H100KS Universal Testing Machine, with a crosshead speed of 5 mm/min and a span distance of 190 mm between supports.

Results: Significant differences in mean maximum force endured were observed between the ten-layered and twelve-layered flat and ridged backslabs (p-values: 0.003 and 0.004, respectively). Ten-layered ridged backslabs exhibited a 56 N higher load-bearing capacity, while twelve-layered ridged backslabs withstood 73.9 N more force than their flat counterparts, underscoring the superior strength of ridged lower limb backslabs.

Conclusion: Ridged backslabs outperformed non-ridged backslabs in terms of strength when subjected to external forces. These findings support the potential adoption of ridged backslabs as a lightweight, costeffective, and robust alternative for immobilization in lower limb fractures.

Christopher Woodward¹, Justin Green^2,3, David Beard⁴, Mike Reed³, Paul Williams¹

¹Morriston Hospital, Swansea, United Kingdom. ²Newcastle University, Newcastle, United Kingdom. ³Northumbria Healthcare NHS Foundation Trust, Newcastle, United Kingdom. ⁴Oxford University, Oxford, United Kingdom

Abstract

Background: The management of orthopaedic waiting lists is challenging.  One way of addressing this is  using High Volume Low Complexity sites. This poses a burden in pre-assessment. OpenPredictor, a machine learning risk prediction tool offers a solution. We present a retrospective trial of OpenPredictor at two trusts, to predict the risk of complications post arthroplasty.

 Methods: A retrospective analysis of 445 patient records from elective lower limb arthroplasty surgeries (302 Swansea, 143 Northumbria) was performed. Using a polynomial logistic regression model, patients had a  risk score calculated and were categorised into  high/moderate, or low-risk groups. 6% or more was considered high/moderate risk. Categorisation incorporated data from various sources, including patient demographics, co-morbidities, blood tests, and overall health status. Risk scores were compared to actual complications  from clinical coding.

Results: 445 patients were assigned scores by OpenPredictor.  There were 253 low risk patients, and 192 high/moderate risk patients. 11  complications occurred in the low risk group, and 26 in the high/moderate group. If considered high/moderate risk, the sensitivity of predicting a complication was 70%. If considered low risk, the negative predictive value(NPV) of having a complication was 96%. The 143 Northumbria patients were compared by their OpenPredictor stratification into high/moderate vs low risk against a consultant anaesthetist doing the same. The sensitivity vs specificity was equal.

Conclusion: This study supports OpenPredictor in stratifying the risk potential of complications in arthroplasty patients. NPV was 96%, supporting that if deemed low risk, a patient is unlikely to experience a complication. Performance was equivalent to anaesthetist stratification. High sensitivity (70%) indicates that OpenPredictor can identify patients for earlier more detailed pre-assessment, and the high NPV supports the ability of OpenPredictor to triage patients to elective hubs, potentially helping to reduce the burden of the pre-assessment clinic workload.

Alice Luesley, Naeem Khan, Anthony McWilliams

Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom

Abstract

Background: The Orthopaedic Department of Barnsley Hospital NHS Foundation Trust (BNHFT) currently follows national guidance for lower limb arthroplasty patients, with a postoperative review at six weeks and one year. A parallel patient-initiated follow-up (PIFU) pathway via an arthroplasty nurse helpline is also utilised. We undertook a retrospective analysis of patient outcomes to determine if adherence to the guidance was the optimal clinical and most cost-effective use of resources. 

Methods: 420 arthroplasty cases were undertaken from April 2021 to March 2022. Trauma, revision surgeries, those with complications identified prior to discharge and patients that did not attend two or more post-operative appointments were excluded, leaving 352 in the cohort. Clinical records from the first two follow-up appointments were reviewed. 

Results: At six-weeks, 61.1% of cases had no complications. Of the 38.9% with complications at this time, 58.4% were identified de novo at this time.  Of those without complications, 83.7% had no new complications thereafter. Of the 17.3% that did develop new complications between six weeks and the one year appointment, 57.1% were identified via PIFU methods. The patients that self-presented had complications including joint infections, dislocations and aseptic loosening that required further medical or surgical intervention. Only 7.0% patients with no complications identified at the six-week appointment had a new concern identified only at one year, none of which required surgical intervention.

Conclusion: With current practices, BDGH achieves outcomes in line with the national expected range. Patients with complications requiring intervention were more likely to present via PIFU. These results indicate that patients without complications at six weeks can be safely monitored via PIFU rather than routine appointments.  Amending our follow-up to exclusively PIFU after the six-week appointment would release over 200 appointments per year without compromising patient safety. 

Zhan Ng¹, Samantha Downie², Navnit Makaram¹, Shivam Kolhe³, Samuel Mackenzie¹, Nick Clement¹, Andrew Duckworth¹, Timothy White¹, MAVCOV Collaborative Authors⁴

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. ²Ninewells Hospital and Medical School, Dundee, United Kingdom. ³Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom. ⁴-, -, United Kingdom

Abstract

Background: Virtual fracture clinics (VFCs) are advocated by the British Orthopaedic Association Standards for Trauma (BOAST). We aimed to assess the impact of the transition from face-to-face fracture clinic review and identify any change in clinical outcome and patient satisfaction.

Methods: A national, cross-sectional cohort study of VFCs across the UK over two separate two-week periods pre- and during the first UK COVID-19 lockdown was undertaken. Data comprising patient and injury characteristics, unplanned reattendance and complications within three months following discharge from VFC were collected by local collaborators. Telephone questionnaires were conducted to determine patient satisfaction and patient-reported outcome for patients discharged without face-to-face consultation. The primary outcome measure was percentage of unplanned reattendances after direct discharge from VFC.

Results: Data was analysed for 51 UK VFCs comprising 6134 patients from the pre-pandemic group (06/05/2019-19/05/2019) and 4366 patients from the first UK lockdown (04/05/2020-17/05/2020). During lockdown, rate of direct discharge from VFC increased significantly (odds ratio (OR) 2.01, p<0.001) from 30% (n=1856/6134) to 46% (n=2021/4366). The rate of compliance with BOAST guidance recommending fracture clinic review within three days increased (OR 1.93, p<0.001) from 82% (n=5003/6134) to 89% (n=3883/4366). There were no differences in rates of unplanned reattendance (6% pre- and 7% during lockdown, p=0.281) or complications (0.2% for both, p=0.815). There were 1527/3877 patients discharged without face-to-face review from VFC who completed telephone questionnaires (mean follow-up 18-months in pre-pandemic group and 6-months in lockdown group). Satisfaction was high in both cohorts (80% pre- and 76% lockdown, p=0.093). Dissatisfaction was associated with an unplanned reattendance (p<0.001) or a missed injury (p<0.05).

Conclusion: Despite a significant rise in direct discharge from VFC, there was no significant change in unplanned attendances, complications, or patient satisfaction. However, there are factors associated with dissatisfaction and these should be considered in the evolution of VFC.

Liang Xiong, Hui Li, Xinzhan Mao

Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, China

Abstract

Background: Sarcopenia has been revealed as an independent predictor of postoperative morbidity and mortality. The aim of this study was to meta-analyze the relation between preoperative sarcopenia and the risk of perioperative blood transfusion in patients undergoing surgery.

Methods: PubMed, Embase and the Cochrane Library were systematically searched up until March 2024 to identify relevant studies. All clinical studies comparing the incidence of perioperative blood transfusion between patients with preoperative sarcopenia and without were obtained. Data were extracted independently by two reviewers. Fixed effect meta-analysis were applied to estimate the pooled odds ratio (OR) with 95% confidence intervals (95% CI) for risk of perioperative blood transfusion. Heterogeneity was evaluated with I² testing. 

Results: A total of 471 citations were identified, and seven studies (1195 patients) were included in the meta-analysis. Among these included studies, two explored the correlation between sarcopenia and perioperative blood transfusion in total hip and knee replacement with 654 patients enrolled. When measuring the total skeletal muscle area, 19.2% of the patients were sarcopenic. The incidence of perioperative blood transfusion in sarcopenia and non-sarcopenia patients was 33.0% and 14.7%, respectively. Preoperative sarcopenia was associated with an increased risk of perioperative blood transfusion (pooled OR: 3.76, 95% CI: 2.64–5.34, P<0.001). The I² was 14%, indicating no heterogeneity detected.

Conclusion: The presence of preoperative sarcopenia is a strong predictor for the risk of perioperative blood transfusion. The finding of this research is consistent over studies as no heterogeneity was detected. 

Implications: Orthopaedic surgeons should be aware of the elevated risk of perioperative blood transfusion in patients with sarcopenia, since the majority of patients undergoing total joint replacement are elderly and prone to sarcopenic condition.

Peter Giannoudis¹, Paul Andrzejwski², George Chloros³, Elizabeth Hensor¹

¹University of Leeds, Leeds, United Kingdom. ²Leeds General Infirmary Hospital, Leeds, United Kingdom. ³Leeds General Infirmary, Leeds, United Kingdom

Abstract

Background: Surgical treatment of pelvic girdle pain (PGP) involves arthrodesis of sacroiliac (SI) and pubic symphysis joints. Fusion of pubic symphysis involves the implantation of an autologous iliac crest tricortical graft harvested from the iliac crest. The objective was to assess the safety of a novel synthetic graft substitute (b.Bone) for iliac crest reconstruction and to evaluate the results of PGP surgical treatment. 

Methods: This was a prospective open label single-arm first-in-human clinical investigation. 15 consecutive participants undergoing pelvic fusion and requiring iliac crest reconstruction were enrolled and followed-up for 12 months.  Adverse events (primary outcome) were documented according to the Clavien-Dindo criteria. An independent Data Safety Monitoring Board (DSMB) reviewed the results with respect to safety.  Health-related quality of life was evaluated using EuroQol-5D-5L questionnaire. A visual analogue score (VAS; 0-10cm) assessed pain severity. Iliac crest defect healing was evaluated by the Modified Lane and Sandhu radiological scoring system (MLS).

Results: All 15 (14 female) participants (median age 46 years) underwent pubic symphysis fusion and 14/15 SI joint arthrodesis. The mean duration of PGP was 9.8 years (range 4-20). One serious adverse event was deemed related to the pelvic iliac crest graft site (the removal of one device that was displaced following a fall due to a non-epileptic seizure). By 365 days complete healing of the defect (MLS score 10) was noted in 12/14 (range 8-10). The EQ-5D-5L scores improved steadily reaching the highest point at 365 days. Median (1^st,3^rd quartiles) pain VAS score decreased from 6 (5,8) at day 1 to 2 (1,3) at 12 months. 

Conclusions: The b.Bone synthetic scaffold found to be safe, with positive radiological assessment of defect healing. Small-sample descriptive data suggested pelvic fusion may improve health related quality of life outcomes and pain scores; this requires confirmation in comparative trials.  

Frank Davis¹, Jan Gosiewski², Joideep Phadnis¹, Sandeep Chauhan^1,2, Benedict Rogers¹

¹University Hospital of Sussex, Brighton, United Kingdom. ²Definition Health, Brighton, United Kingdom

Abstract

Background: Improving the efficiency of elective clinical pathways is a clinical and professional priority, however  traditional pre-operative assessment (POA) processes places a large financial and environmental burden on the NHS. Digital POAs afford the potential to alleviate this burden, though implementation relies on the acceptance of both patients and staff. This study aims to assess the feasibility, usability and economic benefits of implementing a novel digital POA tool (Lifebox).   

Methods: Between April and December 2022, LifeBox, a digital POA was introduced at the Royal Sussex County Hospital (RSCH) across all surgical specialities focusing specifically on elective Orthopaedic Surgery, Patient demographics, number of episodes created in LifeBox, Number of face to face (F2F) POA appointments, number of telephone appointments and number of Did Not Attends (DNAs) were measured. Staff and patient surveys were used to explore patient and staff acceptability with the digital POA 

Results: Fiscal - The number of 30- and 60-minute F2F appointments decreased from 7667 to 4501 and DNAs decreased from 501 to 43 after the digital POA was introduced. The number of telephone appointments increased from 26 to 1079 as patients who did not need F2F POA were successfully identified. This translated into a £1.5 Million pound saving for the trust.  Environmental - A reduction of 6.84 metric tons of CO2 emissions was achieved. This reduction stemmed from minimised travel requirements and reduced paper consumption facilitated by the digital pathway. Usability - Both patients and staff were happy to adopt the digital POA with 82% and 84% stating they were satisfied with using it respectively. 

Conclusions: The introduction of the digital POA demonstrated a reduction in F2F appointments, GHG emissions and a large financial saving without compromising patient safety.

Implications: Embracing a digital POA will create sustained real term benefits for the trust, its staff and patients. 

Bridget Melley, Conor O’Driscoll, Fiachra Rowan, May Cleary

Department of Orthopaedics, University Hospital Waterford, Waterford, Ireland

Abstract

Background: HbA1c has been shown to be associated with higher rates of post operative complications, wound issues and peri-prosthetic infections following arthroplasty. However, it is not always employed in the milieu of tests that are performed as part of the pre-operative assessment. This study aims to determine if associations exist between pre-operative HbA1c and readmission rates, post operative pain management and post operative complication rate.

Methods: Data was collected from patients undergoing arthroplasty (knee, hip or shoulder) relating to their preoperative HbA1c measurement, post operative pain scores, post operative outcome/complications and whether or not they were readmitted to hospital following discharge after arthroplasty surgery.Patients were grouped into those with a HbA1c of 1) less than 48 (normal range), 2) Between 48 and 60 (controlled diabetes) and 3) those with HbA1c > 60 (poorly controlled diabetes).

Results: Data was obtained from 1214 patient’s undergoing arthroplasty. Of note, 20 patients were newly diagnosed with diabetes based on. Their pre operative HbA1c. A significant difference existed in readmission rates between group 1 (43.1%),  group 2 (18.6%) and group 3 (5.8%). Those with higher pre operative HbA1c also tended to have more difficult to manage post operative pain scores.

Conclusion: In conclusion, this study shows that pre operative HbA1c will not only allow patients to be identified pre operatively who need medical optimisation in terms of their diabetes (especially in cases where a new diagnosis is made). But, may be helpful in predicting higher risk of post operative complications, difficult to manage pain and risk of readmission. To identify these risks puts us in the position where we can alter pre operative management in order to optimise patient outcome post operatively.

Nuthan Jagadeesh, Geraint Thomas, Naill Steele, Umair Attar, Vinay Patel, Nithin Unnikrishnan

Robert Jones and Agnes Hunt Hospital, Oswestry, United Kingdom

Abstract

Hospital readmission rates within 30 days post-discharge, particularly for arthroplasty surgeries pose fiscal challenges. Despite initiatives like the Hospital Readmissions Reduction Program, rates remain high. Understanding causes and risk factors is vital for targeted interventions to improve patient outcomes and reduce costs.

This retrospective study examined 18,233 patients who underwent primary total hip arthroplasty (THA) at a tertiary center between January 2007 and December 2022 to assess 30-day readmission and return to theatre (RTT) rates, as well as associated factors. The analysis focused on patients readmitted within 30 days for surgical reasons, excluding medical causes.

Results revealed 255 patients readmitted within 30 days post-surgery, yielding a 30-day readmission rate of 1.40% (14 cases per 1000 surgeries), and a 30-day RTT rate of 0.74% (7.4 cases per 1000 surgeries). Wound complications emerged as the primary cause of readmission, affecting 63.9% of patients, followed by dislocation at 11.8%. Similarly, washout for wound complications constituted the primary reason for RTT (65.8%), followed by revision surgery for dislocation (19.1%). Age, sex, and Charlton comorbidity index showed no correlation with readmission or RTT, while a body mass index (BMI) over 30 correlated positively with both.

In conclusion, the study underscores a relatively low but notable 30-day readmission and RTT rate following THA. Wound complications and dislocation emerged as predominant reasons for both, emphasizing the importance of meticulous surgical techniques and postoperative care. Moreover, a BMI exceeding 30 was identified as a significant risk factor for readmission and RTT, suggesting the need for tailored interventions for patients with higher BMI to mitigate these risks. This study provides valuable insights for improving patient outcomes and refining risk stratification strategies in THA procedure.

Jocelyn Cheuk, Will Mason

Cheltenham General Hospital, Cheltenham, United Kingdom

Abstract

Background: Early diagnosis of scaphoid fractures is important to achieve good outcomes. They are commonly caused by wrist hyperextension from falling on an outstretched hand (FOOSH). However, they can also occur through less common, atypical mechanisms. While there is much literature regarding examination findings in diagnosing scaphoid fractures, there is less focus on the mechanism of injury. We hypothesise that scaphoid fractures resulting from atypical mechanisms are diagnosed later, which may result in a greater incidence of non-union.  

Aims: To evaluate the mechanism of injury in patients undergoing surgery for scaphoid non-union

1. To determine the incidence of scaphoid non-union resulting from typical (FOOSH) versus atypical (non-FOOSH) mechanisms.
2. To evaluate the characteristics and outcomes of these fractures.

Methods: 345 patients across eight UK hospitals were identified to have undergone surgery for scaphoid non-union. Patients undergoing revision surgery or had surgery within the last 6 months were excluded.  Retrospective analysis of patient demographics, mechanism of injury, reasons for delayed presentation or diagnosis, and postoperative outcomes was performed.

Results: 202 (59%) non-unions were caused by a typical mechanism of a fall. 109 (31%) injuries were associated with atypical mechanisms – of these, a large proportion (75%) were caused by pure hyperextension without a fall and were sustained during sport. This comprises 24% of all scaphoid non-unions. Other atypical mechanisms include punch injuries (7%), road traffic accidents (3%), and crush injuries (1%). 28% of non-unions from atypical hyperextension sports injuries were proximal pole fractures, compared to 14% of typical FOOSH injuries (p=0.005). Scaphoid views on initial imaging were performed in 50% patients with a delayed diagnosis, versus 65% patients with no delay.

Conclusion: Nearly one-quarter of scaphoid non-unions are caused by pure hyperextension injuries without a fall. Awareness of this and other unusual injury mechanisms  may help avoid delayed diagnosis and non-union.

Chiranjeevi Srinivasa Gowda, Meg Baker, Tim Halsey, Alex Kocheta, Jayanth Paniker

The Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Background: Wrist arthrodesis is a known salvage procedure following failures of wrist arthroplasty. This can be technically challenging due to inadequate bone stock, which helps restore wrist height and maintain good grip strength. This study aims to report the technique and outcome of wrist arthrodesis following failed wrist arthroplasty using femoral head allograft.

Methods: A retrospective study reviewing the outcomes of all arthrodesis for failed arthroplasty performed over the last 4 years within a single unit. Femoral head allograft along with appropriate fusion devices were used for wrist arthrodesis. Patient notes and radiographic data were reviewed to identity outcomes. 

 Results: A total of 9 patients underwent wrist arthrodesis during this period. Indications included aseptic loosening (n=2), dynamic malposition (n=5) and painful wrist following arthroplasty (n=2). The prosthesis used for the index arthroplasty procedure includes Freedom(n=1), Motec (n=5) and Universal 2 (n=3). 5 patients had successful outcomes with radiological and clinical evidence of union (55%). 2 patients are under regular follow up with clinical and radiological features of healing arthrodesis (22%). 2 patients had non-union (22%). 

Of the patients with non-union, one had revision arthrodesis using iliac crest autograft and the other patient is awaiting revision arthrodesis. All patients had achieved clinical and radiological evidence of union at an average time of 1 year. None of the non-unions had infections, trauma, deformity, or any other complications.

Conclusion: Femoral head allografts have favourable outcomes when used for wrist arthrodesis as a salvage procedure following failures in wrist arthroplasty as they restore wrist height as well as provide stable bony union. 

Implications: Femoral head allografts are easy to procure and can be considered as a favourable bone graft in these situations. Operations can be performed under regional anaesthesia which reduces the morbidity for patients.

Liam Kilbane¹, Sarah Stapley², Daren Roberts²

¹RCDM, Birmingham, United Kingdom. ²Queen Alexandra Hospital, Portsmouth, United Kingdom

Abstract

Aims: It is 10 years since the end of UK kinetic activities in Iraq and Afghanistan. This review assesses how personnel with hand and arm amputations have progressed with regards to working life, function and adaptations to activities of daily living.

Methods: 1067 UK military personnel sustained upper limb injuries resulting from conflicts between 2004-2014. Thirty-two had major upper limb injuries ranging from complete hand loss to trans-humeral amputations. Twenty-two had associated lower limb amputations. A further 46 sustained partial hand amputations (greater than loss of a single finger). Zoom interviews were arranged with two researchers using a semi-structured technique, including Quick DASH and EQ5D outcome scores.

Results: Thirty-three interviews were undertaken. Median age at injury was 24 (range 19-39 years) and, at interview, 38 (range 31-51 years). Injury to medical discharge averaged 4 years, with only one returning to front-line service. No participant remained in an active military role. Twenty-three (70%) had undertaken some form of employment being wide-ranging from personal trainer to entrepreneur. Most were in successful relationships. Two (6%) still reported symptomatic phantom limb pain. There was an association with depressive signs and persistent phantom limb symptomatology. Those utilising an upper limb prosthetic mainly did so for very specific purposes, whilst those initially fitted with lower limb prosthetics, all were still using them. Time from injury to upper limb prosthetic fitting was an indicator of continued use. All identified methods of adaptations to assist in performing ADL’s independently. Four (12%) were persistent wheelchair users. Mean DASH score 18.4 (range 0-41) and mean EQ5D score 75.6% (range 30-95), scoring very good for both health and quality of life.

Conclusion: Most personnel interviewed have achieved post-injury outcomes exceeding expectations. This study demonstrates the overall very good outcomes achieved by military personnel following multiple, complex and life-changing hand injuries. 

Dhamotharan Kamatchi, Maile Wedgwood, Farid Ud-din, Mohammad Faisal

South Warwickshire University NHS Foundation Trust Hospitals, Warwick, United Kingdom

Abstract

Background: Hip Osteoarthritis significantly impacts the patient’s mobility and quality of life. Corticosteroids, produce an immediate reduction in pain as well as an improvement in the patient’s mobility and quality of life, but with a limited long-term efficacy. In this, platelet-rich plasma (PRP) a therapeutic tool with its ability to control inflammatory processes. The effectiveness of intra-articular PRP has been evaluated in knee chondroplasty and osteoarthritis; However, little evidence of its efficacy in hip OA exists.

Aim: The aim of this study to evaluate and compare the therapeutic efficacy of intra articular PRP vs corticosteroid in patients with mild to moderate symptomatic hip osteoarthritis. 

Methods: 60 patients affected by symptomatic radiologically confirmed hip OA (KL II–III) were enrolled in this randomized study. Patients randomized in the PRP group (n = 30) received an intra-articular injection of PRP (3-4mL) while patients randomized in the CS group (n = 30) received Depomedrone 80mg plus levo bupivacaine (8 mL of .25%). The pain and function of target hip evaluated by VAS,OHS, and WOMAC scales at the baseline, day 1, week 1, 2, 6 , and 3 months after treatment. 

Results: No serious adverse effects were observed during the follow-up period. Both treatments were effective in relieving pain and improving hip function in the immediate follow-up visit(1 week). A high improvement of the subjective scores was observed for both groups up to 6 weeks, with no significative differences between groups. After 6 weeks,the PRP group showed significative improvements in all scores when compared to the CS group. 

Conclusions: PRP or CS intra-articular injection is safe and improves the short-term scores of pain and hip function in patients affected by mild to moderate symptomatic hip OA (with no significant differences between groups). PRP demonstrated a statistically significant improvement over CS beyond 6 weeks. 

Ahmed Saad, Alistair Mayne, iosif Pagkalos, Yuvraj Agrawal, Rajesh Botchu, Akash sharma, Edward Davis

Royal Orthopaedic Hospital, Birmingham, United Kingdom

Abstract 

Total hip arthroplasty (THA) is a successful procedure for treating hip arthritis, emphasising the importance of optimal component alignment to enhance patient outcomes and reduce revisions. Interest in robotic assistance has surged, often involving CT imaging. Surgeons must understand radiation risks associated with various imaging protocols used in THA, given the rising prevalence of robotic procedures. Our study aims to assess radiation doses across different imaging modalities in THA, including conventional, navigation, and robotic techniques.

 Methods: A retrospective analysis was conducted using data from our radiology database. The study comprised 50 patients who underwent Mako robotic-assisted total hip arthroplasty (THA) and 39 patients who had Corin OPS-assisted THA. Among the Corin OPS THA group, we specifically examined CT scan radiation doses for 16 patients and evaluated radiation exposure from the Corin XRAY protocol for the remaining 23 patients. Additionally, we assessed radiation doses for 18 randomly selected patients who underwent conventional and/or navigated THA, all of whom received anteroposterior (AP) radiographs. To compare radiation doses, we analyzed the total radiation dose for 13 patients who underwent lateral hip X-rays for other indications within our institution. Dose measurements for each imaging technique were recorded as dose-area product (DLP) in mGycm2. We conducted descriptive statistical analysis and used analysis of variance (ANOVA) tests for comparative measures.

Results: Corin CT scans exhibited a mean DLP of 2959.3 mGycm2, with the highest effective dose. Mako CT scans had a mean DLP of 1060.6 mGycm2. OPS lateral sitting and standing radiographs combined yielded a mean DLP of 819 mGycm2, while combined AP and lateral radiographs had the lowest mean DLP of 340 mGycm2.

 Conclusion: Our study underscores the importance of monitoring radiation exposure in THA imaging. Implementing low-dose CT protocols and alternative modalities can mitigate radiation risks while preserving diagnostic accuracy.

Petra Baji¹, Rita Patel¹, Antony Johansen^2,3, Andrew Judge^1,4,5, Muhammad K Javaid⁴, Elsa M R Marques¹, Yoav Ben-Shlomo⁶, REDUCE Study Group¹, Xavier L Griffin^7,8, Tim Chesser⁹, Celia L Gregson^1,10

¹Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom. ²Division of Population Medicine, School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, United Kingdom. ³National Hip Fracture Database, Royal College of Physicians, London, United Kingdom. ⁴Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. ⁵NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom. ⁶Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom. ⁷Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom. ⁸Royal London Hospital, Barts Health NHS Trust, London, United Kingdom. ⁹Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom. ¹⁰Older People’s Unit, Royal United Hospital NHS Foundation Trust Bath, Bath, United Kingdom

Abstract

Background: Hip fracture care varies between hospitals, potentially explaining variable patient outcomes and costs. We aimed to determine how hospital costs and patient outcomes were affected when patients are reoperated following an initial hip fracture surgery, and how this varies between hospitals.

Methods: A national record-linkage cohort study used data from all patients aged 60+ years who sustained a hip fracture in England (2016-19). Hip reoperation surgeries in the first year were identified through OPCS Classification of Interventions and Procedures codes. Inpatient costs in the 365-days following index hip fracture were calculated.

Results: Overall 164,691 patients received an index hip fracture surgery (70.8% female; mean[SD] age 82.7[8.6] years), and 7,522 (5%) had at least one hip reoperation during the following year. The number of days spent in hospital during that year was median 44 days (IQR 24-75) if reoperated, and 20 (IQR 11-39) days if not reoperated. The mean[SD] inpatient costs per person in the year was £23,923[£13,537] for those reoperated and £14,134[£8,002] for those not reoperated. The most frequent indications for reoperation were periprosthetic fracture (41%) and infection (34%) incurring costs of £21,615[£11,270] and £25,377[£15,174] respectively. Reoperation rates varied among the 159 English hospitals from 2.3 to 9.4%, and costs from £16,161 to £33,750 for those reoperated, and from £10,765 to £20,880 for those not reoperated. The total national cost of reoperated patients in the year following hip fracture surgery was between £49.9-£54.2 million in years 2016/17 to 2018/19.

Conclusion: Reoperations following hip fracture surgery were relatively common at 5%, and most commonly followed periprosthetic fracture. Reoperation conveys very high costs to the NHS, almost doubling annual direct hospital costs. These costs were highly variable between hospitals suggesting variation in clinical and service practice which warrants further study. 

Disclosure: Versus Arthiritis[ref:22086]

Matthew Hague¹, Samuel Walters², Simon Smith³, Eamonn Coveney⁴, Paul Gillespie³, Adrian Day³, Ross Coomber³

¹Croydon Health Services NHS Trust, London, United Kingdom. ²Epsom and St Helier University Hospitals NHS Trust, London, United Kingdom. ³St George's University Hospitals NHS Foundation Trust, London, United Kingdom. ⁴Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Abstract

Background: The aim of this study was to assess outcomes in patients with acetabular fractures treated with surgical fixation and who underwent delayed total hip replacement (THR).

