According to the Scottish Arthroplasty Project the mean inpatient LoS following a Total Hip Replacement (THR) has fallen from 10.3 days in 2001 to only 3.9 days. This reduction in patient LoS has lead units in the UK to follow the example of centres around the world in offering THR as a day case procedure. In this study we examine data gathered from the first 18 months of day case THR within a district general hospital elective orthopaedics unit.

Data was collected prospectively from all patients undergoing THR within our district general hospital elective orthopaedic unit. Patients were selected to day case THR group via consultant review at outpatient clinic and anaesthetic assessment at pre-assessment clinics. Between August 2018 and February 2020 (18 months) 40 patients successfully underwent day case THR. None of the patients discharged home where readmitted within the next 30 days. The average age of successful day case THRs was 60 years old. The at 6 months post-op mean OHS was 45.1 and at 1 year post-op the mean score was 47.2. The average improvement in OHS was 21.1 at 6 months and 26.9 at 1 year post-op. All of the patients successfully discharged as day cases where satisfied with their care and all but one would recommend it to their friends and family.

We have shown that day case THR is not only possible within an NHS district general hospital but gives exceptional patient outcomes with excellent patient satisfaction.

Over the last decade stemless shoulder arthroplasty has become increasingly popular. However, stability of metaphyseal loading humeral components remains a concern. This study aimed to assess the stability of the Affinis stemless humeral component using Radiostereometric analysis (RSA).

Patients underwent total shoulder arthroplasty via a standardised technique with a press-fit stemless humeral component and a cemented pegged glenoid. Tantalum beads were inserted into the humerus at the time of operation. RSA of the relaxed shoulder was completed at weeks 1, 6, 13, 26, 52 and 104 post-operatively. Stressed RSA with 12 newtons of abduction force was completed from week 13 onwards. ABRSA 5.0 software (Downing Imaging Limited, Aberdeen) was used to calculate humeral component migration and induced movement.

15 patients were recruited. Precision was: 0.041, 0.034, 0.086 and 0.101 mm for Superior, Medial, Posterior and Total Point Motion (TPM) respectively. The mean TPM over 2 years was 0.24 (0.30) mm, (Mean (Standard deviation)). The mean rate of migration per 3 month time period decreased from 0.45 (0.31) to 0.02 (0.01) mm over 2 years. Mean inducible movement TPM peaked at 26 weeks at 0.1 (0.08) mm, which reduced to 0.07 (0.06) mm by 104 weeks when only 3 patients had measurable inducible motion. There was no clear trend in direction of induced movement. There were no adverse events or revisions required.

We conclude migration of the humeral component was low with little inducible movement in the majority of patients implying initial and 2 year stability of the stemless humeral component.

The role of mesenchymal stem cells (MSCs) in enhancing healing process has been examined with allogeneic and xenogeneic cells in transplantation models. However, certain factors might limit the use of allogeneic cells in clinical practice, (e.g. disease transmission, ethical issues and patient acceptance). Adipose tissue represents an abundant source for autologous cells. The aim of this study was to evaluate adipose-derived autologous cells for preventing non-union.

Adults male Wistar rats (n=5) underwent a previously published surgical procedure known to result in non-union if no treatment is given. This consisted of a mid-shaft tibial osteotomy with peri/endosteal stripping stabilised by intramedullary nail fixation with a 1mm gap maintained by a spacer. During the same operation, ipsilateral inguinal subcutaneous fat was harvested and processed for cell isolation. After three weeks in culture, the cell number reached 5×106 and were injected into the fracture site.

At the end of the experiment, all tibias (injected with autologous fat-MSCs) developed union. These were compared with a control group injected with PBS (n=4) and with allogenic (n=5) and xenogeneic (n=6) cell transplantation groups. The amount of callus was noticeably large in the autologous cell group and the distal-callus index was significantly greater than that of the other groups, P-value =<0.05, unpaired t-test, corrected by Benjamini & Hochberg.

We report a novel method for autologous MSCs implantation to stimulate fracture healing. Local injection of autologous fat-MSCs into the fracture site resulted in a solid union in all the tibias with statistically significantly greater amounts of callus.

Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial (AM) and trans-tibial (TT) portal femoral tunnel placement techniques on the primary outcome of ACLR graft rupture.

Adult patients (>18year old) who underwent primary ACLR between January 2011 – January 2018 were identified and divided based on portal technique (AM v TT). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables.