Methods: A retrospective cohort study was performed from a prospectively collected institutional database from April 2014 to September 2023. Patients undergoing periprosthetic acetabular fixation or fixation and THR within 3 months were excluded. Clinical and radiographic follow up were examined to identify fracture type, fracture fixation approach, arthroplasty approach, implant type and complications.

Results: 420 cases of operative treatment of an acute acetabular fracture in a native acetabulum were identified. 75 cases that underwent acute fixation and THR within 3 months were excluded.  Of the 345 cases of primary fixation, 26 had delayed THR.  The indication for THR was post-traumatic osteoarthritis in 25, and osteonecrosis in 1. The mean interval between fixation and THR was 1.45 years (Range 0.38-5.58). Mean duration of follow-up from THR was 2.58 years (Range 0.14-6.32). 5 cases underwent removal of metalwork, 3 before or during the THR and 2 after. There was no evidence of nerve injury, periprosthetic fracture, loosening or heterotopic ossification. Two cases developed periprosthetic joint infection, treated with revision THR in one case and DAIR in another. No other cases had a revision of the THR. One case had a dislocation, treated with closed reduction.

Conclusions/Findings: 24% of the operatively treated acetabular fractures had a THR. Only 7.5% of patients treated with primary acetabular fixation required delayed THR. Rates of infection and dislocation may be higher than expected in a primary THR.

Implications: The low numbers of patients requiring THR after acetabular fixation demonstrates that fixation can be an appropriate definitive treatment for many. Higher complication rates demonstrate that post-fixation THR is a complex procedure and should not be undertaken lightly.

Anurag Singh, Prashant Pratim Padhi, Nallamilli Rajyalakshmi Reddy, Balasundaram Ramesh, Madhusudhan Thayur Raghavendra, Krishna Charan Krishnasamy Kannan, Ritu Sumit Agarwal

Glan Clwyd Hospital, Bodelwyddan, United Kingdom

Abstract

Introduction: Heterotopic Ossification (HO) is one of the commonest complications after Total Hip Arthroplasty (THA) with incidence ranges from 15-90%. As per recent studies, HO can be attributed to immune cell infiltration and inflammation involving cytokines and Interleukin (IL). Tranexamic Acid (TXA) is a synthetic derivative of lysine which is mainly used as a fibrinolysis inhibitor in THA to prevent excessive bleeding. Recent studies have shown TXA modulates inflammatory response by reducing levels of CRP, IL-6, TNF-α, reactive oxygen species and MMP-9. Another study showed that TXA reduces the recurrence of HO after excision in elbow injury. There are currently no studies demonstrating effect of local TXA on HO after THA. 

Methods: Patients undergoing elective primary THA at district hospital in Wales from 2017-2023 were selected and divided into two groups depending on whether they received TXA capsular infiltration during the time of closure. Their immediate post op and follow up X rays were then evaluated based on Brooker classification for evidence of HO. 

Results: There were 90 patients in Group A (No TXA) and 45 patients in Group B (TXA). About 55.56% patients in Group A developed HO, with 10% having Grade 3or4. In Group B, 18.7% patients developed HO with 3.125% having Grade 3. There was no significant difference between cemented and uncemented implants. 

Conclusion: Local infiltration of TXA significantly reduces incidence of HO after THA due to its anti-inflammatory properties. However, there is a need of further studies with a larger patient population to support these findings.

a multicentre, parallel group, randomised controlled trial

Susan Ball¹, John Charity², John Timperley²

¹1 NIHR Applied Research Collaboration South West Peninsula (PenARC), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom. ²Exeter Hip Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom

Abstract

Objectives: Assess the effect of a modified muscle sparing posterior technique; SPAIRE (Save Piriformis and Internus, Repairing Externus), in hip hemiarthroplasty for displaced intracapsular fractures on postoperative mobility and function compared to a standard lateral approach.

Design: Pragmatic, superiority, multicentre, randomised controlled trial with two parallel groups. 

Setting: Six hospital sites in South West England.

Participants: 244 adults (aged ≥ 60 years) requiring hemiarthroplasty for displaced intracapsular hip fracture (122 randomly allocated to receive the SPAIRE approach and 122 to receive the standard lateral approach).

Interventions: Surgery using the SPAIRE approach or the standard lateral approach.

Main outcome measure: The primary intention-to-treat outcome measure was de Morton Mobility Index, a function and mobility score collected face-to-face at 120 days post-operation. Due to COVID-19 restrictions, the primary outcome was changed to the Oxford Hip Score (OHS), collected remotely via telephone. Secondary outcomes included function and mobility at 3 days, pain at 3 and 120 days, acute discharge destination, length of acute and total hospital stay, complications and mortality within 120 days of operation, quality of life and place of residence at 120 days. 

Results: There was little evidence of an effect of surgical approach on the OHS at 120 days; adjusted mean difference (SPAIRE – lateral) -1.23 (95% confidence interval (CI): -3.96 to 1.49, p = 0.37). There was some evidence of an effect of surgical approach on the secondary outcome of patient-reported pain at 3 days; adjusted mean difference (SPAIRE - lateral) -0.99 (95% CI: -1.84 to -0.13, p = 0.02).

Conclusions: Participants receiving the SPAIRE approach may experience less pain in the early postoperative recovery period, compared to those receiving the lateral approach. Modification of the posterior approach in hip hemiarthroplasty to follow the SPAIRE technique can be carried out with equivalent patient outcomes to the lateral approach within 120 days post-operation.

Robert Whitham, Vikki Wylde, Elsa Marques, Sian Noble, Andrew Beswick, Rachael Gooberman-Hill, Ashley Blom, Erik Lenguerrand

University of Bristol, Bristol, United Kingdom

Abstract

Background: Pre-operative psychological factors are recognised to affect outcomes following total hip (THR) and total knee replacement (TKR) for osteoarthritis (OA) but the impact of how patients mentally perceive their OA is unclear. The aim of this study was to explore whether illness perceptions influence patient-reported outcomes after THR and TKR.

Methods: A prospective cohort study of patients undergoing primary THR (n=304; 177 female, 127 male) and primary TKR (n=290; 153 female, 137 male) for OA was performed. Patients completed the Revised Illness Perception Questionnaire (IPQ-R) pre-operatively. Composite outcomes for pain, function, and stiffness were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The association between pre-operative illness perception dimensions and 12-month post-operative total WOMAC score was analysed using linear regression models.

Results: Several illness perception dimensions were found to be associated with 12-month WOMAC after adjusting for age, gender, body mass index, and comorbidities. For THR patients, lacking belief in the ability of treatment to control their OA (p=0.008) and having higher emotional representations (p=0.018) were associated with worse outcomes. For TKR patients, higher consequences (p=0.007), lower illness coherence (p=0.023), and poorer treatment control (p=0.005) perceptions were associated with worse outcomes. Further adjusting for pre-operative WOMAC, anxiety, and depression attenuated these associations. However, perceived treatment control remained significantly associated with post-operative WOMAC in both THR (p=0.034) and TKR (p=0.030) patients.

Conclusion/Findings: This study found that illness perceptions, especially treatment control, seem to be associated with post-operative outcomes following THR and TKR. Screening for modifiable psychological risk factors such as poor illness perceptions may help identify patients who could benefit from pre-operative psychological interventions. Further research evaluating complementary interventions aimed at improving pre-operative illness perceptions is needed to determine any positive effect on long-term THR and TKR outcomes.

Hassan Fawi^1,2, Harry Maughan³, Anna Freni-Sterrantino¹, Laure Laure de Preux⁴, Alan Norrish⁵, Catherine Wloch⁶, Iina Hiironen⁷, Theresa Theresa Lamagni⁶, Daniela Fecht¹, Vikas Khanduja²

¹Imperial College London, London, United Kingdom. ²Cambridge University Hospital, Cambridge, United Kingdom. ³University of Cambridge School of Clinical Medicine. Cambridge Biomedical Campus, Cambridge, United Kingdom. ⁴Imperial College London, london, United Kingdom. ⁵Nottingham Univeristy, Nottingham, United Kingdom. ⁶UKHSA, London, United Kingdom. ⁷UK, London, United Kingdom

Abstract

Background: Emerging evidence indicate an association between hip and knee replacements performed during the summer season and an increased risk of Surgical Site Infection (SSI). We provide a synthesis of published studies reporting on this association.

Methods: We searched Medline, PubMed, Scopus, Cochrane, Web of Science, CINAHL, EMBASE, and grey literature from inception until 24^th July 2023. Studies reporting on patients undergoing hip or knee replacements and assessed for SSI were included. Studies that focused on long-standing SSI solely, were excluded. Meta-analysis was performed using random effect models. This study was registered with PROSPERO, CRD42021290254.

Findings: We identified 4,136 articles, of which nine were eligible for inclusion, representing 14 distinct cohorts (1,701,686 participants). There were 1,415,663 total hip replacements; 168,272 total knee replacements; 117,001 hip replacements for hip fractures; and a series of 750 cases that reported on mixed cohort of planned hip and knee replacements. Analysis of the 1,415,663 hip replacements identified a significant reduction of SSI in the protective effect of summer season, OR=0·48 (95%CI 0·39 - 0·59). In contrast, analysis of the 168,272 knee replacements, showed a non-significant elevation in the risk of SSI for operations performed in the summer season (OR= 1·26, 95%CI 0·91,1·76).

Interpretation: Considering a combination of all hip and knee replacements, we found no evidence of an increased risk of SSI during the summer season. Also, subgroup analysis of knee replacements showed no evidence of an increased risk of SSI, however, analysis of planned hip replacements revealed up to 41% reduction in the incidence of SSI during the summer season. Our findings highlight the importance of future work in this area, particularly given the substantial heterogeneity between studies.

Kareem Omran¹, Colleen Wixted², Daniel Waren², Joshua Rozell², Ran Schwarzkopf²

¹University of Cambridge, Cambridge, United Kingdom. ²New York Langone Health, New York, USA

Abstract

Background: Total hip arthroplasty (THA) alleviates pain and improves function in hip disorders such as osteoarthritis. However, up to 1 in 3 patients may not regain adequate function or pain control post-operatively. Identifying patients at risk of not achieving meaningful gains in long-term outcomes enables better presurgical decision-making and optimized management. This study aimed to compare machine learning (ML) models to develop a tool that predicts which patients will achieve a minimal clinically important difference (MCID) by the first year post-operatively based on HOOS-Jr scores.

Methods: This retrospective cohort study analysed all THA patients who completed pre- and post-operative questionnaires from 2013-2023, in a high-volume orthopaedic hospital. The HOOS-Jr MCID was calculated using the distribution-based method. Variables considered included clinical characteristics, demographics, and preoperative scores. We employed four predictive models: Artificial Neural Network (ANN), Support Vector Machine (SVM), Generative Adversarial Network-augmented SVM (GAN-SVM), and Random Forest (RF). The most relevant features were selected using Maximum Relevance Minimum Redundancy (MRMR) criteria, and models were trained to evaluate the optimal number of features (1-13) using grid search and 10-fold cross-validation.

Results: Among the 1,288 patients who met the inclusion criteria, 997 (77.4%) achieved an MCID. Model AUCs ranged from 70.3-77.7, with the ANN model showing the highest discriminative ability (c-statistic: 0.78, 95% CI: 0.75-0.80), and the RF performing the worst. The most predictive variables for MCID achievement were preoperative HOOS-Jr score, gender, ASA score, procedure type (robotic vs conventional), length of stay, and race.

Conclusion: This study is the largest to date using ML to predict the attainment of meaningful improvements in HOOS-Jr scores following THA. The good discriminative ability demonstrates the potential of ML models as clinical tools to help orthopaedic surgeons identify patients at higher risk of suboptimal outcomes, enhancing preoperative discussions, shared decision-making, and individualized care strategies.

Adam T Yasen, Andreas Fontalis, T David Luo, Babar Kayani, Fares S Haddad

University College London Hospitals NHS Trust, London, United Kingdom

Abstract

Objectives: Pre-operative planning in THA, involves utilizing radiographs or computerized tomography scans, for prediction of implant sizing and positioning. This study aimed to compare 3D versus 2D pre-operative planning in primary THA with respect to key surgical metrics including restoration of the horizontal and vertical COR, combined offset and leg length, as well as the accuracy in predicting the size of implants used.
 
Materials and Methods: This study included 60 patients undergoing primary THA for symptomatic hip osteoarthritis randomly allocated to either robotic-arm assisted or conventional THA. Digital 2D templating and 3D planning using the robotic software was performed for all patients. Measurements to evaluate the accuracy of templating methods were conducted on the pre-operative CT scanogram, using the contralateral hip as a reference. Sensitivity analyses explored differences between 2D and 3D planning in patients with predominantly supero-lateral or medial osteoarthritis patterns.
 
Results: Compared to 2D templating, 3D templating was associated with less medialization of the horizontal COR (-1.2 mm vs -0.2 mm, P=0.002) and more accurate restoration of vertical COR (1.63mm vs 0.6mm, P<0.001). 3D templating was superior for planned restoration of leg length (+0.23 mm vs -0.74 mm, P=0.019). Sensitivity analyses demonstrated that in patients with medial osteoarthritis, 3D planning resulted in less medialization of horizontal COR and less offset reduction. In patients with supero-lateral osteoarthritis, there was less lateralization of horizontal COR and less offset increase using 3D planning. 3D planning showed superior reproducibility for femoral and acetabular sizes and stem neck angle, while 2D planning led to undersized implants.
 
Conclusions: Our findings indicated higher accuracy in planned restoration of native joint mechanics using 3D planning, and in predicting sizes of implants used. This study highlights distinct variances between the two planning methods across different osteoarthritis pattern subtypes, offering valuable insights for clinicians employing 2D planning methods.

Yuvraj Chhabra¹, Sarup Saroha¹, Kamrul Hasan², Raj Thakrar³, Akash Patel²

¹University College London, London, United Kingdom. ²Royal Free London NHS Foundation Trust, London, United Kingdom. ³The Lister Hospital NHS Trust, London, United Kingdom

Abstract

Backgrounds and Aims: This study explores the impact of allograft selection in revision anterior cruciate ligament reconstruction (ACLR), a growing area in orthopaedics. Allografts reduce donor-site morbidity and surgery duration. The aim was to assess various allograft subtypes for their efficacy and failure rates in revision ACLR, determining superior outcomes.

Materials and Methods: Following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and a pre-defined protocol (ID: CRD42023432517), a systematic review of Cochrane Library, Embase, MEDLINE, Web of Science, and Scopus was performed for allograft studies. The primary outcome was failure rate (graft re-rupture) and secondary outcomes included functional scores, infection rates, and return to sport levels. The meta-analysis weighted studies by standard error.

Results: Studies assessing Bone Patella Bone (BPTB), Tibialis Anterior, and Achilles allografts were included. The results indicate non-statistically significant odds ratios for BPTB versus Achilles (OR 1.00) and Tibialis Anterior (OR 1.26) with low or no heterogeneity. Tibialis Anterior displayed a lower failure rate than Achilles (OR 1.26 vs. 3.69). Secondary outcomes favoured BPTB, showing positive KOOS and IKDC scores, while Achilles reported Lysholm scores (83.8 ± 11.3) and 62% return to sport. Tibialis Anterior outcomes included a Lysholm score (92 ± 4.0).

Conclusion: This study provides insights into graft selection for revision ACLR. BPTB demonstrated favourable graft failure rates compared to Tibialis Anterior and Achilles allografts. No statistically significant differences were observed in other outcomes between subtypes, emphasising the need for standardised reporting in revision ACLR studies and supporting avenues for future research.

Joshua Lorimer, Alexander Berry, James Robinson

North Bristol Trust, Bristol, United Kingdom

Abstract

Background: Retrospective analyses of knee extensor mechanism trauma have suggested a 30-51% incidence of associated intra-articular knee injuries. We sought to clarify the role of routine pre-operative MRI scanning of patients with a clinical diagnosis of traumatic extensor mechanism injury. The primary outcome was detection of intra-articular injury. The secondary outcomes were rates of additional surgery and whether obtaining the MRI led to a delay to surgery.  

Methods: We performed a retrospective evaluation of quadriceps tendon (QT) and patella tendon (PT) ruptures in adults attending our major trauma centre between April 2018 and April 2023. MRI was performed according to surgeon preference given the clinical presentation and context of trauma. All scans were reported by a musculoskeletal radiologist and retrospectively re-examined.

Results: 113 consecutive quadriceps (n=73, 65%) and patella (n=40) tendon ruptures were diagnosed clinically during the study period. 51 (45%) underwent MRI. Concomitant intra-articular pathology was identified in 21 (41%) cases, of which 13 (25%) were assessed as acute injuries. There were 5 MPFL tears, 2 lateral meniscal tears, one medial meniscus tear, one osteochondral injury and one partial ACL injury identified. The operative plan of tendon repair was not changed by MRI findings in any case and all underwent isolated primary tendon repair without additional procedures. Mean time to surgery was 8 days for those who underwent MRI and 5 days for those proceeded to surgery without MRI (p<0.05). One patient with a clinical diagnosis of a QT rupture was found to have the tendon intact on MRI.
 
Conclusions: MRI scanning may be useful for confirming the diagnosis of PT or QT rupture and evaluate concomitant injury. However, this must be weighed against the delay to surgery. The findings of the MRI scans in this series did not alter the surgical repair and no concomitant procedures were required. 

Amy J. Garner^1,2, Oliver Dandridge³, Andrew A. Amis³, Justin Cobb¹, Richard J. van Arkel³

¹MSk Lab, Imperial College London, United Kingdom. ²Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, United Kingdom. ³Biomechanics Group, Imperial College London, United Kingdom

Abstract

Background: Lateral Unicompartmental Arthroplasty (UKA-L) preserves the cruciate ligaments, native patellofemoral and medial tibiofemoral compartments including the medial meniscus. This study investigates the biomechanics of UKA-L.

Methods: Eight cadaveric knees were dissected of skin and fat. The quadriceps, iliotibial band and hamstring tendons were proportionally loaded in physiological directions according to their cross sectional area. Specimens were tested in the native state, then with a UKA-L or posterior-cruciate retaining TKA in situ. In round one, specimens were tested for extensor moment and arthroplasty efficiency through 0-110° arc of motion, whilst in round two, specimens were optically tracked in a separate kinematics rig to measure anterior-posterior stability through a 90° arc of motion. Variables were subject to RMANOVA with Bonferroni Correction, α = 0.05.

Results: In round one, between 0-100° flexion, UKA-L were statistically similar to native knees in extensor moment, with increased torque >100°.  TKA had significantly reduced extensor moments in the low flexion angles (0-40°) before returning to the normal range between 50-110°. Overall loss of efficiency for TKA was 14% compared to native knees, with losses of 43% in the gait range of flexion. Meanwhile UKA-L remained statistically efficient. No significant increases in anterior or posterior tibial translation were recorded following UKA-L, with minimal overall change to the laxity envelope compared to the native knee, whereas, TKA demonstrated increased laxity (20mm) throughout the flexion-extension cycle.

Conclusions: Compared to TKA, UKA-L preserves the extensor efficiency of the knee and remains anterior-posterior stable during flexion. UKA-L is a viable, high-functioning alternative to TKA in the treatment of isolated lateral-tibiofemoral disease in the presence of a functional anterior-cruciate ligament.

Implications: UKA-L respects the native kinematics of the knee. An increased understanding of the benefits may give surgeons the confidence to use partial knee replacement methods in patients with isolated lateral disease. 

Amy J. Garner^1,2, Oliver Dandridge³, Richard J. van Arkel³, Justin Cobb¹

¹MSk Lab, Imperial College London, United Kingdom. ²Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, United Kingdom. ³Biomechanics Group, Imperial College London, United Kingdom

Abstract

Background: Lateral Unicompartmental Arthroplasty (UKA-L) is a bone and cruciate preserving procedure, but little is known of its associated gait characteristics at top walking speeds. 

Methods: Twenty individuals mean 35 ± 37 months post UKA-L, performed for isolated lateral tibiofemoral arthrosis, were measured on the instrumented treadmill at top walking speeds. Temporospatial parameters and vertical ground reaction forces of gait were analysed and compared to age, sex and BMI-matched healthy controls (n=22) and individuals with unilateral total knee arthroplasty (TKA, n=28) mean 46 ± 48 months post-surgery (p = 0.4). Oxford Knee Scores (OKS) and EuroQoL EQ-5D scores for each arthroplasty group were compared. 

Results: The UKA-L group walked on average at 7.0± 0.6km/h, 0.2km/h (3%) slower than the healthy control group (7.2± 0.7km/h p=0.7), 18% faster than the TKA group (5.5km/h ± 0.7 p<0.001). UKA-L displayed near normal vertical ground reaction forces throughout the stance phase. TKA demonstrated significantly reduced maximum weight acceptance, increased mid-stance and reduced push-off forces compared to healthy and UKA-L subjects (all <0.05). UKA-L equalled the step and stride lengths of healthy controls, 12% and 10% longer than TKA respectively (p<0.05). UKA-L was associated with a median OKS of 44, compared to 36 for TKA (p<0.001) and EQ-5D of 0.90 compared to 0.78 for TKA (p=0.003).

Conclusion: Unlike TKA, UKA-L restores healthy gait characteristics at top walking speeds. Fast walking speeds, near-normal vertical ground reaction forces, longer stride lengths and a more consistent gait pattern demonstrate the importance of a functional cruciate ligaments to gait. UKA-L is associated with high patient satisfaction and good quality of life.

Implications: Evidence of improved outcomes following UKA-L should give surgeons the confidence to utilise a partial knee approach to treatment of isolated lateral gonarthrosis.  

Khay Yong Saw¹, Caroline Siew-Yoke Jee¹, Hui Cheng Chen², Nurul Hayah Khairuddin², Norhafizah Mohtarrudin³, Razana Ali³, Alisha Ramlan¹, Yan Chang Saw⁴

¹Kuala Lumpur Sports Medicine Centre, Kuala Lumpur, Malaysia. ²Faculty of Veterinary Medicine, Universiti Putra Malaysia, Selangor, Malaysia. ³Department of Pathology, Universiti Putra Malaysia, Selangor, Malaysia. ⁴NHS, Aberdeen, United Kingdom

Abstract

Introduction: The purpose of this study was to assess histologically whether intra-articular injections of autologous peripheral blood stem cells (PBSC) resulted in better regeneration of articular cartilage.

Materials & Methods: Fifteen sheep were equally divided into three groups. An 8mm diameter full thickness articular cartilage defect was created, followed by subchondral drilling into the left stifle joint. Group A (Control group) underwent surgery only; Group B (HA group) received 2 mL of hyaluronic acid (Ostenil®, TRB Chemedica AG, Germany) post-surgery; and Group C (PBSC+HA group) received injections of 2 mL PBSC along with 2 mL HA post-surgery. Three injections were administered: on the day of surgery and 1 weekly injection for 2 consecutive weeks. PBSC in Group C were harvested via apheresis one month before surgery. All animals were sacrificed at 24 weeks post-surgery. The stifle joints were harvested and examined macroscopically and histologically, utilizing the ICRS Visual Assessment Scale II and Gill scores. Statistical analysis was conducted using SPSS, with comparative analysis being two-tailed, and the level of statistical significance set at p < 0.05.

Results: All animals in the study survived throughout its duration. Utilising Gill scores, Group C demonstrated a significant improvement compared to Groups A and B, with p=0.036 and 0.020, respectively. Higher ICRS II scores indicate better regenerated cartilage. Group C showed a statistically significant difference compared to Group A (p=0.014) and Group B (p=0.009), highlighting its superior regenerative outcomes.

Discussions: Macroscopic evaluation showed cartilage regeneration in all groups, but incomplete filling of chondral defects due to the short joint harvesting duration. Histological images from PBSC-treated group depicted cartilage most closely resembling normal cartilage, consistent with prior clinical study findings.­

Conclusion: Intra-articular injections with PBSC resulted in better articular cartilage regeneration based on histological evaluation.

Gwenllian Tawy¹, Michael McNicholas^2,3,1, Leela Biant^1,3

¹University of Manchester, Manchester, United Kingdom. ²Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. ³Manchester University NHS Foundation Trust, Manchester, United Kingdom

Abstract

Background: It is unclear whether prehabilitation protocols prior to cartilage repair surgery should be tailored according to defect location. This study compared gait patterns of individuals with symptomatic lesions in the knee's lateral and medial femoral condyles (LFC/MFC) to assess if defect location changes gait, and hence whether prehabilitation needs to be targeted.  

Methods: Three-dimensional gait analyses were performed at a regional Joint Preservation Centre on patients with chondral defects in the MFC or LFC. Participants walked for two minutes on a treadmill. The Plug-in-Gait biomechanical model calculated kinematic and spatiotemporal parameters. Independent t-tests or Mann-Whitney tests compared the outcomes of both cohorts (α=0.05). 

Results: 15 patients with MFC defects and 14 with LFC defects participated. No differences were observed in spatio-temporal parameters - Walking speed: 2.9±0.6km/h vs 3.0±0.7km/h (p=0.695), cadence: 67.8±13.9 vs 69.5±21.5 steps/minute (p=0.797), stride length: 0.907±0.123m vs 0.954±0.147m( p=0.353). Maximum flexion during swing did not differ between cohorts (54.5±6.8° vs 51.4±11.5°:p=0.385). Neither did maximal extension at heel strike (2.9±6.0° vs 4.6±12.0°:p=0.793). On average, the knees remained in adduction throughout the gait cycle, with the degree of adduction greater in flexion in the MFC cohort.   However, differences in adduction were not statistically significant (19.9±9.3° vs 17.0±11.7°:p=0.461). Maximal internal-external rotation patterns were comparable in stance (-0.1±13.1° vs 2.2±7.4°: p=0.598) and swing (7.0±12.2° vs 8.0±9.4°:p=0.814). 

Conclusion: Spatio-temporal parameters and knee kinematics during walking were not statistically different between cohorts, suggesting that the location of the defect has minimal influence on the biomechanical parameters investigated. However, the impact of lesion location on joint loading and on all parameters during more demanding tasks remains unknown.  

Implications: Prehabilitation protocols prior to cartilage repair surgery do not need to be altered according to defect location. 

Satish Rohra, Andrew Miller, Huw Griffiths, Rebecca Wallace, Nimit Goyal

Aneurin Bevan University Health Board, Cwmbran, United Kingdom

Abstract

Background: Knee osteoarthritis (OA) poses challenges for patients' quality of life, especially for those not yet eligible for joint replacement but resistant to nonsurgical treatments. This trial investigates geniculate artery embolisation (GAE) as a potential solution for mild to moderate OA. An end of recruitment update to the trial is presented.

Methods: GAE, an interventional radiology procedure, targets OA-related pain by embolising pathological vessels while preserving essential bone blood supply. Thirty-one patients were enrolled in this prospective trial and will be followed up for 2 years. Up-to-date results of the efficacy and tolerability of GAE using PROMs (patient reported outcome measures) and PREMs (Patient reported Experience Measures), respectively is presented. Pain was recorded using Visual analogue score and quality of life was recorded using the EQ5D, Oxford knee and WOMAC scores. 

Results: The trial demonstrated promising outcomes. Patients experienced significant pain reduction, with VAS scores decreasing from a baseline of 68 to 38 at one month and 23 at six months. Improvements in quality of life were evident through enhancements in EQ5D, Oxford Knee, and WOMAC scores. Notably, no procedural adverse events occurred, indicating GAE's safety. Patients reported high tolerability and positive experiences.

Conclusion: Trial data affirm the effectiveness and safety of GAE for knee OA. GAE not only reduces pain but also enhances quality of life, with patients tolerating and accepting the procedure well.

Implications: GAE offers a low-risk alternative for managing knee OA, potentially alleviating strain on healthcare systems by providing effective relief and reducing knee arthroplasty waitlists. This underscores the importance of exploring diverse treatment options to address the increasing demand for musculoskeletal care.

Disclosure: The study receives funding from the Bevan Commission Planned Care Innovation Program grant and is sponsored by the Aneurin Bevan University Health Board.

Hasan Mohammad^1,2, Andrew Judge³, David Murray²

¹Barts Bone and Joint Health, London, United Kingdom. ²University of Oxford, Oxford, United Kingdom. ³University of Bristol, Bristol, United Kingdom

Abstract

Background: Unicompartmental knee replacement (UKR) is an effective treatment option for end stage arthritis but is associated with higher revision rates than total knee replacement. It is currently unknown whether component size influences the risk of revision and whether there is an interaction with surgical fixation. We undertook a registry-based study to analyse the effect of component size on revision risk.  

Methods: 50,926 mobile bearing UKRs from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man (NJR) were analysed. Outcomes of interest were implant survival for different tibial, femoral and bearing component sizes. Revision rates per 100 component years were calculated. A multivariate linear regression model was used to study the effect of component size on revision rate and study the effect of implant fixation. 

Results: There was a significant linear trend (p<0.001) for decreasing revisions rates with increasing tibial component size and femoral component size. For each increase in tibial and femoral component size the revision rate decreased by 0.08% per annum (pa) and 0.11% pa respectively.  Cementless tibial and femoral components had a significantly lower revision rate (p<0.001) compared to cemented at 0.39% pa and 0.42% pa respectively across all component sizes. There was a significant linear trend for increasing revision rates with increasing bearing size (p<0.001). For each increase in bearing size the revision rate increased by 0.12% pa. The same results were observed on subgroup analyses of cemented and cementless UKRs. 

Conclusion/Findings: Smaller tibial/femoral components and larger bearing sizes increased the risk of revision. Cementless components had lower risk of revision compared to cemented across all component sizes. Therefore, to achieve the best results surgeons should use cementless fixation and aim for a minimal tibial resection to be able to use smaller bearings.

A study from the National Joint Registry of over 14,000 joint replacements

Hasan Mohammad^1,2, Andrew Judge³, David Murray²

¹Barts Bone and Joint Health, London, United Kingdom. ²University of Oxford, Oxford, United Kingdom. ³University of Bristol, Bristol, United Kingdom

Abstract

Background: Unicompartmental knee replacement (UKR) is an effective treatment for medial compartment osteoarthritis but there can be problems with fixation. The cementless UKR was introduced to address this. It is unknown how its implant and functional outcomes compare to the cemented version on a national scale. We performed a matched comparison of the implant and functional outcomes of cementless and cemented UKRs.

Methods: 14,764 Oxford UKRs were identified by the National Joint Registry (NJR) with linked patient reported outcome data. Cemented and cementless UKRs were propensity score matched based on patient, surgical and implant factors. Cumulative survival was determined using the Kaplan-Meier method and compared between groups using cox regression. To compare post-operative scores and changes in scores between groups the Mann Whitney test was employed.  

Results: The 10-year cumulative implant survival for cementless and cemented UKRs were 93.0% (95% CI 90.0-95.1) and 91.3% (95% CI 89.0–93.0) respectively with this difference being significant (HR 0.74; p=0.02). Subgroup analyses showed a stronger effect (HR 0.66) in the high-volume surgeons (≥ 30 UKRs/yr). The postoperative Oxford Knee Score (OKS) was significantly (p=0.001) higher for the cementless 39.1 (SD 8.7) compared to the cemented 38.5 (SD 8.6) UKR. The cementless group gained 17.6 OKS points (SD 9.3) postoperatively compared to the cemented group of 16.5 points (SD 9.6) with a difference of 1.1 points (p<0.001). The differences in OKS points gained after surgery was highest for high volume surgeons where the cementless group gained 1.8 points more than the cemented group (p<0.001).

Conclusion/Findings: The cementless UKR has improved ten-year implant survival and postoperative functional outcomes compared to the cemented. The improvement in implant and functional outcomes observed in the cementless group was greatest for high volume surgeons with a HR 0.66 and higher OKS gain by about 2 points.

A study from the National Joint Registry and Hospital Episode Statistics

Hasan Mohammad^1,2, Andrew Judge³, David Murray²

¹Barts Bone and Joint Health, London, United Kingdom. ²University of Oxford, Oxford, United Kingdom. ³University of Bristol, Bristol, United Kingdom

Abstract

Background: Unicompartmental knee replacement (UKR) is an effective treatment option for knee arthritis. It is currently unknown whether surgeon caseload (number of UKRs performed annually) and usage (number of UKRs as a proportion of knee replacement practice) affects functional outcomes.

Methods: 19,882 UKRs from the National Joint Registry (NJR) were analysed. Surgeon caseload was divided into; (1) >0 and <5 UKRs/yr, (2) ≥5 and <10 UKRs/yr, (3) ≥10 and <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 postoperative Oxford Knee Score (OKS), change in OKS and percentage of possible change (PoPC) after surgery were studied. The effect of surgeon caseload and usage on functional outcomes were studied using the Kruskall Wallis Test.

 Results: The postoperative and difference in OKS significantly increased with surgeon caseload (p<0.001). The highest caseload group (≥30 UKRs/yr) had postoperative scores of 38.9 (SD 8.8) compared to 36.0 (SD 10.5) in the lowest group (>0 and <5 UKRs/yr). The PoPC increased (p<0.001) with surgeon caseload with values of 65.3% in the highest caseload group (≥30 UKRs/yr) compared to 55.7% in the lowest group (>0 and <5 UKRs/yr). The postoperative and difference in OKS significantly increased with surgeon usage (p<0.001). The highest usage group (≥50%) had postoperative scores of 38.4 (SD 9.1) and 36.9 (SD 10.0) in the lowest usage group (>0 to <10%). The PoPC increased with surgeon usage (p<0.001) with values of 63.7% in the highest group (≥50%) compared to 57.7% in the lowest group (>0 to <10%). 

Conclusion/Findings: Higher surgeon caseload and usage were associated with significantly higher functional outcomes. Patients operated on by high caseload and usage surgeons have better postoperative functional outcomes.

Chaiwat Chuaychoosakoon, Wachiraphan Parinyakhup, Tanarat Boonriong, Hafizz Sanitsakul

Prince of Songkla University, Hat Yai, Thailand

Abstract

Background: Various studies have examined the risk of peroneal nerve injury using standard magnetic resonance images (MRIs) of the knee. However, the position of the knee during a standard MRI is different from that during an actual arthroscopic lateral meniscal repair. The purpose of this study was to evaluate and compare the risk of peroneal nerve (PN) injury during simulated inside-out lateral meniscal repairs on the basis of MRIs of the knee in both positions.

Methods: Using axial MRI scans of the knee in 30° of flexion and in the figure-of-four position with varus force and joint fluid dilatation, transparent sheets printed with anterior-, middle- and posterior-curved zone-specific devices combined with a needle were placed from either the anteromedial, accessory-anteromedial, anterolateral or accessory-anterolateral portal to either the medial or lateral border of the popliteus tendon (PT) to simulate inside-out lateral meniscal repairs. If the overlain images showed the needle passing through the PN, it was noted as “injury”. Then, a second transparent sheet printed with the same curve of the zone-specific device was placed from the same portal to the outer border of the PN. The ‘‘danger zone’’ was defined as the area between the two zone-specific devices at the level of the meniscocapsular junction.

Results: In 29 patients, the risk of peroneal nerve injury on the actual arthroscopic MRI scans in relation to the lateral border of the PT was similar or lower than on standard MRI scans and the danger zone was included in the standard MRI scans.

Conclusions: Standard MRI scans of the knee can be used to determine the danger zone at the time of arthroscopic lateral meniscal repair in relation to the lateral border of the PT, although the risks are slightly overestimated.

Disclosure: The authors have no conflicts of interest to declare 

Matthew Bellamy¹, Lily Pearce¹, Sophie Allan¹, Tobias Stedman², Andrew Legg², Alex Anderson²

¹University of Sheffield, Sheffield, United Kingdom. ²Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Introduction: Anterior cruciate ligament (ACL) ruptures often result in knee instability, causing meniscal tears if untreated. New guidance suggests lower priority surgery for ACL tears without meniscal pathology. This study examined the risk of developing meniscal pathology with postponed surgery. 

Methods: We conducted a retrospective cohort study from January 2018 to March 2024 of consecutive patients who had undergone ACL reconstruction. We categorised patients based on pre-operative MRI findings of meniscal tears and time from adding to the waiting list, to surgery. Surgical notes were searched to determine if meniscal tears were identified intra-operatively. Non-parametric testing determined baseline and clinical differences between groups. A binary logistic regression model determined the risk of developing meniscal pathology with delayed surgery.  

Results: From 272 patients, 15.1% developed meniscal tears identified intra-operatively that were not present on the initial MRI scan, with a male to female ratio of 3:1. Additionally, 5% had pathology on MRI not seen during surgery. Median time to diagnosis was 16 days, and median time between listing and operation was 162 days. Age and time to diagnosis didn't significantly affect outcomes between groups (p>0.05). BMI differences weren't significant overall but were significant when high leverage points (BMI>43) were removed (p= 0.038). Binary logistic regression, accounting for gender and BMI, showed that for each day on the waiting list, the chance of developing a meniscal tear increased by 0.3% (p= 0.013). 

Conclusion: This study highlights the risk factors and progression of meniscal pathology following delayed ACL reconstruction. While age and time to diagnosis showed no significant impact, BMI and waiting list duration are important factors. With a delay of a month to surgery, the likelihood of developing a meniscal tear increases by nearly 10%.  These findings emphasise the importance of early intervention and potential revaluation of the current guidance.

Babar Kayani, Fabio Mancino, Joanna Baawa, Mark Roussot, Fares Sami Haddad

University College London Hospital, London, United Kingdom

Abstract

Background: The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up.  

Methods: This study included 297 patients undergoing presumed aseptic single-stage revision THA or TKA at a single treatment centre. All patients with at least three UPCs obtained during revision surgery were treated with minimum three months of oral antibiotics following revision surgery. The prevalence of UPCs, causative microorganisms, recurrence of PJIs and infection-free implant survival were established at minimum 5-years’ follow-up (range 5.1 to 12.3 years) 

Results: Of the 297 patients undergoing aseptic revisions, 37 patients (12.5%) had at least three UPCs obtained during surgery. The UPC cohort included 23 males (62.2%) and 14 females (37.8%), with mean age of 71.2 years (range, 47 to 82 years). Comorbidities included smoking (56.8%), hypertension (48.6%), diabetes mellitus (27.0%), and chronic renal impairment (13.5%). The causative microorganism included Staphylococcus epidermidis (49.6%); Bacillus species (18.9%); Micrococcus species (16.2%) and Cutibacterium acnes (16.2%). None of the study patients with UPCs developed further PJIs or required further surgical intervention during follow-up.

Conclusions: The prevalence of UPCs during presumed aseptic revision THA and TKA was 12.5%. The most common causative microorganisms were of low-virulence, and included Staphylococcus epidermidis, Bacillus species, Micrococcus species and Cutibacterium acnes. Microorganism-specific antibiotic treatment for minimum three months duration of UPCs in presumed aseptic revision arthroplasty was associated with excellent infection-free implant survival at mid-term follow-up.

A cohort study exploring the effect of cartilage status on the survival of the allograft and patient reported outcome measures

Chetan Khatri, Imran Ahmed, Tim Spalding, Nick Smith

University Hospitals Coventry & Warwickshire, Coventry, United Kingdom

Abstract

Background: Due to an absence of effective alternative treatments, the indications of meniscal allograft transplantation (MAT) have widened to include those with substantial cartilage disease. The current literature suggests reduced survival of the meniscal allograft in patients with substantial cartilage disease. 

Aims: We aimed to assess the effect of substantial cartilage disease on survival and patient reported outcomes measures (PROMs). 

Methods: A review of the prospectively maintained Coventry knee meniscal allograft transplant database was performed. Patients with International Cartilage Repair Society (ICRS) 3b or above cartilage grading in either their femur or tibia were classed as having substantial cartilage disease. Post-operative IKDC, Tegner, KOOS4 and Lysolm were compared between those with and without substantial cartilage disease. Kaplan-Meir analysis was used to assess the survival rates. 

Results: Data from 422 patients were included in the analysis with 129 patients found to have substantial cartilage disease and 281 patients without substantial cartilage disease. The group with substantial cartilage disease were significantly older and had a longer time from primary meniscal procedure to MAT. There were no significant differences in PROMs between the two groups at 1-, 2-, 3-, 5-, 7- and 10-years postoperatively. The substantial cartilage disease group had significantly lower survival rates compared to those without (80.62% vs 94.32% at last follow up) and the rate of complications was higher. 

Conclusions: MAT in the context of substantial cartilage disease was associated with an improvement in PROMs up to ten years with no difference to the group without substantial cartilage disease. Although the survival rate of the allograft is lower, as there are no effective alternatives, this survival rate coupled with the improvement in PROMs may be deemed acceptable in this population.

Wendy Bertram^1,2, Josh Lamb^1,3, Jagdeesh Nijjher⁴, Nick Howells⁵, Jessica Falatoori⁶, Thomas Kurien⁷, Chloe Scott⁸, Paul Montgomery⁹, Andrew Moore¹, Vikki Wylde^1,2, Michael Whitehouse^1,2

¹Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom. ²National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, United Kingdom. ³Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wrightington, United Kingdom. ⁴Belfast Health and Social Care Trust, Belfast, United Kingdom. ⁵North Bristol NHS Trust, Bristol, United Kingdom. ⁶Cardiff and Vale University Health Board, Cardiff, United Kingdom. ⁷Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. ⁸NHS Lothian, Edinburgh, United Kingdom. ⁹University of Birmingham, Birmingham, United Kingdom

Abstract

Background: Single centre studies report total knee replacement (TKR) cancellation rates of 5-30%; one UK study reports 26%. Many occur at short notice and for avoidable medical reasons. This can have a negative impact on patient well-being and may result in a loss of over £6700 in NHS tariff income per cancellation. Cancellations could be decreased by taking a proactive role in identifying issues, managing expectations about the potential for cancellation, information signposting, facilitating medical optimisation, and raising issues in advance. We aimed to identify reasons for TKR cancellations in the UK. 

Methods: Routinely collected data on reasons for TKR surgery cancellation were requested from six NHS hospitals, including timing of cancellation. Where reasons were not explicit, such as ‘patient unfit’, medical notes were consulted to establish the specific clinical reason. Data was coded into categories, then compiled and analysed using descriptive statistics.

Results: A total of 9403 cancellations occurred at six UK hospitals over five years (2018-2023), approximately 25-75% of procedures performed. Variability in reporting between Trusts preclude certainty about incidence rates. Cancellation categories were institutional (57%, n=5403), patient preference (24%, n=2248) and clinical (18%, n=1712). Reasons were missing for 0.4% (n=40).  Most occurred more than one week before the scheduled date (52%, n=4852). The remainder (48%, n=4297) occurred at ≤7 days. Dates were missing for 3% (n=254). A quarter of cancellations were at short notice, on the day of or before surgery (25%, n=2390). The majority of short notice reasons were bed not available and ‘patient unfit’, with most clinical reasons being cardiac, wound, infection, or medication not stopped. 

Conclusion: Cancellation of TKR surgery is more common than previously reported and often for avoidable clinical reasons. There is a need for provision of care pathways to provide optimisation, monitoring and information to prevent cancellations. 

Pradyumna Raval^1,2, Yoong Lim¹, Brett Fritsch¹

¹Sydney Orthopaedic Research Institute, Sydney, Australia. ²East of England Deanery, Cambridge, United Kingdom

Abstract

Background: Anterior cruciate ligament (ACL) injuries are common in the pediatric population due to participation in competitive sports. Paediatric and adolescent patients undergoing an ACL reconstruction have a higher incidence of graft failure, as high as 32%, compared to adults. Lateral extra-articular tenodesis (LET) when performed in adjunction to ACL reconstruction has lead to reduction in rate of graft failure. Open physis in the paediatric population pose a technical challenge while operating and the surgeon has to rely on intra-operative fluoroscopy in order to avoid iatrogenic damage to the physis as well as the ACL tunnel. The aim of this study is to identify a safe zone for placement of an anchor while performing Lemaire LET.

Methods: Three dimensional (3D) models were reconstructed of twenty patients between the age of 14  and 18 years using their annual magnetic resonance imaging scans and the position of the LET anchor was defined with relation to three anatomical landmarks, the lateral epicondyle, distal femoral physis (DFP) and femoral ACL tunnel. A 20 mm anchor placement was simulated through various angles and percentage involvement of the DFP and ACL tunnel was graded for each angle.

Results: Minimal physeal involvement was noted for anchor inserted at 30 degree inclination (0.45%) while maximum involvement was noted for 60 degrees (1.08%). The ideal location of the anchor was noted to be 6mm +/- 1 mm distal to the physis and 5mm +/- 2 mm posterior to the lateral epicondyle. The ACL tunnel was not violated in any of the simulations. No difference was noted for either sex.

Conclusion: The ideal position of anchor avoiding physeal damage and ACL tunnel involvement was at 30 degree inclination and at a distance of 6mm +/- 1mm distal to physis and 5 mm +/- 2 mm posterior to lateral epicondyle.

Implication: N/A

A Prospective Cohort Study Investigating Clinical and Cellular Outcomes

Amr Selim^1,2, Tian Lan^1,2, Charlotte Hulme^1,2, Peter Gallacher¹, Jade Perry^1,2, Paul Jermin¹, Karina Wright^1,2

¹The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ²School of Medicine, Keele University, Staffordshire, United Kingdom

Abstract

Introduction: Autologous Conditioned Plasma (ACP) has emerged as an advancement of Platelet Rich Plasma (PRP), aimed at improving clinical outcomes. The objective of this study was to investigate the clinical effectiveness of ACP intra-articular injection in patients with knee osteoarthritis (OA).

Methods: A prospective cohort study included 42 patients (54 knees) with knee pain attributed to OA. Patients underwent a series of 3 injections of ACP at weekly intervals, prepared using Arthrex-ACP® Double-Syringe System. Lysholm scores were collected at baseline, 3-, and 6-months post-injection. ANOVA with repeated measures was employed to compare Lysholm scores at baseline with those at 3- and 6-months. A multilinear regression (MLR) model was utilised to explore predictors of post-injection Lysholm scores.

Results: 40 patients (50 knees) completed the follow-up and were included in the final analysis. The mean age was 53.8±10.16 years. The mean Lysholm scores at baseline, 3- and 6-months were 46.04±19.21, 68.43±22.63, 67.7±21.45 respectively. ANOVA showed a significant difference between Lysholm scores at baseline, 3-, and 6-months (F= 20.91, p< 0.001). The Bonferroni post-hoc test revealed a statistically significant difference between baseline Lysholm scores and those at 3- and 6-months p<0.001, surpassing MCID of Lysholm scores, which is 5. However, there was no significant difference between Lysholm scores at 3-months and 6-months, p=1. MLR indicated that age, mean platelet concentration, Kellgren-Lawrence (KL) stage 3, and a unicompartmetal OA explained 31.62% of the variance in the 3-month Lysholm scores. ANOVA revealed that the model was statistically significant F= 4.85,p= 0.002,R²= 0.32.

Conclusion: ACP provides clinical benefits in patients with knee OA for at least 6 months post-injection. Advanced age and high mean platelet concentration in the ACP are identified as positive predictors of post-injection Lysholm scores. A larger, well-designed study is needed to further explore these benefits.

Faseeh Zaidi¹, Craig Goplen², Joshua Petterwood³, Peter McEwen⁴, Paul Monk¹

¹The University of Auckland, Auckland, New Zealand. ²University of Alberta, Edmonton, Canada. ³Petterwood Orthopaedics, Hobart, Australia. ⁴Mater Medical Centre, Townsville, Australia

Abstract

Background: The Coronal Plane Alignment of the Knee (CPAK) classification has quickly become the gold-standard approach to describing preoperative deformity in total knee arthroplasty (TKA). Little is known, however, about the interaction between pre- and postoperative CPAK change and patient outcomes. The primary objective of this study is to determine if changing a patient's preoperative CPAK classification impacts early functional outcomes after TKA.

Methods: A retrospective multicentre cohort study of patients undergoing primary robotic-assisted TKAs was conducted. Standardized pre- and postoperative long-leg radiographs were obtained for each patient. Radiographic measures included the lateral distal femoral and medial proximal tibial angles (LDFA and MPTA). Pre- and postoperative CPAK classification was calculated by determining the arithmetic hip-knee-ankle (HKA) angle and joint line obliquity (JLO) by the sum or difference of the two coronal measurements. Oxford Knee Scores (OKS) were assessed preoperatively and at 3 months, 6 months and 1 year postoperatively.

Results: 297 patients were included across three sites, with an average age of 66.6 years and mean BMI of 33. Postoperatively, 31.3% of patients remained in the same preoperative CPAK classification, while 62.0% moved one CPAK classification and 6.7% moved two. The mean change in MPTA was 0.25±5.93 degrees, LDFA 0.86±7.76 degrees, HKA 0.90±3.51, and JLO 0.81±15.16 degrees. Of note, patients that changed two CPAK classifications postoperatively had significantly less improvement in their OKS at 3 months, compared to those that had no change in CPAK classification (preoperative OKS 7.5±8.87 vs. postoperative OKS 14.02±10.63; p =0.016).

Conclusions: A shift in coronal alignment by two CPAK classifications postoperatively appears to negatively influence early functional outcomes at 3 months after primary TKA. The impact of larger corrections and the direction of change on outcomes after TKA in the longer term has yet to be established.

Frederick Elsey¹, Ryan Wong¹, Zakk Borton², Sheba Basheer³, Jeevan Chandrasenan¹, Nicolas Nicolaou³, Fazal Ali¹

¹Chesterfield Royal Hospital, Chesterfield, United Kingdom. ²Royal Derby Hospital, Derby, United Kingdom. ³Sheffield Children's Hospital, Sheffield, United Kingdom

Abstract

Background: Anterior cruciate ligament (ACL) injuries are prevalent among adolescents engaged in sports, necessitating ACL reconstruction to restore knee stability. However, the impact of gender on post-reconstruction outcomes remains unclear in this demographic. This systematic review addresses the knowledge gap regarding contrasting rates of ACL re-rupture between male and female adolescents following reconstruction surgery.

Method: A systematic review of literature on SCOPUS and MEDLINE databases were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines to identify studies in which ACL reconstruction in adolescents reported by sex. The Methodological Index for Non-Randomized Studies (MINORS) was used to evaluate quality of included articles. The mean MINORS was 8.3 (range 7 – 11). A total of 6 eligible studies with a total of 750 ACL reconstructions and 121 re-ruptures were included.

Results: 6 studies were selected for inclusion comprising 750 ACLRs in the adolescent population. There were 121 re-ruptures. Of the 750, 330 of ACLRs were in females and 420 in males. Overall re-rupture rate was 16% (121/750). The re-rupture rate in females was 15% (43/330) and in males 18.06% (78/420).  

Conclusion: The re-rupture rate in females was 15% (43/330) and in males 18.06% (78/420). Though significant at a superficial level (χ2 p=0.04) after application of a random effects meta-analysis model (mantel-haenszel) the finding that male patients were more at risk of re-rupture tended strongly towards but did not quite reach significance (RR 0.71, 95% CI 0.50-1.02).

Implications: The lower re-rupture rate following ACL reconstruction in adolescent females is unclear, and likely originates from a complex interplay between multiple variables. The findings emphasize the necessity for further high-quality studies to refine our understanding of these factors and inform evidence-based practices in managing ACL injuries among adolescents.

An analysis using the National Joint Registry dataset

Alex Matthews^1,2, Shiraz Sabah³, William Gray², Andrew Toms¹, Andrew Price³

¹Royal Devon & Exeter Hospital, Exeter, United Kingdom. ²Getting It Right First Time Programme, London, United Kingdom. ³Nuffield Orthopaedic Centre, Oxford, United Kingdom

Abstract

Background: Revision total knee arthroplasty (rTKA) services in the United Kingdom have recently undergone major reconfiguration to form revision networks. An important assumption of revision networks is that a volume-outcome relationship exists; that is, higher volume surgical units achieve better clinical outcomes. We aimed to investigate the relationship of surgical unit caseload on patient-relevant outcomes following single stage revision rTKA for infection.

Methods: Data was extracted from the United Kingdom National Joint Registry, Hospital Episode Statistics Admitted Patient Care, National Health Service Patient-Reported Outcome Measures, and the Civil Registrations of Death. Patients undergoing Single stage rTKA procedures for septic indications performed between 1st January 2008 to 31st December 2017 met the inclusion criteria. Patient-relevant outcomes included re-revision at 2 years, mortality and serious medical complications (up to 90 days postoperatively), and patient-reported outcome measures (at 6 months postoperatively).

Results: 32,519 first time rTKAs for all causes were identified. 1,477 single stage rTKA procedures for infection were undertaken by 716 consultant surgeons at 267 surgical units met the inclusion criteria and were available for analysis. Multi-variable fixed effect models and restricted cubic splines were fit to examine the association between surgical site mean annual volume and risk of re-revision at 2 years. Units performing more than 100 rTKAs had a significantly reduced re-revision rate (OR 0.34, 95% confidence intervals 0.15 to 0.72). A greater mean annual surgical volume was not associated with a significantly lower risk of reoperations, fewer serious adverse events, and worse PROMs.

Conclusions: There may be association between surgical unit volume and early failure of rTKAs for infection. This work supports the management of complex revisions in a network setting.

Ross Sian, Catherine Gordon, Jonathan France, Daniel Deakin

Queens Medical Centre, Nottingham, United Kingdom

Abstract

Background: Open ankle fractures represent a significant burden of work to ortho-plastic centres. Given their differing demographics between the low energy elderly and high energy young patients, as well as the lack of robust evidence on treatment, there is often high variance in management. We looked to review the treatment of these patients at a level 1 MTC to better understand and aim to develop a more robust treatment protocol in order to reduce this variation. 

Methods: An analysis of consecutive patients presenting over a 2 year period (June 2021 to June 2023). Patients identified prospectively using the trauma audit database. Inclusion criteria; Any open ankle fracture as classified by AO “Malleoli” fractures and a minimum of 3 month follow up to identify any complications. Exclusion criteria included; distal tibia and pilon fractures, age <16years.

Results:

• Demographics:
  • 42 open ankle fractures
  • 22 males vs. 22 female
  • 22 High energy vs. 22 Low energy
• Primary and secondary Bone + Soft Tissue intervention recorded
  • Fixation construct also recorded
• 98% initial operation <24 hours – Mean time 13h15mins  
• Mean time to definitive closure (in those not primarily closed) 121 hours.
  •  <72 hours = 27%
• 44% primary closure/12% Delayed closure/44% Tissue transfer (SSG/Local flap/Free flap)
• Limb Salvage 98%
• Complications:
  • 7.1% Deep infection rate
  • 2x subluxations in ex-fix awaiting ORIF
  • 3x Superficial wound issues requiring wound debridement
  • 2x flap failures
  • 1x Amputation
  • 1x Mal-reduction with re-operation

Conclusion: These results support our approach that open ankle fracture wounds should be primarily closed whenever possible. For the minority of wounds requiring second debridement these should be closed, subsequently re-opened at 48 hours for debridement and then re-closed. Slow healing medial traumatic wounds do not appear to represent significant morbidity in open ankle fractures. 

Ross Sian, Jonathan France, jessica nightingale, Skaria Alexander, Benjamin Ollivere

Queens Medical Centre, Nottingham, United Kingdom

Abstract

Background:  Open fractures in the elderly can be devastating with a myriad of associated complications, studies have shown very high mortality rates, similar to those suffering a hip fracture. The aim of this study was to review the outcomes of silver trauma patients presenting to a level 1 Major Trauma Centre with open lower limb fractures. The primary outcomes measures were successful limb salvage and 30 day mortality. Our secondary outcome measures were complications requiring re-operation.

Methods: A retrospective analysis of patients presenting over a 5 year period, identified and data obtained with a combination of electronic clinic databases (Trauma database, Medway, PACS, Bluespier, DHR). Inclusion criteria: any elderly patient (≥65) presenting with an open lower limb fracture (Tibia/Ankle) between November 2015 to October 2020). Exclusion criteria: Inadequate data availability for accurate analysis and those who did not receive operative intervention.

Results: 92 eligible patients with a mean age of 77.9 and a mean charlson comorbidity index of 4.49. 71 (77%) were low energy injuries. 23.9% had Gustilo-Anderson grade IIIA and 29.4% IIIB injuries. Average time to theatre was 12.3 hours. 74 patients (80.4%) received definitive closure within 72 hours. 57 patients (62%) had a 1 stage procedure. Primary wound closure in 53 (57.6%), local flaps used in 13 (14.1%) and free flaps in 6 ( (6.5%) patients. The 30 day mortality was 1.1%. There was successful limb salvage in 94.6% of patients, of the 5 amputations 3 were low energy. The deep infection rate was 6.5%. There was a re-operation rate of 13.1%.

Conclusion: Open fractures in silver trauma can be daunting, however with modern techniques, adherence to national guidelines and utilizing a dedicated combined orthoplastic approach, excellent outcomes in regards to mortality and limb salvage can be achieved. 

Patrick Foster

Leeds Teaching Hospitals, Leeds, United Kingdom

Abstract

Background:The titanium Precice lengthening nail has strong evidence to support its use in adults but is more controversial in children with a much weaker evidence base.

Methods: All cases were included from 2017-2023. Excluded were age over 18 (6), Fitbone nail (2) and steel “Stryde” precice (2). 18 remaining cases were examined retrospectively from a departmental database, single surgeon (adult and paediatric limb reconstruction). 13 boys, 5 girls. Age range 7-18, mean 13.6, 12 aged under 16. Conditions: 5 hip AVN, 5 hemihypertrophy, 4 CFD/FH, 4 olliers/MHE. 17 8.5mm nails used, one 10.5mm diameter. 5 retrograde (hip AVN cases) 13 anterograde (10 degree trochanteric).

Results: 17 patients (94.4%) had no complications (fracture, new hip AVN, implant failure or lysis, regenerate failure). Length gained range 25-50mm, mean 36mm. Consolidation range 76-169 days, mean 123 days. Mean “frame index” 34 days/cm. 7 nails removed, 9 planned, 2 retained at patient choice. One patient (5.6%) with CFD sustained multiple complications (deep infection, regenerate failure, hip subluxation) treated with exchange to solid nail.

Conclusion: With 94% success rate the titanium precice nail is safe and effective in children and adolescents for femoral lengthening 5cm or less.

Implications: NICE guidelines

Peter Calder, Joseph Wanas, Elizabeth Tissingh, Jonathan Wright, David Goodier

Royal National Orthopaedic Hospital, London, United Kingdom

Abstract

Background: Ollier’s disease characterised by multiple enchondromas can result in significant limb length discrepancy and angular deformities. Anecdotal evidence suggests faster healing rates during lengthening. The aim is to evaluate healing rates in Ollier’s and assess need for change in practice.

Methods: Twelve patients underwent limb lengthening utilising an external fixator or motorised lengthening nail. A latency period of six days was followed by a lengthening rate of 1mm per day. Parameters including lengthening index, bone healing index and external fixation index were recorded. The regenerate quality was assessed using the Pixel Value Ratio when lengthening was achieved, at frame removal and equivalent cortex formation following a nail. Change in lengthening rates and complications were noted.

Results: Eleven male and one female underwent 20 lengthening episodes at a mean age of 14yrs(8 – 19yrs). The mean lengthening was 4.7cms(1.8 – 8cms). Following external fixation the mean lengthening index was 17.36 days/cm(9.5-71), bone healing index was 35.58 days/cm(4-133) and 24.7 days/cm(21.57-28.15) with a nail,  and the external fixation index was 55.37 days/cm(21.43-210). The mean PVR was 0.82(0.52-1.18) at the end of lengthening and 0.93(0.64-1.1) at frame removal following frames, compared to 0.75 (0.74-0.77) and 1(0.94-1.06) with nails. No significant difference noted. Complications included one case of premature consolidation. One case of knee flexion deformity required a slowing of the distraction rate. No other cases had a change in lengthening rate or rhythm.

Discussion: All our patients undertook successful lengthening with good bone consolidation. The healing indices recorded are similar to the published literature. We accept the limitations of a retrospective study with small numbers. With only one case of premature consolidation we have no evidence to support the concept of faster regenerate consolidation in patients undergoing lengthening in Ollier’s disease.

C Vella*, A Duguid, T Ankers, B Narayan, B Fischer, N Giotakis, W Harrison

Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

Abstract

Background: Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. Two stage surgery may be necessary in severe deformity and in the presence of active infection or skin ulceration.

Methods: Nine patients underwent treatment between 2020 and 2023. Indications for 2-stage treatment were severe midfoot deformity and active or impending ulceration. Initial deformity correction by Ilizarov or hexapod butt frame was followed by internal beaming with a mean follow up of 11 months.

Results: Mean age at presentation was 53 years (range: 40-59). Mean frame duration was 3.3 months before conversion to beaming. Frame-assisted deformity correction resulted in consistently improved radiological parameters, with correction of planus & valgus deformities. Varying degrees of subsequent collapse were universal, with recurrent pes planus more likely than recurrent midfoot valgus. Ankle subluxation occurred in two (22%) butt frames. Beaming complications were common; hardware migration due to bone failure (N=8, 89%), hardware breakage (N=2, 22%), and infection (N=4, 44%). The unscheduled reoperation rate was 55%. Despite partial recurrence, 5 patients still regained mobility and a stable, plantigrade, ulcer-free foot. One patient had recurrence of rocker bottom deformity, but remains ulcer free in an orthosis. One patient developed collapse of the talus and underwent revision to tibiocalcaneal fusion and revision beaming. One patient died of a stroke 6 months after beaming. One patient developed deep infection requiring an amputation.

Conclusions: Aggressive deformity correction and internal fixation for Charcot arthropathy requires strategic and individualised care plans. Complications are expected for each patient. Patients must understand this is a limb salvage scenario. Amputation will most likely be avoided, but this management strategy is resource heavy, difficult for the patient and requires timely interventions at each stage with a well structured MDT delivering care. 

Mohammed Shaath¹, Elizabeth Tissingh², David Goodier¹, Peter Calder¹, Jonathan Wright¹

¹Royal National Orthopaedic Hospital, London, United Kingdom. ²Royal national orthopaedic Hospital, London, United Kingdom

Abstract

Background: X-linked hypophosphatemic rickets (XLH) is the most common form of inherited rickets; it can cause significant complex deformities. Medical management includes phosphate replacement, vitamin D and more recently novel drugs such as Burosumab. In the skeletally mature, osteotomies may be required to correct alignment, which can be through internal or external methods.

Aims: To assess time to union and complication rates in osteotomies for deformity correction in XLH.

Methods: A retrospective study on a prospectively collected cohort. Electronic patient records were reviewed and radiographs were analysed to assess: Mechanical axis deviation, External fixation index (EFI) for Taylor Spatial Frames (TSF) and mRUST scores for Intra-medullary Nailing (IMN) and plate fixations. Complication profiles were identified.

Results: Eleven skeletally mature patients were included in the study, who underwent 19 episodes of deformity correction. Procedures included were TSF (N=11), IMN (N=7) and one plate fixation. The mean age at intervention was 28 (range 13-58) and mean BMI of 31.8 (range 20.3-53.5). No patients were diabetic however two smokers were included representing a total of five procedures (four IMN and one TSF). Pre-operative mechanical axis deviation improved from 59.9 to 24.4mm (pre-op range 18-137 to post-op range 0-76). The mean frame index was high at 124.5 days/cm. Two TSF patients returned to theatre: one for septic arthritis, one for frame adjustment for delayed union. We observed delayed union in four IMN cases with mean time to RUST score >10 of 253 days for all IMN cases.

Conclusion: Deformity correction in XLH may be associated with delayed union of osteotomies. Additional research is necessary to understand the effect of new medical treatments on union rates. Collaboration is likely to yield more robust data for this rare condition.

Stratton King, Ashish Evans, Duncan Muir, Salman Anwar, Antoinette Guerrero

Ashford and St. Peter's Hospitals NHS Foundation Trust, Chertsey, United Kingdom

Abstract

Background: Ilizarov frames are being increasingly utilised for complex orthopaedic conditions as they facilitate multi-planar fixation with minimal soft tissue trauma. Despite being used in high-energy trauma, a scenario in which pain is a predominating feature, there is little literature discussing the management of pain for patients undergoing this procedure. This study aimed to assess the post-operative pain and analgesic requirements of those receiving an Ilizarov frame at a single centre, and to identify any patterns in patient, care, or injury characteristics that may influence this. 

Methods: A 12-month retrospective review was conducted of all patients undergoing Ilizarov frame application at a single NHS district general hospital. Demographic information alongside pre-, peri-, and post-operative elements of care were recorded. Statistical analysis was performed in SPSS.

Results: 55 patients were identified with a mean age of 50.2 years and an approximately 1:1 ratio of male to female. 49.1% were non-smokers, with mean BMI 26.9. 81.8% were ASA I or II. 58.2% were undergoing fixation of a tibial plateau fracture. Mean total length of stay was 10.9 days. PCA use immediately following surgery reduced opioid requirements by 58.8%. Mobilisation day 1 post-operatively was linked to a 58.9% reduction in opioid requirement also. Patients with extra-articular fractures used significantly less opiates. Female gender was associated with 47.3% increase in length of stay. No significant difference in provision of care could be identified between genders. 

Conclusions: Routine early PCA use could significantly improve post-operative pain in Ilizarov frame surgery and reduce opioid consumption alongside early mobilisation. Further study is needed to establish why female patients have comparatively longer inpatient stays.

Nidhi Vivek¹, Mark Roussot²

¹Brighton and Sussex Medical School, Brighton, United Kingdom. ²University Hospitals Sussex NHS Trust, Brighton, United Kingdom

Abstract

Introduction: Femoral fragility fractures (FFFs) are a significant healthcare concern, with the incidence predicted to rise to 100,000 annually in the UK by 2033. Current secondary preventative strategies focus on the patient’s physical state – overlooking Hospital-associated Deconditioning (HAD), the decline in patient wellbeing post-admission. To prevent HAD, a ‘Games Area’ (GA) was introduced in December 2023 as a service improvement. This study evaluates the GA’s effectiveness in preventing HAD, by assessing patient satisfaction.

Method: We evaluated all patients aged 65yrs or more during their post-operative rehabilitation for their FFF who were deemed fully weight-bearing and medically ready for discharge. The control group received the standard care provided by the ward’s multidisciplinary team, while the GA group also had access to the GA, where patients were encouraged to participate in activities with fellow inpatients. Activities included colouring, jigsaw puzzles and wordsearches. Data were collected via weekly questionnaires and medical records.

Results: Overall, 75 patients participated (38 in the control group, and 37 in the GA group). Patients in the GA group reported higher satisfaction ratings, with a mean score of 3.01 (SD = 0.406) out of 5, while the control group’s mean was 1.83 (SD = 0.279). 

Conclusion: The GA acts as a simple, cost-effective intervention that can mitigate HAD by enriching the ward environment – hence, enhancing patient experience, and may improve patients’ physical, mental, and emotional health. 

Oliver Mann¹, Oday Al-Dadah^1,2

¹South Tyneside District Hospital, South Shields, United Kingdom. ²Newcastle University, Newcastle upon-Tyne, United Kingdom

Abstract

Background: Anterior cruciate ligament (ACL) rupture is a debilitating condition and often requires surgery to restore joint stability. Patient reported outcome measures (PROMs) can be used to assess knee function following ACL reconstruction. Outcomes from this type of surgery are thought to be influenced by demographic factors such as age. The aim of this study was to evaluate the influence of age on early to mid-term clinical outcomes following ACL reconstruction.  

 Methods: Six PROMs were collected before and after ACL reconstruction which included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), Lysholm, Tegner, EQ-5D-5L, and Short Form 12-item Health Survey. PROMs were compared between the Younger Group (<40 years) and the Older Group (≥40 years). The data was also analysed to assess for any correlations between age and post-operative PROMs.

Results: A total of 87 patients were included in the study with a mean post-operative follow-up of 2.3 years (range 1 to 7 years). Pre-operatively, the Younger Group had significantly better KOOS pain (p=0.007), KOOS ADL (p<0.001), KOOS overall (p=0.017), IKDC (p=0.005), Lysholm (p=0.015), Tegner (p<0.001) and SF-12 PCS (p=0.001) as compared to the Older Group. However, post-operatively only the Tegner (p<0.001) was significantly better in the Younger group, whilst all other scores were comparable. Overall, PROMs had very little correlation with age following surgery. 

Conclusion: Older patients with ACL instability have just as much to gain as younger patients from surgical intervention. Therefore, age should not be a contra-indication to ACL reconstruction.

Lucas Ho¹, Benjamin Ford¹, Paul Gaston², Nick Clement²

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

Abstract

Introduction: The primary aim was to assess whether a Total Hip Arthroplasty (THA) was able to restore health-related quality of life (HRQoL) following an intracapsular hip fracture. The secondary aims were to assess changes in hip-specific function, fitness/frailty, mortality risk, complication and revision risk, and factors independently associated with these.

Methods: This retrospective cohort study included all patients aged ≥50 years admitted with a hip fracture from the emergency department at a single centre during a 42-month period. Patient demographics, perioperative variables, complications, revision, and mortality were collected. Patient-reported outcomes measures (PROMs) were assessed at final follow-up.

Results: Among 250 identified patients, 189 (75.6%) were female with a mean age of 70.3 (range 50 to 94 years). Mean follow-up was 2.3 (SD 1.1) years. Older age (Hazard Ratio (HR) 1.22, 95% CI 1.12 to 1.33, p<0.001) and male sex (HR 3.33, 95% CI 1.15 to 10.0, p=0.026) were independently associated with mortality. There were 19 (7.6%) postoperative complications of which there were 6 (2.4%) periprosthetic fractures, 5 (2.0%) deep infections, and 8 (3.2%) dislocations, of which 13 underwent revision. Increasing time to theatre (HR 1.02, 95% CI 1.01 to 1.03, p=0.017) was independently associated with a postoperative complication. Postoperative PROMs were available for 166 patients. There was a significant (p<0.001) deterioration in EuroQol-5D (Mean Difference (MD) 0.192, 95% CI 0.133 to 0.252), Oxford hip score (MD 2.5, 95% CI 1.5 to 3.6), and fitness (Rockwood score MD 0.7 95% CI 0.5 to 0.8) relative to preoperative levels of function. 

Conclusion: THA may be the treatment of choice in a physically active patient with the aim of restoring their HRQoL, hip function, and fitness but this was not observed. Furthermore, there was a high complication rate which was associated with increasing time to theatre.

Tim Dwyer¹, Erin Gordey¹, Prabjit Ajrawat¹, Darius Lameire¹, John Theodoropoulos^1,2, Darrell Ogilvie-Harris¹, Guy Faulkner³, Catherine Sabiston³, Jaskarndip Chahal¹

¹University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, toronto, Canada. ²Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, toronto, Canada. ³Faculty of Kinesiology & Physical Education, University of Toronto, toronto, Canada

Abstract

Background: Wearable activity-measurement devices are increasingly popular but there is little information regarding their use in patients undergoing orthopaedic procedures. The purpose of this study was to assess accelerometer-measured data after surgery and to compare these values to patient-reported measures.

Methods: Adult patients undergoing ACL reconstruction were included. The Tegner activity scale, Marx activity scale, IPAQ-SF, KOOS, and EuroQol 5D were administered pre-operatively and at three, six, and 12 months post-operatively. At these intervals, each participant was asked to wear an Actigraph GT3X triaxial accelerometer for seven consecutive days. Time spent in moderate-to-vigorous physical activity (MVPA min/week), metabolic equivalents of physical activity (MET-min/week), and average daily steps were calculated from the accelerometer and correlated with questionnaires.

Results: Eighteen patients (mean age 30 years; 43% female) completed the 12-month assessment. Significant improvements over time were seen in the Tegner scale, KOOS symptoms, KOOS Sports / Rec, KOOS QOL, and IPAQ-SF MVPA/week (minutes).  There were also non-statistically significant improvements in all accelerometer measurements at the final follow-up. Preoperatively, 3/18 (17%) of patients met the 10,000 steps/day recommendations and at 12 months postoperatively 6/18 (33)% of patients met this guideline.  Preoperatively, 15/18 (83%) met the minimum 150 MVPA min/week recommendations, while postoperatively 17/18 (94%) met the minimum requirement. At six months post-operatively, a moderate correlation was observed between accelerometer MVPA/week and the Tegner activity scale (r=0.74, p=0.004). At 12 months, there was a moderate correlation between the accelerometer MVPA/week and the Marx activity scale (r=0.5, p=0.04).  

Conclusion: Accelerometers may be a useful tool in understanding patients’ activity levels at different time points during their recovery, and to provide tangible targets for patients to achieve post-operatively. Larger patient cohorts are required in creating recommendations for activity levels and determining possible correlations with post-operative activity and return to sport. 

A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Fauzaan Syed¹, Hamzah Amin¹, Biju Bejamin², Michiel Hendrix², Terence Savaridas²

¹Lancaster Medical School, Lancaster, United Kingdom. ²NHS Forth Valley, Falkirk, United Kingdom

Abstract

Introduction: Venous Thromboembolisms (VTE), comprising of Deep Vein Thrombosis (DVT) and Pulmonary Embolisms (PE) are common post operative complications post Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA). Recent studies suggest the use of Aspirin as effective prevention of VTE after major orthopaedic surgery, however it is not currently licensed for this indication. The aim of this meta-analysis is to compare Randomised Controlled Trials (RCTs) which look at Aspirin versus the current guideline recommended drug (Direct Oral Anticoagulants-DOACs) for operative VTE prophylaxis specifically after THA and TKA.

Methods: A sensitive search strategy of the MEDLINE and EMBASE databases, using Boolean operators, was conducted. Only RCTs from 01/01/2017 to 26/11/2023 were included. Applicable studies were identified by two independent reviewers. Data was then extracted and meta-analysed using the Cochrane REVMAN software.

Results: 7 RCTs comprising of 3967 patients were included. Rivaroxaban was the only DOAC used. The Aspirin dosage was between 100mg to 300mg, and a consistent Rivaroxaban dose (10mg OD) was used. Analyses showed no significant differences in the incidence of VTE (P=0.47), PE (P=0.99), asymptomatic DVT (P=0.41) and suspected DVT (P=0.77), between groups. Major bleeding (P=0.40) and minor bleeding (P=0.40) instances were also not different between groups.  Bias levels were relatively low across studies.

Discussion: To our knowledge this is the only review that solely includes RCTs for post TKA & THA VTE prophylaxis. Our stringent inclusion criteria strengthen our finding that aspirin is as effective as rivaroxaban for primary thromboprophylaxis post-THA & TKA, without increased incidence of complications. Further research is needed to determine the optimal dosing regimen of aspirin, as current studies employ various approaches with differing doses and drug combinations. Aspirin should be considered a safe and cost-effective alternative to rivaroxaban. 

Charles H.T. Norrish¹, Devan S. Wasan¹, Sam F. Turner¹, Chandra Pasapula²

¹Imperial College School of Medicine, London, United Kingdom. ²The Queen Elizabeth Hospital King's Lynn NHS Hospital Trust, King's Lynn, United Kingdom

Abstract

Introduction: Altered foot biomechanics, including midfoot instability and/or a valgus hindfoot, may increase strain on the Achilles tendon, a risk factor for the development of Achilles tendonitis (AT). This study aims to identify whether in-shoe orthotics designed to correct foot biomechanics aid the prevention of AT and improve outcomes for those with AT.

Methods: This study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.  For the prevention arm of the study, the prevalence of AT within the study period was compared between controls and those with in-shoe orthotics by Odds Ratio (OR).  For the treatment efficacy arm, the Standardised Mean Difference (SMD) of clinical outcome scores was compared between the control and in-shoe orthotic groups.  Both arms used a random effects model, with significance set at p < .05 and 95% confidence intervals (CI).

Results: In total, 6 studies were included for quantitative analysis, with a total of 3442 patients.   In the prevention arm, there were 3 studies with 3201 patients.  The in-shoe orthotic group were significantly more likely to develop AT than controls in the 12–32-week study period (OR -0.73, 95% CI -1.05 to -0.41, p<.001).   In the treatment efficacy arm, there were 3 studies with 4 comparable outcomes (Short form (SF)-36 physical functioning, SF-36 bodily pain, Victorian Institute of Sport Assessment (VISA-) Achilles (A) scores.  Treatment with in-shoe orthotics did not improve the outcomes for those with AT at 12 weeks (SMD 0.237, 95% CI -0.107 to 0.344, p=0.304).

Conclusions: In-shoe orthotics increase the prevalence of AT in individuals at risk (e.g., military recruits) compared to controls. The symptoms of AT are not improved using in-shoe orthotics over a 12-week treatment period.

Impact: In-shoe orthotics cannot be recommended to prevent or treat Achilles Tendonitis.

...worsening joint specific function, health related quality of life, and personal wellbeing and increased use of opioid analgesia

Nicholas David Clement¹, Ruth Duthie², Liam Yapp¹, Deborah MacDonald³, Chloe Scott¹

¹Edinburgh Orthopaedics, Edinburgh, United Kingdom. ²Glasgow Medical School, Glasgow, United Kingdom. ³Edinburgh University, Edinburgh, United Kingdom

Abstract

Background: It is not known whether chronic knee pain (CKP) influences health related quality of life (HRQoL), knee specific health or wellbeing, and use of opioid analgesia in patients awaiting knee arthroplasty. 

Methods: This study included 217 patients (mean age 69.7-years, 116 [53%] female) who completed questionnaires that included EuroQol (EQ-5D and EQ-VAS), Oxford knee score (OKS), and wellbeing assessment at 6- and 12-months after being listed for surgery. Analgesia use at 12-months was also recorded. CKP was defined as an OKS pain score (PS) of ≤14 at 12-months.

Results: At 12 months 169 (77.9%) patients had CKP. CKP was associated with a clinically meaningfully worse knee specific health and HRQoL at 12-months and were more likely to have a health state worse than death (odds ratio (OR) 29.7, 95% confidence intervals (CI) 4.0to220.2, p<0.001). The CKP group were more likely to use weak (OR 3.03, 95%CI 1.65 to 7.96, p=0.001) and strong (OR 11.8, 95%CI 1.58 to 88.88, p=0.001) opioids for analgesia. The CKP group had worse overall wellbeing with significantly (p<0.001) lower satisfaction with life, life being worthwhile and happiness, and increased anxiety. The CKP group had a significant (p<0.001) deterioration in their OKS, OKS-PS, EQ-5D, and EQ-VAS from 6- to 12-months which was not observed in the group without CKP. A worse OKS-PS at 6-months was independently associated with an increased risk of CKP and a threshold value of <13 (sensitivity 91.7%, specificity 94.7%) was an excellent discriminator (AUC 96.9, 95%CI 94.2 to 99.6, p<0.001).

Conclusion: Four-in-five patients had CKP after waiting 12-months for their surgery and this  was associated with significant deteriorations in HRQoL and knee health and wellbeing, and increased opioid analgesia use. 

Implications: The OKS-PS at 6-months could be used to identify patients at risk of CKP after 12-months of waiting.

Macy Banks¹, Beth Fishwick¹, Lee Hoggett², Charlotte Cross²

¹University of Manchester, MANCHESTER, United Kingdom. ²Lancshire Teaching Hospitals, Preston, United Kingdom

Abstract

Background: Anterior femoral notching has been hypothesised to predispose to early supracondylar periprosthetic fracture (PPF) in the early post operative period. The long-term consequences of femoral notching and subsequent PPF has not been reported in the literature. We aimed to assess whether anterior notching influenced with long term PPF risk.

Method: Retrospective cohort study of 500 total knee replacements. Baseline demographics and operative data were collected from the electronic patient record. Tayside classification was used to grade the severity of femoral notching on post operative lateral radiographs. PPF rate was determined using the regional PACS network. 

Results: 500 TKR were assessed with minimum follow up of 12 years (144-171 months). Mean age 68 (34-99) years. 298 (60%) female. Most common indication for surgery was primary OA 458 (92%). All cases used anterior referencing. Notching occurred in 120 (24%) cases. 79 (15%) grade 1, 38 (8%) grade 2, 3 (0.1%) grade 3. A PPF occurred in 3 cases (0.01%) at 5, 11 and 14 years with one case having grade 1 femoral notching. Two cases were treated with ORIF and one with amputation. No relationship was observed between patients sustaining PPF and those with anterior femoral notching (p=0.55). 43 (8%) cases had a further procedure in the study period of which 9 (2%) cases were revised.

Conclusion: Anterior femoral notching occurs in around a quarter of cases despite the use of anterior referencing. Concerns regarding anterior notching causing periprosthetic fracture appear to be unfounded and no relationship is seen between minimal femoral notching and supracondylar fracture. This is the case with a minimum of 12 years follow up and overall PPF risk is very low.

Implications: Mild anterior femoral notching does not influence risk of supracondylar fracture.

Jamila Tukur Jido¹, Paul Rodham², Vasilis Giannoudis², Adrian Andronic², Paul Harwood²

¹Univeristy of leeds, Leeds, United Kingdom. ²Leeds teaching hospital, Leeds, United Kingdom

Abstract

Background: Routine radiographs in the follow-up of circular frames is commonplace, however the effect on clinical decision making is unclear. Previous work locally has suggested that >95% of radiographs, particularly at early time points, do not affect clinical management. This study was conducted to assess the impact of a transition to early remote follow-up on circular frame patients with limited radiographic assessment.

Methods: Patients were identified from a prospective limb reconstruction database. Data were collected including the number of clinic appointments, type of clinic appointment, number of radiographs performed, and impact this had on clinical management. This was compared to our previous cohort of 79 patients undergoing standard follow-up.

Results: Twenty-nine patients were eligible for inclusion in Phase 2 of the study, with a mean age of 48 (range 22-78) years. Circular frames were primarily indicated for trauma (27 patients) and limb reconstruction (2 patients). Following the implementation of remote follow-up, the median number of face-to-face appointments decreased from 6 to 3 until frame removal. Only one case necessitated conversion from telephone to face-to-face follow-up due to hardware failure. The number of radiographs obtained during treatment decreased substantially, with a median of 25 in Phase 1 compared to 10 in Phase 2 (range 8-77). Data collection for 40 more paitents is ongoing. Adverse events were observed in 20 patients, primarily categorised as problems or obstacles according to the Paley classification. These included 13 cases of pin-site infections and 7 instances of broken wires. Notably, 96% of adverse events were manageable without significant intervention.

Conclusions: Remote follow-up of circular frame patients was associated with significantly fewer radiographs and face-to-face appointments, without significantly increasing complications. We believe this is a safe and effective method of follow-up, optimising resource use in line with the NHS long term plan.  

Maria Gonsalves¹, Kaobimdi Okongwu², Romir Patel¹, Sabri Bleibleh², Akash Sharma²

¹University of Birmingham, Birmingham, United Kingdom. ²The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom

Abstract

Background: Total hip, total knee and unicompartmental knee arthroplasty (THA, TKA and UKA) have exhibited disparities in length of stay (LoS) between White patients and Black, Asian and Minority ethnic (BAME) patients in the literature. We aimed to assess whether there is a significant disparity in LoS between White and BAME patients undergoing THA, TKA and UKA, and to explore whether the level of English proficiency contributes to this. 

Methods: Data collection was obtained between October 2023 and April 2024. Patients coded on the hospital database as having undergone THA, TKA or UKA were identified as either White or BAME, and their LoS recorded. As per the hospital policy, the anticipated LoS for primary THA and TKA is 1-2 days. For BAME patients with an increased LoS (≥3 days), we also documented whether a translator was used during consultations and consent taking. 

Results: A total of 769 patients (THA, n = 365; TKA, n = 367, UKA, n = 37) were reviewed, with 694 (90.25%) of the patients identified as White. The mean LoS was not significantly shorter for White patients compared to BAME patients for THA (3.36 vs. 4.10, p = 0.177), but was significantly shorter for TKA (3.47 vs. 4.44, p = 0.018) and UKA (2.33 vs. 4.00, p = 0.038). None of the THA and UKA patients required a translator. However, for TKA, 6 out of the 50 BAME patients required a translator, and all these patients required a hospital stay of ≥3 days.

Conclusion: BAME patients undergoing lower limb arthroplasty procedures experience prolonged LoS compared to their White counterparts, especially when a translator is required. Significant differences were observed in TKA and UKA patients. Future strategies to reduce LoS should include patient and their relative’s education on LoS and discharge disposition. 

Jessica Larwood, Waseem Hasan, Richard Connell, Alexander Aarvold

University Hospitals Southampton, Southampton, United Kingdom

Abstract

Background: To explore whether a broken Shenton’s line does truly indicate underlying pathology in children with developmental dysplasia of the hip (DDH). 

Methods: Data was collected prospectively on all babies treated in Pavlik harness at our children’s hospital over an 18-month time frame. Babies were included in the study if they were clinically and radiologically normal at 5 years of age and had had anterior-posterior radiographs available from three time points: 1, 2, and 5 years of age. 

Results: There were 101 children (170 hips) with full imaging available for inclusion in this study. 69 (69%) of these children had a broken Shenton’s line(s) on radiographs at 1 year of age, 62 (61%) at 2 years of age, and 36 (35%) at 5 years of age, despite all children being clinically and otherwise radiologically normal. All other radiological parameters were within normal range.  A broken Shenton’s line was also seen in the contralateral, non-diseased hip of 30 (94%) of the 32 children with unilateral DDH, at one or more time point. 

Conclusion: Using Shenton’s line to interpret normality or pathology in paediatric hips is no better than flipping a coin. It should be interpreted with caution in the radiological assessment of children with DDH. A broken Shenton’s line appears to be a normal radiological variant in this age group. 

Adam Galloway^1,2, Heidi Siddle², Anthony Redmond², Colin Holton¹, Daniel Perry³, David Keene⁴, Suzanne Richards²

¹Leeds Children's Hospital, Leeds, United Kingdom. ²University of Leeds, Leeds, United Kingdom. ³Alder Hey Children's Hospital NHS Trust, Liverpool, United Kingdom. ⁴University of Exeter, Exeter, United Kingdom

Abstract

Aims: The study sought to produce clinical consensus recommendations regarding non-surgical treatments in Perthes’ Disease. The recommendations are intended to support clinical practice in a condition for which no robust evidence exists

Methods: A two-round, modified Delphi study was conducted online. An advisory group of children’s orthopaedic specialists designed a survey. In round one, participants also had the opportunity to suggest new statements. The survey included statements related to ‘Exercises’, ‘Physical activity’, ‘Education/information sharing’, ‘Input from other services’ and ‘Monitoring assessments’. The survey was shared with clinicians who regularly treat children with Perthes’ Disease in the UK via clinically relevant specialist groups and social media. A pre-determined threshold of ³75% consensus was used for a clinical consensus recommendation, with a threshold between 70-75% considered ‘points to consider’.

Results: Forty participants took part in round one of the Delphi study, of whom 31 completed the second round. Eighty-seven statements were generated by the survey advisory group and included in round one. At the end of round one, 31 statements achieved clinical consensus and were removed from the survey and an additional four statements were generated. Sixty statements were included in round two of the Delphi study. A total of 45 statements achieved the threshold for clinical consensus across the two rounds, with three achieving the threshold for points to consider. Recommendations predominantly include self-management, particularly relating to exercise advice and education for children with Perthes’ Disease and their families.

Conclusion: Children’s orthopaedic specialists have reached consensus on recommendations for non-surgical treatments in Perthes’ Disease. The statements will support decisions made in clinical practice and act as a foundation to support clinicians in the absence of robust evidence. The dissemination of these findings and the best way of delivering this care needs careful consideration and future research is exploring this. 

Ben Doughty, Nia Mckay, Rachel Grayson, Michael Stoddart, William Levitt, John Jeffery, Simon Thomas

Bristol Royal Hospital for Children, Bristol, United Kingdom

Abstract

Background: Both bone forearm fractures are a common Paediatric Orthopaedic injury. One surgical solution is the use of Elastic Stable Intramedullary Nailing (ESIN). There is varying practice surrounding pre-bending prior to insertion, despite manufacturers’ guidance. We report on our experience of 65 patients treated with elastic nails. 

Methods: A retrospective cohort analysis study was undertaken of all patients presenting to Bristol Royal Hospital for Children who underwent ESIN for both bone forearm fractures (AO class 22-D) from 2016 - 2021. The primary outcome measure was radiological malunion, whilst secondary outcomes were time to radiological union and time to achieve full range of pro-supination. Statistical significance was set at p<0.05. 

Results: We identified 65 patients (mean age 10.2 years S.D. +/- 2.6), where 19 patients received a pre-bent ESIN whilst 46 patients did not. There was no incidence of fracture displacement in either cohort. Median time to radiological union across both cohorts was 150 days (IQR 118.0). There was no statistically significant difference in time to union between either cohort, pre-bent 141 days (IQR 99.5) versus unbent 153 days (IQR 130.0) (p>0.05). Median time to achieve full ROM across both cohorts was 83 days (IQR 94.0). There was no statistically significant difference in time to achieve ROM between either cohort, pre-bent 125 days (IQR 104.5) versus unbent 81 days (IQR 76.0) (p>0.05).  

Conclusion: In our cohort, the use of unbent nails had no statistically significant impact on rates of radiological malunion, time to radiological union or time to achieve full pro-supination. Our study lends weight to recent literature that bending of nails has little impact on post-operative outcomes for paediatric forearm fractures. Given these results, we are expanding the scope of the cohort, with a view to further substantiate our findings. 

Christopher Marusza, Zakirnaseem Haider, Daniel Fontannaz, Kelvin Miu, Deborah Eastwood

Great Ormond Street Hospital, London, United Kingdom

Abstract

Background: X linked hypophosphataemic (XLH) rickets is the commonest inherited form of rickets. Children often present with lower limb deformities. Burosumab, approved in 2018 for the treatment of XLH is now the preferred medical treatment. We report the use of hemi-epiphysiodesis in XLH patients pre and post introduction of Burosumab. 

Methods: XLH patients referred to orthopaedics since 2005 were reviewed. Hemi-epiphysiodesis was undertaken if there was progressive mechanical axis deviation after one year of medical treatment. Rate of correction of deformity per month (RoC) was calculated from standing radiographs using Traumacad.

Results: Since 2005, 28 patients were seen by orthopaedics. 16 patients required guided growth (27 limbs). Mean age 10.2 (4.3–14.7) years. Mechanical axis was restored in 13/27 (48%) limbs: a further 7/27 (26%) improved. Mean follow-up was 65 (9 – 154) months. 4 limbs underwent an osteotomy. RoC with hemi-epiphysiodesis was 0.49° for the distal femur and 0.26° for the proximal tibia. Diaphyseal deformity RoC was 0.39° in the femur and 0.18° in the tibia. Younger patients (≥ 3 years of growth remaining) corrected at a greater rate than older patients. 38 patients commenced Burosumab treatment, 4 were referred to orthopaedics. 14 patients (28 limbs) had radiographs available for analysis, mean age 7.8 (0.5 – 14.5) years. Follow-up 31 (5-53) months. RoC with Burosumab was 0.21° for the distal femur, 0.15° proximal tibia, 0.18° for femoral deformity and 0.17° tibial diaphyseal deformity. 11 limbs achieved a correction to mechanical axis, 7 maintained.  Hemi-epiphysiodesis provided greater improvement than Burosumab for correction of the distal femur but no significance in other measurements. No patient on Burosumab has required surgery. 

Conclusion: This confirms that hemi-epiphysiodesis is effective in correcting lower limb deformity. Burosumab alone demonstrates similar improvement.

Implications: Burosumab treatment of XLH improves deformity and reduces the need for surgery.  

Arwel Poacher¹, Owain Ellis², Joesph Froud³, Amy Smith⁴, Mohamed Abdelrazek⁵, Gregor Ramage⁴, Lily Scourfield⁶, Hari Bhanchoo¹, Clare Carpenter⁴

¹Cardiff University, Cardiff, United Kingdom. ²West Yorkshire Integrated Care Board, Leeds, United Kingdom. ³Guys and St Thomas Trust, London, United Kingdom. ⁴Cardiff and Vale University Health Board, Cardiff, United Kingdom. ⁵Severen Deanery, Bristol, United Kingdom. ⁶Kings College London, London, United Kingdom

Abstract

Introduction: There is a well-documented association between socioeconomic status and worse health outcomes. However, there is no evidence of the impact of socioeconomic factors on the screening efficacy and management outcomes of developmental dysplasia of the hip (DDH). This study aims to investigate the relationship between socioeconomic status and screening programme effectiveness and treatment outcomes.

Methods: This study utilised routinely collected multi-centre registry data of all live births within Wales between 2011 and 2020 (n=104,631). Cases of pathological DDH (Grade 2b-4) identified by the screening programme (diagnosis <12 weeks of age), were compared against those with late presenting cases (diagnosis >24 weeks of age). The socioeconomic status of these groups was compared using the Welsh Index of Multiple Deprivation and compared statistically using multivariate logistical regression and odds ratio. 

Results: There was a statistically significant association between the rates of missed DDH cases and overall deprivation (p<0.001) other factors including household income, employment, health and education scores were also associated with (p<0.001). There is no statistically significant impact of deprivation (p=0.789) on the outcome of conservative interventions.

Conclusions: In conclusion, those who live in more deprived areas are more likely to have a late diagnosis of DDH, principally when the deprivation is related to employment and education, but not access to medical services. This early data identifies demographic factors which put infants at higher risk of the morbidity associated with a late DDH diagnosis, however, further research is needed to fully understand the issues effective interventions. 

Mohammed Shaath, Shady Mahmoud, Ariadni Papadopoulou, Christine DOuglas, Penina Edel, Aresh Hashemi-Nejad, Neil Segaren

Royal National Orthopaedic Hospital, London, United Kingdom

Abstract

Introduction: The management of IHDI 2 hips following “successful” Pavlik harness treatment is controversial with no consensus. Treatment includes Active Monitoring, Abduction Bracing, Abduction Casting or Closed Reduction. 

Aim: To assess the remodelling potential of IHDI grade 2 hips (Identified at 6 months old) following “successful” Pavlik harness treatment, and outcomes of subsequent treatment modalities.

Methods: Retrospective cohort study included children diagnosed with DDH treated with a Pavlik harness between 2015- 2018 at the RNOH. We included hips graded IHDI 2 on their 6 months follow up X-ray and excluded neuromuscular, syndromic or genetic conditions with abnormal tone and those lost to follow up. Demographics, treatments and radiographs (Acetabular Index, IHDI grade and Shenton's line) were reviewed at different age groups: 6 months, 12-24 months, and 3-5 years. Radiographs were analysed by two fellowship trained paediatric orthopaedic surgeons.

Results: 58 IHDI 2 hips were included from a database of 424. Treatment modalities included : active monitoring (N=37, 63.8%%) abduction brace N=(12, 20.6%), abduction casting (N=3, 5.2%) and closed reduction (N=6, 10.4%). 57/58 (98.3%) hips improved to IHDI 1 at the final follow up regardless of treatment modality (1 diagnosed late with ipsilateral tibial hemimelia). 26/58 (44.8%) normalised to IHDI 1 after 12-24 months. 15.5% (9/58) had an Acetabular Index >25° at final follow up. Shenton's line was broken in 77.6% of X-rays at 6 months, improving to 12% at final follow up. 

Conclusion: 98.3% of hips improved to IHDI 1 regardless of treatment modality. 44.8% normalised to IHDI 1 after 12-24 months.We therefore feel Active Monitoring for residual IHDI 2 hips following “successful” Pavlik Harness treatment is justifiable.                

Balakumar Balasubramanian, Ben Marson, Christopher Bache

Birmingham Children's Hospital, Birmingham, United Kingdom

Abstract

Objective: The purpose of this study is to evaluate the efficacy of the Modified Dunn osteotomy for the management of severe slipped capital femoral epiphysis in children through the Birmingham experience.

Methods: A retrospective analysis was conducted on 57 Modified Dunn osteotomy procedures performed on 56 children by the senior author between 2006 and 2019. The case notes were reviewed in April 2024 to determine arthroplasty-free survival rates, avascular necrosis rates, and other complications requiring return to theatre. The average age at the time of slip was 13.5 (SD 1.5) years.

Results: The median time to case notes review was 7.6 [IQR 10.3-13.1] years. The 5- and 10-year arthroplasty-free survival rates were 98.2 (95% CI 99.8-88.0%) and 94.9% (95% CI 98.8-80.2%), respectively. Out of the 57 procedures, two patients underwent hip replacements, one for AVN and the other for cartilage damage. During the 2-year clinical review, seven patients were diagnosed with avascular necrosis, resulting in an incidence rate of 12.3%. Two patients had labral tears, and two cases required additional surgery due to postoperative instability. Out of the 32 children without a simultaneous contralateral pin, 5 (15.6%) developed a contralateral SUFE treated with a pin in situ.

Conclusion: The Modified Dunn osteotomy is an effective technique for managing severe slipped capital femoral epiphysis in children, offering reliable hip preservation outcomes. However, there is a 15% risk of contralateral slip in children. The 5- and 10-year arthroplasty-free survival rates were found to be high, indicating that the Modified Dunn osteotomy is a viable option for treating this condition. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these results.

Abhinav Singh¹, Allison Clement¹, William Wynell-Mayow², Daniel Perry³, Deborah Eastwood⁴, Irina Voiculescu¹

¹University of Oxford, Oxford, United Kingdom. ²Imperial College Healthcare NHS Trust, London, United Kingdom. ³University of Liverpool, Liverpool, United Kingdom. ⁴Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom

Abstract

Background: The UK screening programme has not improved early detection of developmental dysplasia of the hip (DDH) since 1986. Artificial Intelligence (AI) methods show reasonable performance in calculating Graf angles and diagnostic class from predicted anatomical landmarks. This study evaluated AI’s performance after training it on additional diagnostic data alongside labelled images.

Methods: Our study utilised two routine anonymised datasets containing hip ultrasound 2D images from babies aged 4-12 weeks. Dataset A (DA) had 516 images from 397 babies from one hospital and dataset B (DB) had 50 images from 34 babies from a different hospital. Two clinicians (X and Y) labelled the five anatomical landmarks which represent the ilium (1^st and 2^nd points), turning point (3^rd), lower limb (4^th) and labrum (5^th). Labelled images were quality-checked by two different blinded senior clinicians before inclusion. The AI model was trained with both landmarks and weighted diagnostic data. Its output was the alpha angle and Graf class (centred or decentred). The performance between clinicians (X vs Y) and AI vs clinician X were measured.

Results: For the DA test dataset (n=77), the best-performing model predicted alpha to within 2 degrees of the clinician more frequently (81.9%) than when clinicians (X vs Y) were compared to each other (33.2%). This performance was maintained on the smaller (n=50) external DB dataset (93.7%). The AI’s prediction of the Graf class was also superior to the clinician on both DA (90.2% sensitivity, 66.7% specificity) and DB (93% sensitivity, 80% specificity).

Conclusions: Our AI model outperformed clinicians in generating the alpha angles and Graf class on both datasets. Additional diagnostic data may allow the model to better understand the relationship between anatomical landmarks. 

Implications: When translated into the clinical setting, this method will improve the accuracy and objectivity of DDH screening.

Rohan Prakash¹, Ahmed Nasser², Akshat Sharma², Deborah Eastwood³, Mike Reed⁴, Yuvraj Agrawal¹

¹Royal Orthopaedic Hospital, Birmingham, United Kingdom. ²The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom. ³Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom. ⁴Northumbria Healthcare NHS Foundation Trust, Northumbria, United Kingdom

Abstract

Background: Arthroplasty has been shown to generate the most waste amongst all orthopaedic subspecialties and it is estimated that hip and knee arthroplasty generate in excess of 3 million kg of waste annually in the UK. Infectious waste generates up to 10 times more CO2 compared with recycled waste, and previous studies have shown greater than 90% of waste in the infectious stream is misallocated. We assess the effect of real-time waste segregation by an unscrubbed team member on waste generation in knee and hip arthroplasty cases, and compare this with a simple educational intervention during the ‘team brief’ at the start of the operating list across 2 sites. 

Methods: Waste was categorised into 5 categories: infectious, general, recycling, sharps and linens. Each category was weighed at the end of each case using a digital weighing scale. At Site A (a tertiary orthopaedic hospital) pre-intervention data were collected for 16 TKA and 15 THA cases. Subsequently for 10 TKA and 10 THA cases, a non-scrubbed team member actively segregated waste in real-time into the correct streams. At Site B (a district general hospital), both pre- and post-intervention groups included 10 TKA and 10 THA cases. The intervention included reminding staff during the ‘team brief’ to segregate waste correctly.  

Results: Active real-time waste segregation reduced infectious waste by a mean of 2.51kg in TKA, and 1.83kg in THA cases (p<0.05). Educational intervention reduced infectious waste by 3.52kg in TKA and 2.09kg in THA cases (p<0.05). Total waste was significantly reduced in both groups post-intervention for TKA cases.

Conclusion: Simple educational measures alone can significantly reduce the amount of infectious waste. Extrapolated nationally our results would yield a reduction of approximately 315004 – 594577 kg of CO2 annually, which equates to 70-132 gasoline-powered passenger vehicles driven for a year. 

David Wong¹, Ethan Allen¹, James Loader¹, Nyi Tun San², David Bowrey²

¹Leicester Medical School, Leicester, United Kingdom. ²University Hospitals Leicester, Leicester, United Kingdom

Abstract

Background: Shared decision-making and consent are fundamental to good medical practice. St. John et al. (2022) suggests digital consent may enhance shared decision-making. The importance of shared decision-making (SDM) for informed consent has been emphasised in the updated regulatory guidelines. Digital consenting software, Concentric®️, was introduced to University Hospitals Leicester, in May 2022. However, its adoption within the orthopaedic team varies. Commissioning for Quality and Innovation (CQUIN) states that the shared-decision making score should be maintained at 75%.

Methods: 98 patients who underwent orthopaedic procedures were included in this study. Patients consented by either a paper or Concentric®️ digital consent form. A validated shared decision-making questionnaire (SDMQ-9) with a 6-point Likert scale was used during the patient interviews, and score ranges were transformed to intuitive percentage score. We aimed for a comparable distribution between trauma and elective patients to ensure a representative sample. Data was pseudo-anonymised to ensure confidentiality. Inclusion criteria were as follows: Post-operative patients who had either digital or paper consent, consented operation performed on current admission. 

Results: Among the 98 patients interviewed. Digital consent was used in 47 patients (23 elective and 24 trauma) and paper consent was used in 51 patients (25 elective and 26 trauma). Overall, patients who consented digitally, achieved a higher mean score of 95%, while those who consented with paper had an average score of 74%. Further analysis shows, in trauma patients, patients who consented digitally achieved 95%, compared to 71% for paper consent. And in elective patients, those who consented digitally achieved 95%, compared to 77% for paper consent. The Mann-Whitney U Test highlighted a significant difference with p-value <0.5. 

Conclusions: This study indicates that digital consent positively impacts shared decision-making quality, as the scores meet the CQUIN standards in elective and trauma cases, suggesting potential advantages over traditional paper consent.

Adam Ali, Shiraz Sabah, Joe Dixon, Alex Shearman, Andrew Price, Abtin Alvand

Nuffield Orthopaedic Centre, Oxford, United Kingdom

Abstract

Background: Understanding the determinants of Length of Stay (LOS) after Revision Knee Replacement (RKR) is important to enable effective service planning within revision networks and when counselling patients. The Revision Knee Complexity Classification (RKCC) is an established method for categorising RKR, but its correlation with LOS is unclear.

Methods: We calculated LOS for all RKRs over a 4-year period at our hospital, a major revision centre, together with a range of patient- and procedure-related variables. We identified independent predictors of LOS using multiple linear regression and compared median LOS for subgroups using Kruskal-Wallis analysis. 

Results: 684 RKRs were included in the analysis: 396 single stage procedures (62 for infection), 80 1^st stage for infection, 95 2^nd stage for infection, 111 DAIR. Across all RKRs, there was a significant association between increased LOS and patient age (p<0.01), male gender (p=0.04) and higher BMI (p=0.03). There was no significant difference in median LOS between single stage RKR for infection and 1^st stage RKR (14 vs 14.5 days, p=0.40). Median LOS for 2^nd stage revision= 10 days, DAIR= 11 days, aseptic loosening= 5 days. There was a moderate positive correlation between LOS for 1^st and 2^nd stage RKR where both procedures were performed at our centre (correlation coefficient= 0.33). For patients undergoing RKR, the RKCC was: RKCC1 (291= 42.5%), RKCC2 (181= 26.5%), RKCC3 (212= 31%). There was a strong association between RKCC and median LOS (RKCC1= 5 days, RKCC2= 9 days, RKCC3= 11 days; H-statistic= 96.7, p<0.00001).

Conclusions: RKCC is a strong predictor of LOS, with the greatest increase in LOS being seen at the transition from RKCC1 to RKCC2. There is no significant difference in LOS between single stage RKR and 1^st stage RKR performed for infection. 

Mustafa Alnaib^1,2, Irrum Afzal³, Sarkhell Radha^3,1

¹Croydon University Hospital, Croydon, United Kingdom. ²Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom. ³South West London Elective Orthopaedic Centre, London, United Kingdom

Abstract

As patient data continues to grow, the importance of efficient and precise analysis cannot be overstated. The employment of Generative Artificial Intelligence (AI), specifically Chat GPT-4, in the realm of medical data interpretation has been on the rise. However, its effectiveness in comparison to manual data analysis has been insufficiently investigated. 

 This quality improvement project aimed to evaluate the accuracy and time-efficiency of Generative AI (GPT-4) against manual data interpretation within extensive datasets pertaining to patients with orthopaedic injuries. 

A dataset, containing details of 6,562 orthopaedic trauma patients admitted to a district general hospital over a span of two years, was reviewed. Two researchers operated independently: one utilised GPT-4 for insights via prompts, while the other manually examined the identical dataset employing Microsoft Excel and IBM® SPSS® software. Both were blinded on each other's procedures and outcomes.  Each researcher answered 20 questions based on the dataset including injury details, age groups, injury specifics, activity trends and the duration taken to assess the data.

Upon comparison, both GPT-4 and the manual researcher achieved consistent results for19 out of the 20 questions (95% accuracy). After a subsequent review and refined prompts (prompt engineering) to GPT-4, the answer to the final question aligned with the manual researcher's findings. GPT-4 required just 30 minutes, a stark contrast to the manual researcher's 9-hour analytical duration. 

This quality improvement project emphasises the transformative potential of Generative AI in the domain of medical data analysis. GPT-4 not only paralleled the accuracy of manual analysis but also achieved this in significantly less time. For optimal accurate results, data analysis by AI can be enhanced through human oversight. Adopting AI-driven approaches, particularly in orthopaedic data interpretation, can enhance efficiency and ultimately improve patient care. We recommend future investigations on large and more varied datasets to reaffirm these outcomes. 

Reuben Johnson¹, Inderpal Samra², Nischay Keshava¹, Amit Yadav¹, Janam Merchant¹, Sunil Panchani¹

¹Wrightington Hospital, Wigan, United Kingdom. ²Royal Orthopaedic Hospital, Birmingham, United Kingdom

Abstract

Background: Increasing demand and financial burdens are placing significant strain on current health resources. There has been increased emphasis on improving patient flow and saving costs within the health service to help ease pressures. Routine postoperative blood tests in otherwise healthy patients may add to delays and healthcare costs without influencing subsequent management. Recent studies have demonstrated that routine postoperative blood tests may not be required for healthy elective patients. 

Methods: We conducted a retrospective review of 1595 consecutive elective hip and knee replacements in ASA 1 and ASA 2 patients at our institution over a 1-year period from 2021-2022. Operation notes and electronic databases were analyzed to collect data regarding demographics, co-morbidities, treatment, pre and post-operative blood tests and any documented interventions.  

Results: 1595 elective hip and knee replacements were included for analysis with 790 THR and 805 TKR. All cases were ASA 1 and 2 (164 ASA 1, 1431 ASA 2). Mean age was 66.4 +/- 10.8 (range 18-90 years). Overall, 5.0% (80/1595) patients had deviations from routine postoperative care influenced by routine blood tests. 0.69% (11/1595) patients required documented transfusions. 12 patients had severe hyponatraemia, 28 patients had moderate hyponatremia and 435 patients had mild hyponatremia. Only 44 patients were treated with fluid restriction and 5 required active oral treatment. Mean haemoglobin drop in TKR was 17.1g/L (+/- 19.2), whilst THR had a 17.7g/L (+/-38.2) reduction in Hb between pre and postoperative blood tests. Lower preoperative Hb levels were associated with Moderate Anaemia <10 (p<0.001) but did not predict transfusion requirement (p>0.05). 

Conclusions: Post-operative blood tests rarely influenced management in this cohort of patients with low post-operative intervention rates. Selective blood testing utilizing validated scoring systems may allow safe targeted testing in this low-risk cohort of patients minimizing costs and saving valuable resources.

Iain Rankin, James Dixon, Caitlin McGrane, Emma Macrae, Iain Stevenson

Aberdeen Royal Infirmary, Aberdeen, United Kingdom

Abstract

Background: The incidence and clinical significance of incidental findings identified on preoperative computerised tomography (CT) planning scans for hip and knee arthroplasty is not known. This study aimed to determine this within a single hip and knee arthroplasty unit.

Methods: A retrospective cohort study was performed for all patients that underwent CT planning scans for hip or knee arthroplasty at our institution over a 30-month period (Dec 2021 – May 2024). CT scan reports were reviewed and incidental findings noted. Incidental findings were graded into one of three categories: no action required, further action may be considered, urgent action required e.g. potential malignancy. Medical records were reviewed to ascertain if incidental findings were previously known to the patient and their primary healthcare provider.

Results: 1367 CT arthroplasty planning scans were identified over a 30-month period. A radiologist report was not provided in 42 (3%) cases, leaving 1325 available for further analysis. 560 (42%) incidental findings were noted, of which 231 (17%) were graded further action may be considered and 16 (1%) urgent action required. All patients identified as urgent action required received appropriate management.

Conclusions: Pre-operative CT arthroplasty planning scans have a high incidence (42%) of incidental findings, most of which most require no further management. A significant proportion (17%) of scans have incidental findings for which further action may be considered, whilst a small proportion (1%) have incidental findings for which urgent action is required. 

Implications: Pre-operative CT planning scans should receive a formal radiologist report due to the high incidence of significant incidental findings. In addition to providing operative information, CT planning scans may lead to treatment of conditions otherwise not known to the patient.

Kevin ilo, Ben Van Duren, Mark Higgins, Andrew Manktelow, Ben Bloch

Nottingham Elective Orthopaedic Services, Nottingham University Hospitals, Nottingham, United Kingdom

Abstract

Introduction: Total hip and knee arthroplasty, though highly successful, pose challenges to healthcare systems due to increasing demand, lengthy waiting lists and substantial financial burdens. This study explores the implementation of a short-stay pathway in an NHS hospital, aiming to assess its impact on length of stay, cost-effectiveness, and bed availability.

Methods: Conducted at Nottingham University Hospitals NHS Trust, the study introduced the Nottingham short-stay joint arthroplasty pathway in August 2023. The development of this innovative pathway for day-case surgery involved a multidisciplinary team of healthcare professionals. This collaborative effort was pivotal in ensuring a seamless and efficient implementation process, with the ultimate goal of streamlining surgical care and reducing the need for postoperative hospitalization. Data collection spanned 15 months, comparing pre and post-implementation phases, including length of stay, 30-day readmission rates, and cost-effectiveness.

Results: Post-implementation, the short-stay protocol significantly reduced the length of stay from 4.78 to 2.53 days, with a 14.14% discharged on day 0 and 57.17% by day 1. There was a  30-day readmission rate of 5.58% and 35.71% were for non-implant-related cases. There was no increase compared to pre-implementation of the short-stay protocol. Cost savings by eliminating routine post operative blood tests and reducing inpatient days would lead to a cost saving of £1,507,623.66 over a one year period

Conclusion: The short-stay pathway for hip and knee arthroplasty emerges as a safe, cost-effective, and patient-centric solution, offering significant financial savings and potential relief for winter bed pressures. Its successful integration showcases a commitment to efficient healthcare delivery and sets a precedent for future orthopaedic practices in the NHS, aligning with both patient preferences and the sustainability of healthcare systems.

Meet Vaghela^1,2, Daniel Benson³, Alexander Arbis³, Guy Selmon³, Benedict Rogers^4,2, Gareth Chan^4,2

¹Withybush General Hospital, Pembrokeshire, United Kingdom. ²Brighton and Sussex Medical School, Brighton, United Kingdom. ³East Sussex Hospitals NHS Trust, Eastbourne, United Kingdom. ⁴University Hospitals Sussex NHS Trust, Brighton, United Kingdom

Abstract

Background: The Nottingham Hip Fracture Score (NHFS) is a validated risk stratification tool used to predict mortality after fragility neck of femur fractures (NOF). Risk stratification is a useful adjunct in obtaining informed consent from patients/next of kin, the decision for peri-operative optimisation, and surgical case prioritisation. The NHFS is a reliable predictor of other fragility fractures at 30-days and 1-year post-injury. Fragility distal femur fractures (DFFs) occur in a comparable population to fragility NOFs with similar morbidity and mortality outcomes. Surgical treatment, akin to NOFs is often indicated in these patients to allow for early weight-bearing and mobilisation to reduce morbidity and mortality.

Methods: A multi-centre study of 3 high volume trauma units was performed via retrospective analysis of prospectively collected databases. Patients >60 years-of-age who presented with native and periprosthetic DFFs over 86 months between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Patients with an NHFS of >5 were classified as the ‘high-risk’ cohort, with all others considered ‘low-risk’

Results: 285 patients were eligible for inclusion, with 92 considered to be low-risk, and their mortality was 0% and 8.7% at 30-days and 1-year respectively. The 30-day and 1-year mortality in the high-risk cohort was 6.2% and 35.7% respectively. Receiver Operator Characteristic (ROC) curves demonstrated the greater sensitivity in predicting mortality in the high-risk cohort at 30-days with an area-under-curve of 0.718. The sensitivity of the score in predicting mortality decreased in the high-risk cohort at 1-year with an area-under-curve of 0.644.

Conclusions: The NHFS demonstrates a comparable sensitivity in predicting 30-day and 1-year mortality in fragility DFFs as seen with fragility NOFs. As such the NHFS should be used by surgeons and anaesthetists when consenting, risk-stratifying and optimising patients for surgery to identify high-risk patients early as suitable candidates for surgery.

Jennifer Lane^1,2, Usama Rahman^1,2, Alexios Iliadis², Hiba Junaid², Xavier Griffin^1,2

¹Barts Bone & Joint Health, Queen Mary University of London, London, United Kingdom. ²Barts Health, London, United Kingdom

Abstract

Background: NHS England has mandated development of secure data environments (SDEs) and recommending electronic healthcare data is translated into a common data format. This project aimed to identify if this common data format (observational medical outcomes partnership common data model- OMOP CDM) could be used to undertake clinically relevant research and audit at speed and scale.

Methods: Electronic healthcare data from 2010-2021 in a large multi-centre NHS trust covering 2.3 million patients was converted from Cerner Millennium into the OMOP CDM. Academic clinicians then established a Data Consult Service, where the orthopaedic department was asked to propose key studies in both research and audit that was most important to improve local patient care. The OMOP CDM translated dataset and associated software tools were then used to carry out the studies, with time to generate results and quality of results generated analysed. Study packages made were offered for replication at other NHS sites and international groups where data has also been converted to the OMOP CDM.

Results: The orthopaedic department proposed 6 studies in the areas of upper limb, lower limb, general trauma and elective reconstructive surgery to the data consult service in the first round. Once cohorts definitions of patients were made, software generated results in 1 minute 19 seconds -2 minutes 53 seconds with patient demographics, comorbidities, surgical procedures and devices associated included. Studies were replicated succesfully in 1 other NHS site, and 2 international orthopaedic centres. 

Conclusions: Rapid reproducible research and audit can be generated from routinely collected NHS data using the OMOP CDM and associated software platforms. New SDEs offer great possibilities for future orthopaedic studies that can be replicated across multiple sites. 

Implications: This work represents the first use of new technology to lead efficient, reproducible orthopaedic quality improvement. Future work focusses on using this for device surveillance. 

Luke Farrow^1,2, Nick Clement³, Diane Smith⁴, Dominic Meek⁵, Mandy Ryan¹, Katie Gillies¹, Lesley Anderson¹

¹University of Aberdeen, Aberdeen, United Kingdom. ²Grampian Orthopaedics, Aberdeen, United Kingdom. ³Royal Infirmary Edinburgh, Edinburgh, United Kingdom. ⁴Patient Partner, Aberdeen, United Kingdom. ⁵Queen Elizabeth University Hospital, Glasgow, United Kingdom

Abstract

Background: Prolonged waits for hip and knee arthroplasty have raised questions about the equity of current approaches to waiting-list prioritisation for those awaiting surgery. We therefore set out to understand key stakeholder (patient and surgeon) preferences for the prioritisation of patients awaiting such surgery, in order to guide future waiting list redesign.

Methods: A combined qualitative/quantitative approach was utilised. This comprised a Delphi study to first inform which factors patients and surgeons designate as important for prioritisation of patients on hip and knee arthroplasty waiting lists, followed by a Discrete Choice Experiment (DCE) to determine how included factors should be comparatively weighed. Coefficient values for each included DCE attribute were utilised to construct a “priority score” (weighted benefit score) that could be used to rank individual patients waiting for surgery based on respective characteristics. The published study protocol is available at https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071.

Results: 43 people participated in the initial Delphi study round (16 patients and 27 surgeons), with a 91% completion rate across all three rounds. 73 surgeons completed the DCE. Following the final consensus meeting of the Delphi component the 7 final factors designated for inclusion were Pain, Mobility/Function, Activities of Daily Living (ADL’s), Inability to Work/Care, Length of Time Waited, Radiological Severity and Mental Wellbeing. Output from the adjusted MNL revealed radiological severity as the most significant factor (Coefficient 2.27 [SD 0.31], p<0.001), followed by pain (Coefficient 1.08 [SD 0.13], p<0.001) and time waited (Coefficient for 1-month additional wait 0.12 [SD 0.02], p<0.001). The calculated trade-off in waiting time for a 1-level change in pain (e.g., moderate to severe pain) was 9.14 months.

Conclusion: These results present a new robust method of determining comparative priority for those on primary and knee hip arthroplasty waiting lists. Evaluation of potential implementation in clinical practice is now required.

James Dixon, Iain Rankin, Nadia Sciberras, Kash Khan, Scott Barker, David Cairns, Kapil Kumar

Woodend General Hospital, Aberdeen, United Kingdom

Abstract

Background: In recent years, use of anatomic stemless total shoulder arthroplasty (AsTSA) has increased. Despite evidence to suggest good mid-term results at 2-year follow-up there is a paucity of evidence for longer term follow-up. This study aimed to investigate clinical and radiological outcomes at a minimum of 5 years post-operatively following primary AsTSA.

Methods: This study was an observational cohort study using prospectively collected data at set follow-up times. Study period of Mathys Affinis AsTSA cases implanted from July 2010 (first case) to August 2018 (to allow minimum 5-year follow-up). Clinical outcomes included revision rate, range of motion and patient reported outcomes (Oxford Shoulder Score and Numerical Satisfaction Score). Radiological outcome was assessment of radiolucent lines for Lazarus grading.

Results: A total of 105 stemless TSAs were implanted, 103 cases had revision data available. Five patients underwent revision (4.85%). Seventy-five AsTSA’s were included in the final study for analysis of 5-year outcomes. Median follow-up time was 6.1 years. Median age was 69 years old and 81% were female.  Oxford shoulder score showed a range of 18 to 48, with a median score of 47. Satisfied or very Satisfied was selected in 94.4%. Median range of motion assessments showed forward elevation 160°, abduction 150°, external rotation 40°, and mode internal rotation was to the lumbar spine. No glenoid lucency was present in 79.7%. There were 9.5% with Lazarus Grade 1 lucency, 5.4% with Lazarus Grade 2, and 5.4% Lazarus Grade 3. No humeral lucency was observed. 

Conclusions: This cohort study demonstrates promising clinical and radiological outcomes for the Mathys Affinis Stemless TSA at minimum 5 years post-operatively, with patients achieving excellent ROM and high satisfaction rates.

Andrew Davies¹, Sanjeeve Sabharwal², Alexander Liddle^2,3, Bernarda Zamora-Talaya³, Amar Rangan⁴, Peter Reilly¹

¹Department of Bioengineering, Imperial College London, London, United Kingdom. ²Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust, London, United Kingdom. ³Department of Surgery and Cancer, Imperial College London, London, United Kingdom. ⁴Department of Health Sciences, University of York, York, United Kingdom

Abstract

Background: Metal and ceramic humeral head bearing surfaces are commonly used in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are limited. This study aimed to compare the risks of revision and reoperation following metal compared to ceramic humeral head TSA and HA using data from the National Joint Registry (NJR).

Method: NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 11 characteristics. The primary outcome was revision arthroplasty and the secondary outcome was non-revision re-operation. 

Results: 5,078 TSAs (3776 metal, 1302 ceramic) and 1,384 HAs (1038 metal, 346 ceramic) were included. The risk of revision was higher for metal compared to ceramic TSA, hazard ratio (HR) 0.30 (95% CI: 0.17 – 0.55). At 8 years, prosthesis survival for ceramic TSA was 98.3% (95% CI:96.8 – 99.1) compared to 95.4% (95% CI:94.2 – 96.3) for metal TSA. The majority of revision TSA were for cuff insufficiency or instability/dislocation. There was no difference in the risk of revision for ceramic compared to metal head HA, HR 0.69 (95% CI:0.40 – 1.21). For ceramic HA 8 year prosthesis survival was 92.8% (95% CI:87.0 – 96.1), compared to 90.2% (95% CI:87.7 – 92.3) for metal HA. The majority of revision HA were for cuff failure. 

 Conclusion: The risk of all-cause revision was higher following metal compared to ceramic humeral head TSA in patients with osteoarthritis and an intact rotator cuff. There was no difference in the risk of revision HA according to bearing surface.

Andrew Davies¹, Sanjeeve Sabharwal², Peter Reilly¹, Andrew Sankey³, Dylan Griffiths², Stephanie Archer^4,5

¹Department of Bioengineering, Imperial College London, London, United Kingdom. ²Department of Trauma & Orthopaedics, Imperial College Healthcare NHS Trust, London, United Kingdom. ³Department of Trauma and Orthopaedics, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom. ⁴Department of Psychology, University of Cambridge, Cambridge, United Kingdom. ⁵Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom

Abstract

Introduction: Shoulder arthroplasty is effective in the management of end stage glenohumeral joint arthritis. However, it is major surgery and patients must balance multiple factors when considering the procedure. An understanding of patients’ decision making processes may facilitate greater support of those considering shoulder arthroplasty and inform the outcomes of future research.

Method: Participants were recruited from waiting lists of three consultant upper limb surgeons across two National Health Service hospitals. Semi-structured interviews were conducted with 12 participants who were awaiting elective shoulder arthroplasty. Transcribed interviews were analysed using a grounded theory approach. Systematic coding was performed; initial codes were categorised and further developed into summary narratives through a process of discussion and refinement. Data collection and analyses continued until thematic saturation was reached.

Results: Two overall categories emerged: the motivations to consider surgery and the information participants used to inform their decision making. Motivations were broadly the relief of pain and the opportunity to get on with life and regain independence. When participants’ symptoms and restrictions prevented them enjoying life to a sufficient extent, this provided the motivation to proceed with surgery. Younger participants tended to focus on maintaining employment and recreational activities, and older patients were eager to make the most of their remaining lifetime. Participants gathered information from a range of sources and were keen to optimise their recovery where possible. An important factor for participants was whether they trusted their surgeon and were prepared to delegate responsibility for elements of their care.

Conclusion: Relief of pain and the opportunity to get on with life were the primary reasons to undergo shoulder arthroplasty. Participants highlighted the importance of the patient-surgeon relationship and the need for accurate information in an accessible format which is relevant to people of different ages and functional demands.

Guoqing Cui, Aofei Gao

Peking University Third Hospital, Beijing, China

Abstract

Background: Compared with the Latarjet procedure, the Bristow procedure has a lower screw-related complication rate but poor bone healing. A modified Inlay Bristow procedure has been reported to significantly improve the bone healing rate, but the biomechanical mechanism is unclear. The aim of this study was to evaluate the biomechanical stability of the bone graft between a modified Inlay Bristow procedure and the classic Bristow procedure.

Methods: Sixteen left scapula models (Sawbones®, Composite Scapula, 4th generation) were randomly divided into two groups (8:8). The bone graft in the first group was fixed with a 3.5 mm screw using the Inlay structure. The bone graft in the second group was fixed with a 3.5 mm screw via thetraditional method. The maximum cyclic displacement, ultimate failure load, stiffness and rotation stability were evaluated biomechanically. The failure type was recorded for each model.

Results: Cyclic loading tests demonstrated that the maximum cyclic displacement of the Inlay procedure was significantly smaller (P = 0.001) than that of the classic procedure. The Inlay Bristow technique resulted in a significantly higher (P = 0.024) ultimate failure load than the classic Bristow technique. The stiffness of the classic group was 19.17±4.01 N/mm and that of the inlay group was 22.34±5.35 N/mm (P = 0.232). Failure was mainly due to bone graft fractures through the drill hole or glenoid bone fractures. The Inlay structure resulted in a significantly better (P = 0.017) rotation stability than the classic technique.

Conclusion: Inlay Bristow fixation of the bone graft in a Sawbones® model provides significantly stronger fixation and better time point zero stability than classic Bristow fixation, suggesting a higher likelihood of graft union. Although the current clinical outcome is satisfactory, the Inlay Bristow procedure should be directly compared to the Latarjet procedure both in cadavers and in vivo.

Siddharth Virani^1,2, Senthooran Kanthasamy¹, Nick Little¹, Vipul Patel¹

¹Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom. ²East Kent Hospitals University NHS Foundation Trust, Canterbury, United Kingdom

Abstract

Background: There is limited data available on survivorship of elbow hemiarthroplasty done for unreconstructible distal humerus fractures (AO-OTA C3). The aim of the study is the determine the survivorship at a minimum follow-up of 5 years and patient reported clinical outcomes.

Methods: This is a retrospective analytical study of patients who underwent an elbow hemiarthoplasty at a single centre. The inclusion criteria were a minimum follow up of 5 years and surgery performed in the acute setting (<3 weeks). Patient having undergone delayed hemiarthroplasty for trauma sequelae or total elbow arthroplasty for trauma were excluded.

Results: A total of 16 patients underwent distal humerus hemiarthroplasty for comminuted distal humerus fractures having had more than 5 year follow up(2009-2018). Seven patients had died of other causes during the follow-up period but the minimum five year follow up available. One patient had a medial condyle fixation done additionally and another had an olecranon fixation done with a locking plate. The mean age of the patients at surgery was 74.4 years. The mean follow-up period was 91.8 months(60-124 months). There was 100% survivorship at the last follow-up with no revisions performed. The mean subjective elbow value was 80% while the average VAS score was 2.5. The mean Oxford shoulder score 38.1 for the patients in whom it was recorded. There were no cases of instability or post-operative deep infections. Asymptomatic heterotrophic ossification was noted in five cases. There was no evidence of loosening or osteolysis on the last follow-up radiograph

Conclusions and Implications: The National Joint Registry has recorded elbow hemiarthoplasty procedures only from 2018 and there is limited data available as to the medium to long-term survivorship of the implant. This study concludes that elbow hemiarthroplasty provides good clinical outcomes in the medium term with excellent survivorship. 

Ajay Kumar Goel¹, Rohan Bidwai², Vipendra Singh³, Shivam Malaviya⁴, Kapil Kumar⁵, David Cairns⁵, Scott Barker⁵, Kash Khan⁵

¹Homerton University Hospital, London, United Kingdom. ²RNOH, Birmingham, United Kingdom. ³The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ⁴AIIMS, Rishikesh, India. ⁵Woodend General Hospital, Aberdeen, United Kingdom

Abstract

Background: We aimed to analyse the clinical outcomes and survivorship of anatomic total shoulder arthroplasty using a stemless humeral component with cemented pegged polyethylene glenoid performed with eccentric reaming to partially correct retroversion.

Methods: A retrospective case series was performed using a prospectively collected database of anatomic TSA patients operated at Woodend General Hospital, Aberdeen, UK. Between 2010 and 2019, 107 total shoulder arthroplasties (TSA) were done using standard anatomic stemless TSA implants (Affinis Short, Mathys) in 98 patients. Standardized preoperative and postoperative shoulder radiological imaging for glenoid retroversion was collected. Patients were divided into retroverted and non-retroverted glenoids as per the Walch Classification. Lazarus grading was used to assess the radiological outcome at the final follow-up. Five TSAs were excluded from the analysis due to unsatisfactory postoperative radiographs. Hence, a total of 102 shoulders were available for analysis.

Results: The mean follow-up was 3.48 years (2-10.2 years) in the retroverted group (n=44) and 3.9 years (2-8.9 years) in the non-retroverted group (n=58). The mean pre-operative retroversion of the glenoid in the retroverted group was 20.18, and the post-operative retroversion was 15.87, with a mean correction of 4.31. There was no significant difference between the two groups in the percentage of radiological loosening. The mean Oxford shoulder score was 41.4 (16-48) in the retroverted group and 42.1 (20-48) in the non-retroverted group. Three patients in the retroverted group required revision surgery for rotator cuff failure. There were no revisions for aseptic loosening or instability.

Conclusion: The degree of severity of retroversion of the glenoid was not associated with poor clinical outcomes, revisions, or failure in stemless TSA. At medium-term follow-up, partial correction of retroversion seems to provide comparable outcomes with the non-retroverted group.

Epaminondas Markos Valsamis¹, Marie Louise Jensen², Gillian Coward³, Adrian Sayers⁴, Rafael Pinedo-Villanueva¹, Jeppe Vejlgaard Rasmussen², Gary S Collins⁵, Jonathan L Rees¹

¹Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. ²Department of Orthopaedic surgery, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. ³National Joint Registry, Oxford, United Kingdom. ⁴Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom. ⁵Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom

Abstract

Background

Despite a rising rate of serious medical complications after shoulder replacement surgery, there are no prediction models in widespread use to guide surgeons in identifying high-risk patients and to provide them with personalised risk estimates to support shared decision-making.

Our aim was to develop and externally validate a prediction model for serious adverse events (SAE) within 90 days of primary shoulder replacement surgery.

Methods

Linked national joint registry and hospital data from both England and Denmark were available. Patients aged 18 to 100 years having a primary shoulder replacement were included. A multivariable logistic regression model was developed using the English dataset to predict the risk of 90-day SAEs which included medical complications requiring admission to hospital and all-cause death. We undertook internal validation using bootstrapping, and internal-external cross-validation across different geographical regions of England. The English model was externally validated on the Danish dataset.

Results

40,631 primary shoulder replacements, of which 2,270 (5.6%) had a 90-day SAE, were used for model development. On internal validation the model had a C-statistic of 0.717 (95%CI 0.707-0.728) and was well calibrated. Internal-external cross-validation showed consistent model performance across all regions in England. Upon external validation on Danish data (n=6,653), the model had a C-statistic of 0.750 (95%CI 0.723-0.776). Decision curve analysis demonstrated clinical utility, with net benefit across all risk thresholds.

Conclusion 

This externally validated prediction model uses commonly available clinical variables to accurately predict the risk of serious medical complications after primary shoulder replacement surgery. The model is generalisable and applicable to most patients in need of a shoulder replacement. Its use offers support to clinicians and could inform and empower patients in the shared decision-making process.

Gina Penswick

University of Nottingham, Nottingham, United Kingdom

Abstract

Primary Elbow Osteoarthritis (PEOA) is a rare condition that affects 1-2% of the osteoarthritis population. With little research surrounding this condition, the current epidemiology is based off small studies, from around 30 years ago. The elbow joint is complex and unlike any other in the body. Therefore, it cannot be presumed that the epidemiological features or treatment of PEOA will be reflective of other joints. Conservative treatment for this PEOA has no research to support its effectiveness, yet it has been in use since the 1930s. Research surrounding debridement treatment mainly focuses on the individual procedures, not as a whole treatment group. 

This retrospective study identified 356 patients admitted under the Royal Derby Hospital between 2010-2024 with elbow osteoarthritis. After exclusion of secondary osteoarthritis and conditions that could interfere with the results, 262 patients were analysed. Epidemiological features were noted for the whole cohort. Patients were separated by the treatment they received: 41 patients received conservative treatment, and 99 patients received debridement treatment. Pre-treatment and post-treatment range of motion and oxford elbow score were compared through a Mann-Whitney U test for each treatment group (significance level: p<0.05).

Out of 262 elbows, most were elderly (66 years), white British (92%) males (69%) with a heavy manual occupation (66%). The most prevalent symptom is cubital tunnel syndrome (19%) followed by locking (18.3%), whilst crepitus was in only 4% of elbows. Elbow range of motion was limited mostly by extension (57.1%) and this PEOA cohort had a common association with knee osteoarthritis (24.4%). 41% of elbows received debridement treatment, 18.3% had conservative treatment and 6.2% were given a total elbow replacement. 

Debridement treatment significantly improved oxford elbow score (p=0.001) and range of motion (p<0.001) for PEOA. Conservative treatment did not significantly improve oxford elbow score (p=0.333) or range of motion (p=0.828) for PEOA. 

Mohammed Lyeeq Ahmed, Raheel Shakoor Siddiqui, Jae Rhee

The Shrewsbury & Telford Hospital NHS Trust, Telford, United Kingdom

Abstract

Background: The rotator cuff provides dynamic stability to the glenohumeral joint. Massive rotator cuff tears can be managed nonoperatively or operatively by partial cuff repairs, tendon transfers and reverse total shoulder arthroplasty. Superior capsular reconstruction (SCR) is a joint preserving option to prevent proximal humeral migration and thus restoring force coupling. NICE recommends performing this procedure only in context of research due to limited evidence for SCR safety and efficacy. 

Methods: Prospective single-surgeon study. Thirty-nine patients who underwent arthroscopic SCR between 2017 and 2022 were included. The inclusion criteria were posterosuperior tear pattern, advanced retraction, fatty infiltration, failed nonoperative management and subscapularis intact or reparable. Graft type used was Arthrex xenograft (DX) matrix. Average follow-up period was 9 months. Range of motion and patient reported outcome measures (PROMS) including Constant Shoulder Score (CSS), Oxford Shoulder Score (OSS) and Visual Analogue Score (VAS) were assessed pre and post operatively. Key efficacy and safety outcomes measures selected according to NICE interventional procedure guidance. 

Results: Mean ROM improvement post op were: 56° flexion (p=0.008), 59° abduction (p=0.004) and 11° external rotation (p=0.01). The CSS and OSS improved +22 (p=0.003) and +10 (p=0.001) respectively. VAS showed an improvement of +4 (p=0.02). Procedure success rate was 94.8%. The rate of graft failure and persistent post-op pain was 2.5%. Two patients had secondary procedures. No patients had graft detachment, infection, suture anchor pull-out.  

Conclusion: SCR is a successful procedure in select patient populations. Our study compares with similar studies in literature with successful improvement in ROM, PROMS and negligible rates of graft detachment, failure, re-tear and anchor pull out.  

Implications: Further randomized controlled trials and case-controlled studies should be conducted to on a larger population size to analyse long term outcomes of SCR in patients with massive rotator cuff tears. 

Abdus S. Burahee^1,2, Colin Shirley¹, Mark JW van der Oest³, Michiel J. Zuidam³, Liron S. Duraku², Dominic M. Power¹

¹Queen Elizabeth Hospital, Birmingham, United Kingdom. ²Amsterdam University Medical Center, Amsterdam, Netherlands. ³University Medical Center Rotterdam, Rotterdam, Netherlands

Abstract

Background: Cubital tunnel syndrome (CuTS) reflects a dysfunction of the ulnar nerve due to compression at the elbow. There is no consensus regarding optimal management, with conflicting evidence in the literature. This study aims to report on the treatment of CuTS with medial epicondylectomy (ME), including clinical outcomes and complication rates. 

Methods: A retrospective cohort study of cubital tunnel decompression with medial epicondylectomy was conducted over an 8-year timeframe at a single centre for peripheral nerve surgery. Disease severity was assessed using the McGowan grading and baseline neurophysiology studies.  Clinical outcome was rated using the Wilson Krout reporting system for disease response to intervention.  We compared the primary outcome variable (McGowan grade) using anova omnibus test and used linear regression models to assess the effect of different intraoperative findings on the clinical outcome at 24 weeks. A minimum of 12 months follow up data was required for analysis of complications

Results: The study included 185 patients.  82% had a Wilson Krout grade of Good or Excellent.  Patients improved significantly during the first six weeks after surgery (MD 1.065, 95% CI 0.90 - 1.23). However, no statistically significant improvement was noted in the period between 6 and 24 weeks (24 MD 0.168, 95% CI -0.01 - 0.35).  A severe neurophysiology score at intake was associated with a worse outcome (Df 5, X2 = 2.37, F = 3.69, p = 0.004).  There was a 7.6% overall rate of complications from performing a ME but no elbow instability was evident.

Conclusion: ME is a safe and effective treatment for cubital tunnel syndrome with an acceptable complication rate. 

Richard Doxey, Matthew Weston, Nikita Minhas, Fiona Ashton, Andrew Dekker, Amol Tambe, Marius Espag, David Clark

Royal Derby Hospital, Derby, United Kingdom

Abstract

Background: Fracture dislocation of the elbow is a complex injury which is challenging to manage. The approach can either be operative or non-operative, with recent research suggests operative intervention for improved outcomes.

Aim: To review the functional outcomes of patients with fracture dislocation of the elbow and to compare the outcomes between operative and non-operative groups.

Method: A retrospective review of adult patients referred to the Royal Derby trauma and orthopaedic department sustaining a fracture dislocation of the elbow. The injuries were grouped using the Wrightington classification, and postal questionnaires sent to all patients. The primary outcome assessed was the Oxford Elbow Score(OES) at the last follow-up, secondary outcomes included range of movement and pain score measured using a visual analogue scale(VAS).

Results: Ninety patients(41 male, 49 female) with a mean age of 50 years were included, with a mean follow-up of 33 months. The injuries were classified using the Wrightington classification. The mean OES was 17 in the operative group and 14.5 in the non-operative group, with no statistical difference between the two(p=0.25). Similarly, there was no statistical difference in the mean flexion arc and pain score between the operative and non-operative groups.

Discussion: The results indicate good outcomes in terms of function, range of movement, and pain in this cohort of patients presenting with fracture dislocation of the elbow. No statistical difference was observed in these domains when comparing operative and non-operative treatments. Most injuries treated operatively were of severe types(C, D, or D+), yet outcomes were comparable to less severe injuries managed non-operatively. This suggests that appropriate surgical intervention yields favourable outcomes even in severe cases. Moreover, the study highlights that a conservative approach in non-severe injuries does not compromise outcomes, challenging the notion of universal operative intervention for all fracture dislocations.

Nikita Minhas, Fiona Ashton, Richard Doxey, Caroline Dover, Chiraag Pandya, Aziz Haque, Amol Tambe, David Clark

Royal Derby Hospital, Derby, United Kingdom

Abstract

Background: Acromioclavicular joint (ACJ) disruption is a prevalent shoulder injury, comprising approximately 12% of shoulder injuries. Despite its frequency, considerable debate remains regarding the optimal management, particularly for displaced ACJ injuries of Rockwood Grade III and above.

Objectives: To assess the patient-reported functional outcomes of isolated, acute, traumatic displaced ACJ injuries managed operatively and non-operatively.

Methods: Retrospective data was gathered from compiled trauma database at a large university teaching hospital. Patients with isolated displaced ACJ injuries were identified and their notes reviewed to classify the injuries according to the Rockwood classification. Eligible patients received postal questionnaires including QuickDASH score, Nottingham Clavicle Score (NCS), and a custom questionnaire assessing return to work, sport, and ability to sleep on the affected side.

Results: From January 2016 to December 2020, 308 patients presented with acute traumatic ACJ injuries, of which 168 were displaced Grade 3-5 injuries. Scores were available for a minimum of one year follow-up for 71 patients, with 63 males and 8 females, with an average age of 52 years (range 16-77 years). Fourteen patients underwent acute surgical stabilisation of their injuries, while 57 patients were initially managed non-operatively. Among those initially managed non-operatively, twenty-two (39%) eventually underwent delayed surgical intervention after a minimum 8-week trial of conservative management. This study revealed significantly superior QuickDASH scores (p=0.0137), NCS (p=0.0006), earlier return to work (p=0.0027), and earlier ability to sleep on the affected side (p=0.0023) in patients managed with early operative intervention compared to late operative and non-operative groups.

Conclusion: This study suggests that early surgical intervention leads to the most favourable outcomes in ACJ injuries. Delayed operative intervention is associated with poorer outcomes and prolonged disruption to work, sport, and sleep. Identifying patient and injury factors predisposing to poor outcomes with delayed operative management is crucial for informed decision-making at presentation.

Nicholas Wei¹, Thomas Baldock², Reece Walker¹, Lucksy Kottam¹, Shashi Kumar³, Amar Rangan^1,4

¹South Tees NHS Foundation Trust, Middlesbrough, United Kingdom. ²Northumbria NHS Foundation Trust, Newcastle upon Tyne, United Kingdom. ³Sherwood Forest NHS Foundation Trust, Ashfield, United Kingdom. ⁴University of York, York, United Kingdom

Abstract

Introduction: Prosthetic Joint Infection (PJI) is a significant complication following shoulder and elbow arthroplasty. However, there is a relative paucity of evidence in this area when compared to other arthroplasties. PRISE aimed to determine the most common pathogens in shoulder and elbow arthroplasty PJI (SE-PJI), sensitivity profiles and intra-operative sampling technique. 

Methods: PRISE was a retrospective multicentre service evaluation across the United Kingdom. Data was collected through a collaborative approach with information obtained on patient demographics, implant characteristics, organisms grown, antimicrobial sensitivities and sampling methodology. Patients who underwent revision shoulder or elbow arthroplasty between 01/01/2018-01/01/2023 with a positive intra-operative sample were eligible.

Results: 29 hospitals contributed 173 cases treated as SE-PJI. Median age was 70. There was a male preponderance for shoulder arthroplasty (65.2%; 88/135) compared with elbow (39.5%; 15/38). 22.5% of patients were diabetic and 15% rheumatoid. 80.9% of cases were performed on primary arthroplasties. The reverse shoulder arthroplasty (52.6%; n=71/135) and linked elbow arthroplasty (44.7%; n=17/38) were the most common shoulder and elbow prosthesis. Coagulase-negative Staphylococcus spp. [CNS] (tissue n=56/173; fluid n=15/81), Cutibacterium acnes [C. acnes] (tissue n=45/173; fluid n=16/81), Staphylococcus aureus [MSSA] (tissue n=29/173; fluid n=13/81), Streptococcus (tissue n=9/173; fluid n=3/81) and Proteus mirabilis (tissue n=7/173, fluid n=381) were the most common micro-organisms. Other micro-organisms ranged from 1-3 samples. For C. acnes and MSSA, sensitivity to the penicillin group (62.9% & 85.0%) was most frequently reported and for CNS, it was Vancomycin (42.9%). The most common antibiotic prophylaxis was teicoplanin with another agent (57%). Oxford sampling method was utilised in 46.5% cases. 83.5% cases were discussed at MDT.

Conclusion: Majority of revisions for SE-PJI occurred in primary arthroplasties with either CNS, C. acnes or MSSA often being identified as the organism. Less than half of cases followed the Oxford sampling method and majority were discussed at MDT level.

Mohammed Shaath, Mark Falworth, William Rudge, Addie Majed, David Butt, Deborah Higgs

Royal National Orthopaedic Hospital, London, United Kingdom

Abstract

Background: Management of bone loss in both primary and revision total elbow arthroplasty (TEA) is surgically challenging. Techniques used include mega prosthesis (distal humeral replacement) and large segment allograft struts and/or allograft prosthetic composites. However, these techniques have high complication and failure rates.  We present a novel solution of salvage TEA using a custom intramedullary humeral prosthesis with a locking flange.

Methods: We prospectively reviewed data on 11 complex cases performed between 2017 and 2023. Electronic patient records, clinic letters, surgical logbook and the patient recorded outcome measures (PROMS) database were reviewed. 

Results: All eleven cases were revisions of previously failed prostheses; following trauma (N=5) inflammatory arthritis (N=4), osteoarthritis i(N=1) and following a tumour resection (N=1). Mean age at operation was 64 (range 40-75). The mean number of previous arthroplasty procedures per patient was 6 (range 3-10). At a mean follow up of 29 months (range 2-81) ten of eleven prostheses remain fully in situ; however all humeral components remained well fixed. Post-operative outcome data was omitted for one patient who died of an unrelated cause. Clinical satisfaction was high with an average improvement in visual analogue scale for pain (VAS) of 8 preoperatively to 1 postoperatively. Average function improved from 21% of normal function (SANE) pre-operatively to 75% following revision. The Oxford Elbow Scores improved from an average of 11 to 32. EQ-5D index improved from an average of 0.5 to 0.6. At most recent follow up there was no evidence of progressive radiographic lucency in any implant. One patient required removal of the ulna component 43 months post-operatively for continued infection and remains on antibiotic suppression. The humeral component remains well fixed.

Conclusion: When faced with extensive humeral bone loss, customised distal humeral replacements with a locking flange offer an alternative solution with acceptable medium-term outcomes.

Mohamed Elmeligy¹, Alistair Bevan², Zoe Mitchell³, Benjamin Curley³, Ryan Kimber², Nanette Oakes², Katie Wheeldon², Apruv Sinha², Shantanu Shahane²

¹Royal Berkshire Hospital NHS Foundation Trust, Reading, United Kingdom. ²Chesterfield Royal Hospital NHS foundation trust, Chesterfield, United Kingdom. ³University of Sheffield, Sheffield, United Kingdom

Abstract

Background: Reverse shoulder arthroplasty is a recognized treatment for complex proximal humerus fractures, particularly in elderly patients. Greater tuberosity non-union and migration have been linked to poorer outcomes. We sought to compare outcomes between patients who underwent repair of the greater tuberosity alone versus those who received dual repair (greater and lesser tuberosity), analysing any statistical differences in their overall results.

Methods: We conducted a retrospective review of all patients with proximal humeral fractures who underwent reverse shoulder arthroplasty between January 2015 and February 2024. Patient demographic data, fracture classification, Oxford Shoulder Score, pain score, intraoperative tuberosity repair technique, radiological tuberosity healing, and postoperative physiotherapy protocols were standardized for all patients.

Results: Among the 71 patients included, 62 were female, with an average age of 74.5 years (range: 56-89). Fracture types included 33 with 3-part fractures, 19 with 4-part fractures, and 18 with head split or fractures with dislocation. The average time between injury and surgery was 21.96 days. Dual repair (greater and lesser tuberosity) was performed in 59 patients, while only greater tuberosity repair was done in 12 patients. Follow-up X-rays (minimum 3 months) showed a non-union rate of 3.4% in the dual repair group compared to 50% in the greater tuberosity repair alone group. Postoperative complications such as infection, dislocation, or revision were not reported. The mean follow-up duration for 59 available patients was 39.22 months. The Oxford Shoulder Score averaged 40 out of 48, with pain subset scores ranging from 3.0 to 3.6. While there was a significant difference between the two groups in tuberosity healing and migration, no statistically significant correlation was found between OSS and tuberosity healing.

Conclusion: Dual repair of the greater and lesser tuberosity significantly reduces non-union and migration rates compared to repair of the greater tuberosity alone.

Nanjundappa S HARSHAVARDHANA, Kalana RATHNAYAKE, Ankit Prasad, Subodh Srivastava, Sameh Ansara

Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom

Abstract

Introduction: Proximal humeral fractures’ incidence is increasing and head preserving surgery involves fixation using a contoured locking plate that are associated with high complication rate (viz. intra-articular screw perforation, impingement, Mal-union with Varus collapse, Avascular necrosis[AVN] and need for Revision surgery).  

Aim: The purpose of this study was to undertake a long-term review and share surgical technique and tips to minimize the above complications at a mean follow-up of 9.4years in a single surgeon’s cohort of 68 patients. 

Methods: Sixty-eight patients (19M and 49F) with proximal humeral fractures that were operated by a locking plate fixation formed the study cohort against stringent inclusion vs. exclusion criteria. The mean age at surgery was 66.6years (range: 25–89y) and the mean follow-up was 9.4years (range: 3.5–14.2y).  Serial radiographs were taken at first visit, pre-op, post-op and final follow-up. Adverse events causing unplanned return to theatres, instrumentation failure along with infections and AVN were recorded and managed appropriately. The operative technique included use of a Delto-pectoral approach and Ethibond sutures to reduce the tuberosities and performing a plate reduction (after initial fixation of chosen plate to the head fragment) to humeral meta-diaphysis in Valgus using a non-locking screw.

Results: 55patients were operated for acute fractures and 13patients presented had non-union with unacceptable function or on-going pain. All other 68fractures healed with improvement in Constant / DASH score and one patient warranted implant removal for plate-related complication.

Conclusion: Fracture reduction in slight Valgus and performing a plate reduction reduces the risk of Varus collapse and impingement. Bone graft (or its substitute) minimizes the risk of implant failure. These practical surgical tip minimizes the risk of need for re-operation at long-term.

Ibrahim Haq¹, Siddarth Raj¹, Mattia Zappalà², Nicola Heneghan², Adrian Gardner³

¹University Hospitals Coventry & Warwickshire, Coventry, United Kingdom. ²School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom. ³The Royal Orthopaedic Hospital NHS Foundation Trust, The Woodlands, Bristol Road South, Northfield, Birmingham, United Kingdom

Abstract

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity affecting those between 10-18 years. Surgical fusion leads to a potential loss of lumbar spine movement. Accurate measurement of spinal range of motion (ROM) is critical for assessing the severity of the curve to plan treatment and evaluate post-operative outcomes. Existing methods of measuring spinal ROM vary in reliability, validity, and feasibility, necessitating a review to identify and critique the methods utilised in the clinical setting.

Methods: The protocol for this review has been registered on PROSPERO (CRD42021282264) and published (PMID: 36180881). The review adheres to the PRISMA-P guidelines and COSMIN methodology. PubMed, Scopus, Web of Science, Cochrane database, EMBASE, MedLine and Ovid databases were searched for studies on AIS patients that report quantitative data on lumbar ROM. Data on methodological quality, measurement properties (validity, reliability and responsiveness) and clinical utility were extracted and analysed.

Results: Of 3,677 articles identified, 24 were eligible for inclusion. The studies included 1071 patients (mean age of 14.8, 84.96% female). Methods of measurement were classified into three broad categories: radiographs (16 studies), computerised motion models with sensors (6 studies) and basic measuring tape techniques (2 studies). 

Conclusion: There are multiple heterogeneous techniques for measuring spinal motion in the literature, thereby precluding meta-analysis. While radiographs predominant, implementation varies widely in practice. Computerised models lack uniformity across the included studies. Simple measuring techniques are potentially reproducible, however, data were limited.

Implications: Stage two of this review will assess pre- and post-operative measurements of spinal motion after lumbar fusion in patients with AIS.

Srikar Namireddy^1,2, Saran Gill^1,2, Amaan Peerbhai^1,2, Abith Kamath^1,2, Daniele Ramsay^1,2, Hariharan Subbiah Ponniah^1,2, Dragan Jankovic³, Darius Kalasauskas³, Jonathan Neuhoff⁴, Andreas Kramer³, Florian Ringel³, Santhosh Thavarajasingam^1,3

¹Imperial Brain & Spine Initiative, London, United Kingdom. ²Imperial College School of Medicine, London, United Kingdom. ³Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany. ⁴Center for Spinal Surgery and Neurotraumatology, Berufsgenossenschaftliche Unfallklinik, Frankfurt, Germany

Abstract

Background: The use of Artificial Intelligence (AI) and Machine Learning (ML) technologies for vertebral fractures has shown promising potential in enhancing diagnostic accuracy and efficiency. With increasing prevalence of vertebral fractures, the need for accurate diagnosis and prognostication becomes paramount.

Methods: This study assesses the effectiveness of AI algorithms in diagnosing and predicting risk of vertebral fractures. A comprehensive search was conducted across major databases, selecting studies that utilized AI for vertebral fracture diagnosis or prognosis, with a subsequent meta-analysis to quantitatively synthesize the findings. Diagnostic models were stratified based on the pathology for which they were tailored, namely non-pathological vertebral fractures, osteoporotic vertebral fractures, and vertebral compression fractures. The primary outcome measure was AUROC.

Results: Out of 14,161 studies initially identified, 79 were included in the final analysis, with 40 undergoing meta-analysis. AI based programmes can accurately diagnose and predict the risk of vertebral fractures (predictive AUROC= 0.82 [0.78-0.85]; osteoporotic vertebral fracture diagnosis AUROC= 0.92 [0.88-0.96]; non-pathological vertebral fracture diagnosis AUROC= 0.85 [0.81-0.88]; and vertebral compression fracture diagnosis AUROC= 0.87 [0.83-0.91]) at a significant level (p<0.001). Traditional models had the highest median AUROC (0.90) for fracture prediction. Deep learning models had the highest median AUROC for diagnosis of all 3 fracture types. Notably, high heterogeneity was observed among the studies (I² > 99%, p<0.001), suggesting a large variation in model design and performances.

Conclusion: AI technologies exhibit considerable promise in improving the diagnosis and prognostication of vertebral fractures, as evidenced by high accuracy levels in both domains. However, the observed heterogeneity and the high risk of bias in studies underscore the necessity for further research. Future efforts should focus on the standardization of AI models and validation across diverse datasets to ensure their clinical utility and effectiveness in diagnosing vertebral fractures.

P Mc Carroll¹, M Kostka¹, C Stanley¹, Hazel Denton¹, MJ Delaney¹, C McCarthy¹, S Murphy¹, L Smith¹, S Mooya¹, P Coughlan¹, C Byrne², A Ryan², F Rowan¹, M Cleary¹, Bridget Melley¹

¹Department of Orthopaedics, University Hospital Waterford, Waterford, Ireland. ²Department of Radiology, University Hospital Waterford, Waterford, Ireland

Abstract

Background: There has been an increasing trend in the prevalence of osteoporotic vertebral compression fractures (VCF), over the past 20 years. The incidence of hospital admissions for VCF increased by 170% causing a significant burden. Patients on average spend 10 days as an inpatient.  Management currently consists of analgesia and physiotherapy - often as an inpatient, due to poor supports in place in the community. Hip fracture care has significantly improved in recent times due to the use of a clinical care pathway. The aim of our study is to develop a clinical care pathway for vertebral compression fractures that shifts the treatment of this complex patient cohort to community based care.

Methods: This is a retrospective cohort study of patients referred to model 4 tertiary centre with stable VCF from the 17/02/2021 to 28/08/2021. Each patient was followed for 90 days post referral involving virtual review  at the 2 and 6 week mark. 

Results: A total of 70 patients were included in our analysis with a mean age of 74 years. All patients received onward referral for bone health assessment. In total 63 patients completed their virtual follow up. A total of 147 bed days were recorded in the 6-month period, 20 patients were admitted over the period with only 8 admitted for VCF.

Conclusion: The clinical care pathway implemented at  UHW for the management stable VCF has produced tangible improvements in patient care and institutional efficiency. Through interdisciplinary collaboration and education programs, we observed increased rate of bone health assessment, reduced hospital bed days, and fewer inpatient admissions for this cohort. 

Laura Casey¹, Diego Lastoria², Rebecca Beni², Alexa Papanastasiou³, Arya Kamyab², Konstantinos Devetzis², Chloe Scott⁴, Caroline Hing¹

¹St George's University Hospitals NHS Trust, London, United Kingdom. ²St George’s University of London, London, United Kingdom. ³University College Dublin, Dublin, Ireland. ⁴University of Edinburgh, Edinburgh, United Kingdom

Abstract

Introduction: Orthopaedic surgery has the lowest proportion of female surgeons of all surgical specialties, with women comprising 20% of specialist trainees and 7% of consultants in 2021. This study aims to establish the proportion of female consultants within the subspecialties of orthopaedic surgery in the National Joint Registry in 2023, and to calculate difference in time since specialist registration between male and female surgeons.

Methods: Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the general medical council (GMC) website using GMC number in order to extract surgeon demographic data including gender, region of practice, and dates of full and specialist registration.

Results: Of 2,895 surgeons contributing to the NJR in 2023, 102 were female (3.5%). The highest proportion of female surgeons were among those who performed elbow (25, 4.7%), shoulder (24, 3.8%) and ankle (8, 3.8%) arthroplasty. Hip (66, 3.0%) and knee arthroplasty (39, 2.0%) had the lowest female representation. Female surgeons were a mean of 11.0 years since specialist registration compared to 14.4 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8.3%), and North Wales had no female arthroplasty surgeons. A greater proportion of male surgeons worked in private practice (63.1% vs 23.6%, p < 0.001) and in multiple hospitals (74.0% vs 40.2%, p < 0.001).

Conclusion: Only 3.5% of surgeons currently contributing cases to the NJR are female with the highest proportion performing elbow arthroplasty (4.7%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons.

Elizabeth Ojelade^1,2,3, William Gray¹, Tim Briggs^1,2

¹Getting It Right First Time, NHS England, London, United Kingdom. ²Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom. ³Royal Free London NHS Foundation Trust, London, United Kingdom

Background: During the COVID-19 pandemic in England, orthopaedic surgery trainees experienced a reduction in training opportunities due to periods of elective surgery suspension. We aimed to explore training opportunities for orthopaedic trainees in trusts with and without access to an elective surgical hub.

Methods: This retrospective analysis of administrative data used eLogbook data for registrars who performed six high volume, low complexity orthopaedic procedures in NHS hospitals in England between April 2017 and March 2023. Data included training grade, role in the procedure, trust where the procedure was performed and procedure date. These were linked at a trust level to Hospital Episodes Statistics (HES) data on the total number of these procedures conducted during the study period and whether the trust hosted or fed into an elective surgical hub at the time of the procedure. 

Results: Data were analysed for 1,755 trainees acting as first surgeon in 125,759 procedures. Trusts with access to an elective surgical hub significantly increased the proportion of procedures conducted by a trainee from 16.8% in 2017/18 to 18.3% in 2022/23 compared to an increase from 16.0% in 2017/18 to 16.2% in 2022/23 in non-hub trusts. Most of the increase in trainee involvement was associated with more senior trainees (ST6-8) but this was not enough to offset the 17.7% decline in the absolute number of procedures conducted by trainees (25,598 (2017/18), 21,057 (2022/23)). This fall is largely due to the 23.2% reduction of the included procedures conducted in NHS hospitals (157,775 (2017/18), 121,162 (2022/23)).

Conclusions: Elective surgical hubs have made a positive contribution to training opportunities for orthopaedic trainees but not enough to offset the post-pandemic fall in activity. The number of procedures conducted in NHS hospitals and the rate of training opportunities must be increased as a priority.

Disclosure: No funding was received for this study.

Irrum Afzal, Holly Wetherell, Richard Field

South West London Elective Orthopaedic Centre, London, United Kingdom

Abstract

Medicine and surgery attract a spectrum of personality types. We report a service evaluation on investigating whether the personality of consultant orthopaedic surgeons differ from the general population, whether orthopaedic anaesthetists differ from their surgical colleagues and whether length of service has an implication on personality traits. Fourty-two consultant orthopaedic surgeons with varying sub-specialist interests and 10 orthopaedic anaesthetists were invited to the complete ‘The Big Five Personality Test’, which scores respondents in five key personality domains (openness, conscientiousness, extraversion, agreeableness and neuroticism). Twenty-four of the 42 consultant orthopaedic surgeons had been consultants for 10 years or greater, whilst the other 18 consultant orthopaedic surgeons had been consultants for less than 10 years.

Mean scores, analysis of the Big Five Personality Test showed that the orthopaedic surgeons had higher levels of openness, conscientiousness, extraversion and agreeableness and a lower level of neuroticism than the general population and orthopaedic anaesthetists. While the differences between orthopaedic surgeons and the general population were greater than those between orthopaedic surgeons and anaesthetists, we were only able to access published mean score data for the general population so were unable to assess whether these differences were significant.

Mann-Whitney U tests only revealed statistical significance in the extroversion domain (P < 0.05) when comparing orthopaedic surgeons and anaesthetists.  When comparing the five domains for those who had been consultant orthopaedic surgeons for 10 years or greater, they showed lower levels of openness, conscientiousness, extraversion and agreeableness and a higher level of neuroticism. These differences were statistically significant for extraversion and neuroticism (P < 0.05).

Our results confirm that consultant orthopaedic surgeons have outstanding personalities. Further investigation would involve comparing personality types of the operating surgeon and patient reported outcomes satisfaction following a surgical procedure. 

Robert Kay¹, Nick Clement^1,2,3, Lucas Ho⁴, Andrew Duckworth^1,5, Andrew Hall^2,6,3

¹Edinburgh Orthopaedics, Edinburgh, United Kingdom. ²Scottish Hip Fracture Audit, Edinburgh, United Kingdom. ³Scottish Centres for Orthopaedic Treatment & Innovation in Surgery & Healthcare (SCOTTISH) Network, St Andrews, United Kingdom. ⁴University of Edinburgh, Edinburgh, United Kingdom. ⁵Usher Institute, University of Edinburgh, Edinburgh, United Kingdom. ⁶School of Medicine, University of St Andrews, St Andrews, United Kingdom

Abstract

Background: Hip fractures are associated with high morbidity and mortality, and patients that sustain a subsequent contralateral fracture experience inferior outcomes, with increased mortality and functional decline. The risk of contralateral fracture is highest within the first year; however, the incidence and associated factors remain poorly understood. The aims were to investigate (i) the incidence of a subsequent contralateral hip fracture within the first year, (ii) identify factors associated with an increased risk of contralateral fracture and (iii) compare early mortality risk after index versus contralateral hip fracture.

Methods: This study included all patients aged over 50 years admitted to NHS hospitals in Scotland between 1st March 2020 and 31st December 2020 (n =  5566) as routine activity of the Scottish Hip Fracture Audit (SHFA). Multivariate logistic regression was used to examine factors associated with 30-day mortality, and Cox regression was used to identify factors associated with a contralateral fracture.

Results: During the study period 2.5% (138/5566) of patients sustained a contralateral hip fracture within 12 months of the index hip fracture. Socioeconomic deprivation was inversely associated with increased risk of contralateral fracture (odds ratio 2.64, p <   0.001), whilst advancing age (p =   0.427) and sex (p =  0.265) were not. After adjusting for significant cofounders, there was no significant difference in 30-day mortality following contralateral fracture compared to index fracture (OR 1.22, p = 0.433).

Conclusion: One in 40 (2.5%) hip fracture patients sustained a contralateral fracture within 12 months of their index fracture, and deprivation was inversely associated with  risk of contralateral fracture. No difference in 30-day mortality between index hip fracture versus contralateral hip fracture was found.

En Lin Goh¹, Amulya Khatri², Alexander Costa¹, Andrew Ting³, Kat Steiner⁴, May Ee Png⁵, David Metcalfe¹, Jonathan Cook⁶, Matthew Costa¹

¹Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. ²Department of Trauma and Orthopaedics, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, United Kingdom. ³Department of Trauma and Orthopaedics, St Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Surrey, United Kingdom. ⁴Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom. ⁵Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom. ⁶Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom

Abstract

Background: Older adults with hip fractures are at high risk of experiencing complications after surgery but estimates of the rate of specific complications vary by study design and follow-up period. This systematic review aimed to determine the prevalence of complications in older adults after hip fracture surgery.

Methods: MEDLINE, Embase, CINAHL and CENTRAL were searched until 30th June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (≥60 years) undergoing hip fracture surgery.

Results: A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications: the 30-day prevalence of re-operation was 2.3%, surgical site infection 1.7%, and deep surgical site infection 1.0%; the 365-day prevalence of prosthesis dislocation was 1.1%, fixation failure 1.8%, and peri-prosthetic/implant fracture 2.2%. For general complications: the 30-day prevalence of acute kidney injury was 1.2%, blood transfusion 25.6%, cerebrovascular accident 0.8%, lower respiratory tract infection 4.1%, myocardial infarction 2.0%, urinary tract infection 7.0%, and venous thromboembolism 2.2%.

Conclusion/Findings: The prevalence of complications was high. Re-operation rates within the first year were over two times higher than estimates from hip fracture registries and are likely to be more representative of the true real world risk. The prevalence of complications continued rising during the first year after surgery, which is important to appreciate as many of the observational studies of larger hip fracture populations have focused on complications occurring during the index hospital admission.

Implications: Studies reporting complications after hip fracture surgery were generally of low quality. We advocate for routine monitoring of complications in registries and clinical trials, which will improve the quality of evidence. Our findings provide a reference range against which service performance can be benchmarked and can inform power calculations for future studies of interventions in hip fracture.

En Lin Goh¹, May Ee Png², David Metcalfe¹, Jonathan Cook³, Matthew Costa¹

¹Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. ²Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom. ³Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom

Abstract

Background: Older adults with a hip fracture are at high risk of experiencing complications after surgery. There is a little information available on the complication profile of routinely used orthopaedic implants in clinical practice. This study aims to describe and compare the complication risks between hip hemiarthroplasty (HHA) and total hip arthroplasty (THA).

Methods: The World Hip Trauma Evaluation (WHiTE) study is a multi-centre, prospective cohort study that enrolled patients age ≥60 years who received operative treatment for their hip fracture. Patients were prospectively followed up for 120 days after surgery. We report the cumulative incidence of each complication and comparisons between the study groups.

Results: A total of 13,359 patients who had a HHA (n=11,283) or THA (n=2,076) were included in the analysis. For surgery-specific complications, THA had higher risks of prosthesis dislocation (HR:1.91) and re-operation for any indication (HR:1.11); and lower risks of peri-prosthetic fracture (HR:0.41); surgical site infection (HR:0.80) and re-operation for infection (HR:0.76) compared to HHA. For general complications, THA had higher risk of venous thromboembolism (HR:1.11); and lower risks of acute kidney injury (HR:0.53); blood transfusion (HR:0.69); cerebrovascular accident (HR:0.21); lower respiratory tract infection (HR:0.46); myocardial infarction (HR:0.32); and urinary tract infection (HR:0.44) compared to HHA.  

Conclusion/Findings: THA was associated with higher risks of surgery-specific complications compared to HHA. These findings are consistent with recent data, supporting judicious patient selection. The THA group had a lower risk of general complications, which can be attributed to the healthier baseline state of this population. The elevated risk of venous thromboembolism is a new and important observation, warranting further investigation to understand potential risk factors that may be implicated.

Implications: THA confers a higher risk of surgery-specific complications compared to HHA. This should be weighed up against the patient-specific benefits that THA may offer.   

En Lin Goh¹, May Ee Png², David Metcalfe¹, Jonathan Cook³, Matthew Costa¹

¹Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. ²Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom. ³Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom

Abstract

Background: In recent years, there has been a trend towards the use of cephalomedullary nail (CMN) over sliding hip screw (SHS) for the treatment of trochanteric fractures, despite the lack of good quality evidence supporting either implant, and higher costs of CMN. This study aims to describe and compare the complication risks between SHS and CMN fixation.

Methods: The World Hip Trauma Evaluation (WHiTE) study is a multi-centre, prospective cohort study that enrolled patients age ≥60 years who received operative treatment for their hip fracture. Patients were prospectively followed up for 120 days after surgery. We report the cumulative incidence of each complication and comparisons between the study groups.

Results: A total of 8,187 patients had a SHS (n=5,544) or CMN (n=2,643). For surgery-specific complications, CMN had higher risks of fixation failure (HR:1.73); peri-implant fracture (HR:3.47); re-operation (all-cause) (HR:1.72); revision surgery (HR:2.04); and deep surgical site infection (SSI) (HR:1.47) compared to SHS. For general complications, CMN had higher risk of blood transfusion (HR:1.27); and similar risks of acute kidney injury (HR:1.03); cerebrovascular accident (HR:0.77); lower respiratory tract infection (HR:0.90); myocardial infarction (HR:1.03); urinary tract infection (HR:0.86); and venous thromboembolism (HR:1.13) compared to SHS.

Conclusion/Findings: We observed higher risks of surgery-specific complications with CMN compared to SHS. Internal fixation with CMN caused one additional re-operation per 112 patients, one additional peri-implant fracture per 200 patients, and one additional deep SSI per 250 patients. CMN are used for more complex trochanteric fractures in some hospitals in the United Kingdom, which may explain the higher rates of these complications.

Implications: CMN confers a higher risk of surgery-specific complications compared to SHS, which may be due to the use of CMN for more complex trochanteric fractures. For patients with stable fracture configurations, the SHS is likely to offer better value-based care.

Dhamotharan Kamatchi, Maile Wedgwood, Farid Ud-din, Andrew Shepherd, Steve Young, Mohammad Faisal

South Warwickshire University NHS Foundation Trust, Warwick, United Kingdom

Abstract

Background: As the number of total hip arthroplasties (THAs) is increasing, number of periprosthetic femur fractures is also expected to increase. As such, thorough evaluation, patients optimization and management of periprosthetic femur fractures is imperative. 

Aim: The aim of this study is to analyse the periprosthetic femoral fractures around total hip arthroplasty (THA). The outcome of the operated patients has been investigated depending on the type of treatment provided surgical fixation and replacement.

Methods: In this retrospective 10 years study, specifics of all patients, like gender, age at fracture, ASA, mechanism of injury, mini-mental score, time of surgery, primary implant (stem) used, fracture pattern, Revision surgery (fixation/Replacement), length of stay, and complications such as infections, re-fracture, mortality were recorded. Further, the patients were followed up with Oxford hip score and mobility status at the time of discharge. 

Results: We operated 177 out of 455 PPF patients in the last 10 years. Mean age of presentation is 82.34 yrs (Range 78 – 89), Gender (65.6% females, 34.4% males), preop mean ASA (2.84), Mean AMTS 8.33, Mechanism of injury (trivial 96%, High velocity 3%), fracture patterns (Vancouver A (4%), B1 38.2%, B2 32.6%, C 18.5%). Pre-injury mobility status (no aids 53.7%, 1 stick 15.8%, frame 23.7%). Primary stem used (collarless uncemented femur 40.1%, cemented polished stem 33.9%, Surgery (Revision stem replacement 58.5% ORIF Long plates & cables 34.5%). Discharge destination (own home 45.8%, Rehab unit 32.8%, Nursing home 7.4%). Post op follow up Mean OHS (38.47)

Conclusions: Our single centre study clearly demonstrates, the collarless stems & cemented polished stems were 2.6 times more likely to result in PFF than collared stems (P<.05). Treatment strategy must be based on the fracture, the prosthesis, and the patient. Vancouver classification is not only helpful in classifying the fractures, but also in guiding the treatment. 

Lalasa Bommireddy, Zakk Borton, Amy Firth, Sammie-Jo Arnold, Rye Yern Yap, Neel Badhe, Jessica Nightingale, Benjamin Ollivere

Queens Medical Centre, Nottingham, United Kingdom

Abstract

Introduction: The Nottingham Hip Fracture Score (NHFS) is an established risk-stratification tool for 30-day mortality in patients sustaining femoral neck fractures. Despite increasing awareness of similarities between hip fractures and those sustaining periprosthetic or other femoral fractures there is a paucity of research identifying whether the NHFS could be used to prognosticate mortality in this wider cohort. 

Method: We retrospectively reviewed a consecutive series of patients presenting to a UK major trauma centre between December 2015-June 2022. Identified from a prospectively maintained trauma database, inclusion criteria were patients age >65years with AO femoral fracture 32/33 and periprosthetic femoral fractures type B-E (Unified Classification System). Open fractures and polytrauma patients were excluded. Clinical notes were reviewed for NHFS and mortality data. Statistical analysis was principally survival analysis by the Kaplan-Meier Method and Receiver Operating Characteristic (ROC) curve analysis.

Results: 431 patients were included comprising 221 periprosthetic and 220 femoral fractures. 74.7% were female (n=322) with median age 83 years (IQR 76-89). Median NHFS was 5 (IQR 4-6). NHFS was calculable in 427 (99%). Overall mortality during the study period was 53.8%. 30-day and 1-year mortality was 7.4% and 25.1% respectively. Survival curves diverged significantly between NHFS subgroups at all time points (Breslow test p=<0.001). Considering the area under the ROC curves (AUROC), NHFS discriminated mortality at 30-days (AUROC 0.746, 95% CI 0.666-0.826), 1-year (AUROC 0.7770.730-0.825) and throughout the study period (AUROC 0.733, 0.686-0.780) at p<0.001. 

Conclusion: NHFS was able to discriminate survival at all time points with similar accuracy to validating studies in the hip fracture cohort. We advocate its use to help prognosticate, improve patient counselling, direct perioperative care and allow adjustment for cohort morbidity during audit. We hope adopting a unified risk-stratification tool for fragility femoral fractures might improve the disparity with which they are treated with respect to hip fractures.

Amr Selim^1,2, Deepak Menon^1,2, Nikhil Ponugoti³

¹Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ²School of Medicine, Keele University, Staffordshire, United Kingdom. ³North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, United Kingdom

Abstract

Background: Subtrochanteric fractures present a challenge in treatment due to their varied aetiologies and complexities. Surgical intervention aims to alleviate pain and facilitate early mobility, but associated post-operative mortality remains considerable. The mortality further increases should a surgical complication occur, necessitating appropriate implant choice and surgical technique. While intramedullary nailing is the standard treatment, the choice between short and long nails remains contentious. This meta-analysis aims to compare the complication outcomes of short and long cephalomedullary nail (CMN) fixation for subtrochanteric hip fractures.

Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Medline, Embase, and CINAHL databases were searched for relevant studies. Inclusion criteria comprised studies directly comparing short and long nails in treating subtrochanteric fractures, including Randomised Controlled Trials (RCTs) and comparative studies. Data synthesis and statistical analysis were performed using RevMan 5.23.5 software.

Results: After screening, three retrospective comparative studies met the inclusion criteria. This involved a total of 4097 subjects with subtrochanteric fractures, of whom 785 were treated with short nails and 3312 with long nails. The mean ages across the studies ranged from 78.9 to 83.2 years. Peri-implant fracture and implant failure were statistically higher in short nails, with p values 0.005 and 0.01, respectively. The overall reoperation rates, non-union, and deep infection weren’t statistically different in both groups, with p values 0.55, 0.92, and 0.40, respectively.

Conclusion: Our findings challenge previous recommendations favouring the use of short nails across all per-trochanteric hip fractures and suggest that long nails are safer than short nails for the subtrochanteric group, since they are associated with lower rates of implant failure and peri-implant fractures. This is the first meta-analysis to investigate the effect of nail length on the outcomes of subtrochanteric fractures ,in particular, among all proximal femoral fractures.

William Oliver¹, Katrina Bell¹, Thomas Carter¹, Timothy White¹, Nicholas Clement¹, Andrew Duckworth², Samuel Molyneux¹

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. ²University of Edinburgh, Edinburgh, United Kingdom

Abstract

Background: This single-centre prospective randomised trial aimed to assess whether there was any difference in outcome between surgery and bracing for adults with an isolated, closed humeral shaft fracture.

Methods: Seventy patients (mean age 49yrs, 54% female) were randomised to either open reduction and plate fixation (n=36/70) or functional bracing (n=34/70). Seven patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); intention-to-treat analyses were employed. The primary outcome measure was the DASH score at 3mths. Secondary outcomes in the year following intervention included health-related quality of life (HRQoL), shoulder/elbow range of motion (ROM), complications and return to activity.

Results: At 3mths, 66 patients (94%) had complete follow-up. The mean DASH favoured surgery (mean difference [MD] 14.9; p=0.006). Surgery was also associated with a superior DASH at 6wks (MD 14.7, p=0.005), but not at 6mths or 1yr. Surgery was associated with superior HRQoL (EQ-5D: 6wks, MD 0.126, p=0.03; EQ-VAS: 6mths, MD 7, p=0.039; SF-12 MCS: 6wks, MD 9.3, p=0.001; 3mths, MD 6.9, p=0.008; 6mths, MD 7.1, p=0.007) and pain scores (body pain: 6wks, MD 12/100, p=0.02; 6mths, MD 10/100, p=0.023; limb pain: 6mths, MD 1.2/10, p=0.027). Surgery conferred superior shoulder elevation, abduction and external rotation at 6wks and 3mths, and elbow flexion at 3mths and 1yr (all p<0.05). Brace-related dermatitis was more common in the non-operative group (18% vs 3%; OR 7.8, p=0.049). There were eight nonunions (non-operative 18% vs operative 6%; OR 3.8, p=0.14). There was no difference in return to work, but surgery conferred a higher rate of return to sport (94% vs 57%; p=0.027). There were no other differences in outcomes between groups.

Conclusions: Surgery confers early functional advantages over bracing. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in outcomes at 1yr.

Ahmed Daoub¹, Saad Azhar², MTFE Collaborative*^3,4,5,6,7, Amr Selim^1,8, Rajesh Shah²

¹The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ²Hull University Teaching Hospitals, Hull, United Kingdom. ³Shrewsbury and Telford NHS Trust, Shropshire, United Kingdom. ⁴University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, United Kingdom. ⁵Huddersfield Royal Infirmary, Huddersfield, United Kingdom. ⁶Wye Valley NHS Trust, Hereford, United Kingdom. ⁷University Hospitals Coventry & Warwickshire, Warwick, United Kingdom. ⁸School of Medicine, Keele University, Staffordshire, United Kingdom

Abstract

Background: The mortality rate of tibial shaft fractures in the elderly is comparable to that of hip fractures, yet there is no consensus on their management. Operative treatment allows for earlier weight-bearing and reduces potential complications of non-weight bearing, however it carries risks for this co-morbid cohort. The main objective of this study is to assess whether there is a difference in the 1-year mortality between operative and non-operative management.

Methods: A multi-centre study was conducted, collating data from 6-trusts across England. Data was collected retrospectively, covering a 5-year period from January 2017 to December2021. The study included all patients aged 65 and over with diaphyseal tibial fractures (AO42). Patients with non-acute (>3 weeks), periprosthetic, pathological, or multiple lower limb fractures were excluded. Logistic regression analysis was used to identify the effect of non-operative management on 1-year mortality while adjusting for Age, Sex, ASA, Smoking, and Pre-Injury mobility.

Results: A total of 171 patients were identified, comprising 38% males and 62% females. Of these, 59.65% were managed operatively, while 40.35% were managed non-operatively. The median age was 82(IQR75-89) years in the non-operative group Vs. 74.5(IQR70-82) in the operative group p=0.002,r=0.23. Mortality was higher in the non-operative group 39.34% Vs. 13.04% in the operative group p<0.001. The median Length of Stay was 8 days(IQR2-18.5) in the non-operative group Vs. 8.5(IQR5-17) in the operative group p=0.87. Non-union was higher in the non-operative group 21.74% Vs. 6.25% in the operative group, p<0.001. The regression model showed that non-operative management was the second highest independent predictor of 1-year mortality with coefficient B=1.4,p=0.012, following wheelchair pre-injury mobility coefficient B=2.89,p=0.004.

Conclusion: This study showed that non-operatively treated tibial shaft fractures in the elderly have a significantly higher non-union, and 1-year mortality rate. A national guidance is required for the management these patients. 

Caroline Selvakumar, James Gill, Konrad Wronka

West Suffolk NHS Foundation Trust, Bury St Edmunds, United Kingdom

Abstract

Background: Intracapsular hip fractures are common debilitating injuries among the elderly, often treated with hip hemiarthroplasty. In the UK, the anterolateral approach is widely utilized for this procedure. However, the SPAIRE (Save Piriformis and Obturator Internus, Repair Externus) approach, developed at the Exeter Hip Unit, offers promising results by preserving key structures and enhancing joint stability. Our study aims to assess the efficacy of the SPAIRE approach in hip hemiarthroplasty and compare its outcomes with the anterolateral approach.

Methodology: We retrospectively analyzed outcomes of hip hemiarthroplasty using the SPAIRE approach at our institution from 2019 - 2024. Patient data were obtained from electronic records and local databases. Outcome measures such as mobilization, discharge destination, mobility at follow-up and mortality were assessed. These results were compared with a matched cohort undergoing anterolateral approach, performed exclusively by hip specialists, to mitigate bias.

Results: There were 54 patients in each group. More than 80% of the patients under both the groups mobilised on day 1. SPAIRE group achieved superiority by being more independent by day 7 post-surgery. Length of stay was similar however a higher percentage from the SPAIRE group were discharged to their usual residence (87% vs. 72%). There were no dislocations in the SPAIRE group versus 2 dislocations in the control group, one required excision arthroplasty. There was one wound haematoma that required surgical evacuation in control group. There were no sciatic nerve palsies or other surgical complications in either cohort. There were no cases of abductor weakness nor limp in the SPAIRE group at final follow up. In control group there were 2 patients with documented abductor deficiency.

Conclusion: The SPAIRE approach for hip hemiarthroplasty demonstrates safety and favorable outcomes with minimal complications. Our findings underscore the importance of training surgeons in adopting the SPAIRE approach for treating hip fractures.

Julian Pietrzycki, Ofir Ben-Gal, Elspeth Murray, Sarah Vaughan, Ashish Mahendra, Sanjay Gupta

Glasgow Royal Infirmary, Glasgow, United Kingdom

Abstract

Background: Primary chondrosarcomas are defined as those which arise de novo, whereas secondary chondrosarcomas develop from precursor lesions (enchondromas or osteochondromas). Despite lacking literature, there is consensus opinion amongst specialists in orthopaedic oncology that chondrosarcomas have precursor lesions and therefore are secondary in nature.

Methods: This thirteen-year retrospective cohort study primarily aims to ascertain whether patients with a diagnosis of primary chondrosarcoma have abnormal imaging of the affected region which predates their diagnosis. Secondarily, we evaluated the duration and nature of any reported preceding symptoms. We have broken down our results to look specifically at intermediate to high-grade chondrosarcomas (grade 2 and grade 3) in more depth. Radiological reports and Consultant Orthopaedic Oncologist reviews of historical imaging were sought to evaluate relevant studies.

Results: More than half of our study population had no prior imaging for comparison. Of those imaged, 71.4% (20.4% of cohort) had previously abnormal imaging at a site which went on to develop a presumed primary chondrosarcoma. All grade 2 and grade 3 diagnoses of chondrosarcoma which had prior imaging were on review found to have evidence of precursor lesions. Almost all patients had a significant duration of preceding symptoms.

Conclusions: The idea that all chondrosarcomas have precursor lesions remains contentious. As over half our patients had no prior imaging, conclusions cannot confidently be applied to all presumed primary chondrosarcomas. Furthermore, of those with positive prior imaging, the suboptimal and non-dedicated modalities on which they have been identified creates significant diagnostic uncertainty as to their nature. We must however acknowledge that all our presumed primary intermediate to high-grade lesions with prior imaging, have demonstrated previous abnormalities

Nicholas Eastley^1,2, Marium Jafri³, Manoj Raghavan³, Paul Cool⁴, Jonathan Stevenson⁵

¹University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. ²The University of Leicester, Leicester, United Kingdom. ³University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom. ⁴Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ⁵The Royal Orthopaedic Hospital, Birmingham, United Kingdom

Abstract

Background: A subgroup of patients present with musculoskeletal (MSK) metastases but no discernible primary tumour. An inability to employ disease-specific treatment in this cohort means their median survival is just 6-10 months.  We present a novel, prospective, pilot study investigating the role of targeted Next Generation Sequencing (NGS) of MSK metastases in these ‘Cancer of Unknown Primary’ (CUP) patients, reporting on diagnostic, therapeutic and prognostic benefits. 

Methods: Patients with an MSK lesion radiologically consistent with a metastases, no previous cancer diagnosis and a chest, abdomen and pelvic CT negative for a primary tumour were identified as potentially eligible. After a metastases biopsy ruled out sarcoma, analysed patients’ tumoural DNA and RNA was analysed using targeted NGS. Data was processed using a custom bioinformatics pipeline and variants classified by their biological and clinical significance.

Results: 19 patients (8F:11M, median age 70 years, range 40-76) were analysed. 18 (95%) had one or more variant with a ‘potential’ or ‘strong’ clinical significance. 8 (42%) patients’ variants highlighted them as eligible for an open clinical trial(s). 3 (16%) had variant(s) with potential therapeutic or prognostic ramifications.  Median survival of the cohort was 15 months (range 0 – 41). 11 (58%) patients were referred to an appropriate MDT for disease specific treatment based on their genomic analysis. 5 of these 11 (45%) died during follow up (median survival 11 months, 4—32) compared to 7/8 (88%) managed by a CUP MDT (median survival 9 months, 0-18).

Conclusions: As personalised medicine becomes commonplace, the ability to identify patients’ primary tumour is paramount.  Our data suggests that the use of real-time genomic sequencing to characterise CUP patients has multiple diagnostic and therapeutic benefits. Larger, prospective trials are needed to characterise the genomics of this vulnerable patient cohort, and investigate any potential survival benefits of this analysis.

Rossel Morhij¹, Muhammad Sarmad Tamimy^2,1, Anna Raurell^2,1, Kathryn Steele^1,2, Robert Ashford^3,1,4, Nicholas Eastley^3,4,1

¹East Midlands Sarcoma Service, East Midlands, United Kingdom. ²Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. ³University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. ⁴University of Leicester, Leicester, United Kingdom

Abstract

Background: The majority of soft tissue tumours can be accurately assessed using appropriate radiological investigations. However, characterising small lesions prior to excision can often remain a challenge. Such tumours are commonly referred to regional sarcoma services, and take up a significant proportion of the workload of the triage MDTs now often run in such services. This study aims to investigate the aetiology of small, indeterminate, soft tissue lesions, and the safety of their primary excision biopsy.

Methods: We retrospectively reviewed all patients who underwent an excision biopsy of an indeterminate, superficial, soft tissue tumour >3cm in size under the remit of the East Midlands Sarcoma Service between 2020 and 2024. Patients’ clinical notes, radiological investigations, multidisciplinary team discussions, histological diagnoses were all reviewed. Any case requiring further treatment was also characterised fully.

Results: 103 patients were included (mean age 58 years, range 18-78). Every patient underwent imaging prior to their excision (100% US scan, 45% MRI). 13  patients (13%) underwent a core biopsy which failed to provide a diagnosis prior to surgery. 98 excised tumours (98% cases) were benign. The commonest diagnoses in this cohort was Angioleiomyoma. 2 malignant tumours were identified (1 undifferentiated sarcoma, 1 metastatic adenocarcinoma). Neither of these patients’ usual first-line definitive treatments was prohibited by their primary excisions. No post-excision complications were noted.

Conclusions: We have performed the largest review of superficial, small, indeterminate, soft tissue tumours.  Our data confirms that the primary surgical excision of this cohort is generally safe, potentially negating their discussion with a regional sarcoma service. However, in anatomical regions where a re-excision may be complex (i.e. overlying a key joint/ distal in an extremity) vigilance and early (pre-operative) involvement of a sarcoma surgeon remains necessary.

Monketh Jaibaji¹, Nauman Hafiz¹, Glen Alder¹, Alys Nicholson¹, Avinash Rai², Abigail Bainbridge³, John Norman³, Henry Chandler³, Mohamed Elmubark¹, Peter Moriarty¹, Corey Chan¹, Reginald Chinweze⁴, Jayadeep JS⁴, Ian Carluke⁵, Suresh Thomas⁶, Murali Krishnan⁷, Simon Jameson³, Anwar Jafri², Milton Ghosh⁸

¹Health Education England North East, Newcastle Upon Tyne, United Kingdom. ²North tees NHS foundation trust, Stockton-on-Tees, United Kingdom. ³South Tees NHS foundation trust, Middlesbrough, United Kingdom. ⁴North Cumbria NHS Foundation trust, Carlisle, United Kingdom. ⁵Northumbria Healthcare NHS Foundation trust, Ashington, United Kingdom. ⁶County Durham and Darlington NHS foundation trust, Durham, United Kingdom. ⁷South Tyneside NHS Foundation trust, Sunderland, United Kingdom. ⁸Newcastle University Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom

Abstract

Background: Metastatic bone disease is a debilitating secondary manifestation of malignancy. A recent study has demonstrated the disparity between current UK practice and national guidelines. The increasing demand and complexity of these cases necessitates a regional network where challenging cases can be discussed with centres with the appropriate expertise. We conducted and audit assess our region’s disease burden and analyse current practice.

Methods: Data was prospectively collected from February 2022 to December 2023. The initial 12 months of data contained only patients referred for advice from the regional tumour centre. Subsequently this was expanded to include all cases referred to and manged by local orthopaedic departments. Data was collected and analysed centrally.

Results: 153 consecutive pelvic and appendicular metastatic cases were included. All regional units have a recognised bony metastatic disease lead. The mean age was 68.2 years. 32% of cases were referred from the local emergency department, 34% were referred via oncology and the remaining cases referred from other specialties. 32% of cases were pathological fractures, 49.6% of patients presented with pain and the rest were incidental findings. 78% of cases had oncology input and a prognosis estimate was provided in 16% of cases. Tertiary centre opinion was sought in 56% of cases and 79% of solitary metastasis cases were discussed with a tertiary centre. 56% of cases were managed surgically and 23% of surgically managed cases presenting to peripheral units were transferred to the tertiary centre for operative management.

Conclusion: Metastatic bone disease forms a significant disease burden on Orthopaedic units within our region. Overall, our region performs significantly better than the national average when assessing against BOAST guidelines. More work is needed to provide optimal care for this patient group which can be achieved through the establishment of formal regional pathways such as NEON.

Rahul Geetala^1,2, Sandra O'Malley², Murtadha Al-Khafaji³, Mustafa Al-Khafaji³, Majeed Shakokani², Chris Gooding²

¹University of Cambridge, Cambridge, United Kingdom. ²Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, United Kingdom. ³University of Debrecen, Debrecen, Hungary

Abstract

Background: Despite clear BOAST guidelines for the management of metastatic disease, some UK hospitals are yet to have a defined pathway for these patients. This study investigated the number of the BOAST guidelines that this department meets.

Methods: Pre-operative demographics, operative information and outcome data from patients who were diagnosed with lower limb metastatic disease between 26/05/2020-04/03/2024 and treated at a major trauma centre were collected. Primary bone disease patients were excluded. Percentage adherence to the standards, the accuracy of the prognosis and the impact of neoadjuvant therapy were assessed.

Results: 87 patients met our inclusion criteria. The most common primary tumours were prostate (21.84%), breast (19.54%) and renal (17.24%). Two-thirds of our cohort had a Mirel score >9, indicating the need for prophylactic fixation. All patients received orthogonal radiographs of the bone, but only 8.05% had received a staging CT-TAP within 24h of orthopaedic assessment. Moreover, 62.79% of men had a serum PSA and only 34.48% of all patients were screened for myeloma. The average time from admission to surgery was 5.31 days. All surgery was consultant-led and only three cases of implant failure. 98.85% received VTE prophylaxis. Only 22.99% of patients received an accurate pre-operative prognosis of their condition, with 41.38% having no clear prognosis on record. 42.53% of patients died within 365-days post-operation. Overall, five of the six applicable BOAST standards were followed in >80% of the patients.

Conclusion: This investigation illustrates the shortcomings of the current metastatic bone disease pathway and proposes a new pathway to meet BOAST Standards. Current recommendations such as CT-TAP within 24 hours of assessment may be unrealistic and therefore, we propose a new pathway which ensures the patient is reviewed by oncology with a defined prognosis, has a formal pre-operative assessment in non-emergency cases and followed-up at 2-& 6-weeks post-operatively.

Sophie Howles¹, Rachel Mahoney², Jonathan Stevenson¹

¹Royal Orthopaedic Hospital, Birmingham, United Kingdom. ²Cardiff and Vale University Health Trust, Cardiff, United Kingdom

Abstract

Background; Early diagnosis of sarcoma has a huge impact on long term outcomes, and in both Sarcoma UK and Bone Cancer Research Trust patient surveys, improving the pathway to diagnosis was reported to be the leading priority for patients. The aims of this national collaborative audit were to assess compliance with BSG, NICE & Scottish referral guidelines for suspected sarcoma, to identify patterns in symptom recognition and modes of referral for sarcomas in the UK.

Methods: All centres diagnosing appendicular and pelvic sarcomas were invited to participate in this national audit. Collaborators prospectively collated data from September to November 2022 (inclusive).  Data included demographics, symptoms, initial management, dates of symptom onset, presentation, referral and MDT diagnosis. 

Results: Across 12 centres, data was collected for 163 patients meeting inclusion criteria (36 bone & 127 soft tissue sarcoma).  Mean patient age was 57 years (range 7-99 years). The most common initial presenting complaint was painless lump/mass (59%), followed by pain (19%) and painful mass (17%).  26% of patients had grade 1 sarcoma, 25% grade 2 and 49% grade 3; overall 12% had metastases at presentation. The outcome of the first consultation was urgent imaging or referral in 43% and non-urgent imaging or referral in 23%. Initially, 20% were offered an alternative diagnosis and 14% were reassured. Mean time to tertiary referral (TTR) from presentation was 130 days. Time from symptom onset to diagnosis (TTD) was >60 days in 80% of cases. 27% of patients underwent biopsy outside of the tertiary centre and 10% underwent inadvertent surgery.

Conclusion: There is a need to improve diagnostic and referral pathways to allow earlier diagnosis. It is well established that a delay in diagnosis leads to negative outcomes. Next steps include working alongside emergency medicine and primary care colleagues to improve diagnostic pathways. 

William Beedham, Kumaran Rasappan, Vineet Kurisunkal

The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom

Abstract

Introduction: Surgeons are often left with a difficult decision whether to re-resect soft tissue sarcomas (STS) with a involved or close margin post primary resection. However, not much evidence exists if it makes any difference in outcomes. In this study, we hypothesise that location of the narrowest margin in STS resection specimens does not influence location of future local recurrence (LR) and thus re-resecting wound beds with narrow or involved margins is not required.

Methods: This retrospective study evaluated patients with STS who were surgically treated at a single institution over the last 22 years. Data such as post-operative margins and location of narrowest margin, tumour type/grade, neo-adjuvant / adjuvant therapy, LR, LR-free survival, and metastasis were collected and analysed.

Results: One hundred and twenty seven patients with STS and LR were identified during this 22 year period. 105 patients were excluded, due to lack of availability of full set of images and unavailability of histology reports or data on margins. In 100% of the 22 included cases, the closest resection margin was the location where LR occurred ( p < 0.001). Our data also demonstrated that there was no significant effect of resection margin distance to time of LR, or between time of LR to time of death.

Conclusion: Our data demonstrates that the narrowest or involved resection margin is where LR is most likely to occur. This data debunks our initial hypothesis and provides evidence that there may be a role for wound bed re-resections where narrow or involved margins exist in STS.

Tareq Altell, Waleed Ahsan, Sanjay Gupta

Glasgow Royal Infirmary, Glasgow, United Kingdom

Abstract

Background: Proximal femur replacement (PFR) is undertaken following tumor resection. This involves resection of the proximal femur and reconstruction with an endoprosthesis. The hip abductors and flexors are initially dissected and then reattached to the endoprosthesis. While the importance of reinsertion of the hip abductors and flexors to the endoprosthesis has been extensively studied, there has been limited research on the most effective method of achieving this reinsertion. Our aim was to assess radiological failure rates associated with GT osteotomy and use of GT washer to achieve reattachment to the endoprosthesis. 

Methods: A retrospective study was carried out to include date from 2010-2023. Patients with a PFR and an Endoprosthetic reconstruction (EPR) due to oncological reasons were included. 23 participants were included who underwent GT osteotomy. Electronic data and national PACS system were used to assess radiological failure. No patients were lost to follow-up.  

Results: 23 participants were identified with a GT osteotomy. Average age was 60.5 (33-81) and average follow-up was 30.2months (1.8-107.8). The average number of months between the last x-ray and the operation was 20 (3-66). The radiological failure was found to be 0% at the time of the last AP x-ray.

 Conclusion: There are several ways to achieve reinsertion of hip flexors and abductors after proximal femur replacement. Two such methods outlined commonly are re-attachment by GT osteotomy and retention of GT or re-attachment of abductor muscles by soft tissue repair only. While we still need more studies to determine the functional outcome of PFR, It can be concluded that since there was no GT migration on radiological follow-up of our patients, the GT-washer maintains the hip musculature in its anatomical position on the EPR and therefore in theory improves function outcome.

Thomas Ward¹, Robert Ashford^1,2,3, Nicholas Eastley^1,2,3

¹University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. ²East Midlands Sarcoma Service, Nottingham, United Kingdom. ³University of Leicester, Leicester, United Kingdom

Abstract

Background: Tenosynovial Giant Cell Tumours (TGCTs) are a group of rare, benign mesenchymal tumours involving the synovium, bursa and tendon sheath. There are two subtypes nodular (nTGCT) and diffuse (dTGCT). Current guidelines on TGCT management is limited.

Methods: A questionnaire on investigations (including biopsy), management, use of additional therapies and choice of follow up was distributed to members of the British Orthopaedic Oncology Society to investigate how surgeons manage primary and recurrent TGCT. Descriptive analysis of the qualitative data was performed through data coding.

Results: There were 18 responses all from orthopaedic consultants subspecialising in sarcoma surgery. MRI was unanimously the primary investigation of choice (50% with contrast). Indication for biopsy varied depending on extent of disease, imaging appearances and MDT decisions from 11% in nTGCT to 44% in extra-articular dTGCT. The majority of surgeons manage TGCT through an open excision. In units where surgery is performed by a knee or soft tissue knee surgeon, excisions were more likely to be performed arthroscopically. A staged approach was most commonly utilised for primary and recurrent dTGCT when disease involves the anterior and posterior joint. Indications for additional therapies in dTGCT vary between units based on active trials and policies. Follow up regimens vary, although dTGCT and recurrent disease currently receive longer more regular surveillance.

Discussion: TGCT is a rare but complex disease encompassing a range of different phenotypes. Despite a recent global consensus meeting, our study shows that TGCT is investigated, managed, and followed up with great variation across the UK. 

Thomas Ward¹, Samuel Oldfield², Robert Ashford^1,3,2, Nicholas Eastley^1,3,2

¹University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. ²University of Leicester, Leicester, United Kingdom. ³East Midlands Sarcoma Service, Nottingham, United Kingdom

Abstract

Background: Metastatic bone disease (MBD) is estimated to affect >50% of all cancers and is a common cause of patient morbidity. Current British Orthopaedic Oncology Society MBD guidance states that the biopsy of a presumed metastasis may reveal a benign diagnosis, a different primary tumour or a change in metastasis immunophenotypes resulting in new oncological treatment strategies. Considering this, when orthopaedic surgery is performed for MBD, and open biopsy should be strongly advised

Methods: We performed a retrospective review of patients that underwent an orthopaedic surgical procedure at our tertiary referral centre for known or suspected MBD between 9/1/22 to 4/9/23 reporting specifically on biopsy technique and results. Patient were identified from a prospectively updated database and all cases discussed with a local MBD multidisciplinary team prior to surgery.

Results: 59 patients were included for analysis (mean age 71, range 41-92, M28:F31). 54 (92%) underwent an intra-operative biopsy of some kind (41 open, 6 reamings, 4 core needle, 3 not documented). Only two of the six reamings performed were diagnostic. One patient who had a negative histology from a reaming sample had a simultaneous tissue biopsy that was positive for malignancy. Every open and core needle biopsy sample was adequate for analysis. In three patients the biopsy confirmed a different malignancy to that initially suspected.

Conclusions: Tissue biopsy in patients with MBD is important to confirm a histological diagnosis, even in the setting of known (or historical) cancer diagnosis, or cases where a primary tumour is radiologically suspected.  In an era of rapid development in many oncology fields, biopsy also offers patients the best opportunity for optimal systemic anti-cancer treatment. Open or core needle biopsy should be performed, as reamings are not adequate for diagnostic purposes.