473 patients were analysed. Median age at surgery was 27 years old (range 18–70). A total of 152/473, (32.1%) patients were AM group compared to 321/473 (67.9%) TT. Twenty-five patients (25/473, 5.3%) sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odds for graft rupture was associated with the AM group, which trended towards significance (OR 2.03; 95% CI 0.90 – 4.56, p=0.081). Older age at time of surgery was associated with a lower odds of rupture (OR 0.92, 95% CI 0.86 – 0.98, p=0.014).

There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. There was a trend towards higher rupture rates in the anteromedial portal group.

The aims were: (1) assess the influence of COVID-19 on mortality in hip fracture; (2) identify predictors of COVID-19 status, and (3) investigate whether social lockdown influenced the epidemiology of hip fracture.

A multicentre retrospective study was conducted of all patients presenting to six hospitals with hip fracture over a 46-day period (23 days pre-/post-lockdown). Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, ASA grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded.

Of 317 patients with hip fracture 27 (8.5%) had a positive COVID-19 test; only 7 (26%) had symptoms on admission. COVID-19-positive patients had significantly lower 30-day survival compared to those without COVID-19 (67% versus 92%, p<0.001). COVID-19 was independently associated with increased 30-day mortality adjusting for: (1) age, sex, residence (HR 2.93, p=0.008); (2) Nottingham Hip Fracture Score (HR 3.52, p=0.001), and (3) ASA (HR 3.45, p=0.004). Platelet count predicted subsequent COVID-19 status; a value <217 ×109/L was 68% specific and sensitive (95% CI 58 to 77, p=0.002). A similar number of patients presented with hip fracture pre-lockdown (n=160) and post-lockdown (n=157); there was no significant difference in demographics, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management.

COVID-19 was independently associated with an increased 30-day mortality in hip fracture. Most patients with COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have urgent implications for the delivery of hip fracture services.

Aims

Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation.

Aims

The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

Aims

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Aims

Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients.

Aims

Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Aims

Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients.

Aims

The aim of this study was to describe variation in hip fracture treatment in Norway expressed as adherence to international and national evidence-based treatment guidelines, to study factors influencing deviation from guidelines, and to analyze consequences of non-adherence.

Aims

COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographics and outcomes of patients treated during lockdown to a matched period from 2019. Findings have important implications for service development.

Aims

To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures.

Aims

The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation.

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy.

A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D.

There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039).

These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced.

There is a lack of evidence surrounding selective patella resurfacing, but patella cartilage loss at time of total knee arthroplasty (TKA) is often used as an indication in those who perform it. This study compares the outcomes of TKA without patella resurfacing in patients with and without patella cartilage loss (PFOA).

Prospective case control study of 209 consecutive patients undergoing cruciate retaining single radius TKA without patella resurfacing for KL≥3 osteoarthritis. The presence and location of full thickness patella cartilage loss was documented intra-operatively at TKA, identifying n=108 cases with PFOA (mean age 70±9.7, mean BMI 31±6.2, 72 (67%) female) Vs n=101 controls without PFOA (age 68±9.2, BMI31±5.6, 52 (51%) female). Primary outcome measure was improvement in the Oxford Knee Score (OKS) at one year.

There were more females in the PFOA group (67% Vs 51%, p=0.037), but no other preoperative differences. There was no difference in preoperative OKS between patients with patella cartilage loss (20.6±7.9) and those without (21.0±7.2, p=0.720). There was no difference in OKS improvement following TKA without patella resurfacing between those with full thickness patella cartilage loss (14.2±9.8) and those without (15.4±9.5, p=0.365). Facet involvement (number and location) did not affect OKSs. No differences were found in the individual OKS questions between groups (p>0.05).

There was no difference in one-year OKS or improvements therein between patients with and without full thickness patella cartilage loss treated with single radius cruciate retaining TKA without patella resurfacing, questioning its use an indication for selective patella resurfacing.

Mechanical ankle instability is elicited through examination and imaging. A subset of patients however report “functional” instability ie/ instability without objective radiological evidence. Little research compares operative outcomes between these groups. We hypothesised patients with “mechanical instability” were more likely to benefit from operative intervention than those with “functional instability”.

This was a single centre, retrospective case note review of prospectively collected data. Inclusion criteria: over six months of symptoms, failed conservative management, surgical stabilisation between 2016–2018. Data collected: demographics, operative procedure, preoperative and postoperative PROMs.

Nineteen patients were included. All had preoperative MRIs determining ligamentous involvement. Nine had radiological evidence of instability, eight had negative radiographs. Two were excluded due to no intraoperative radiographs.

There was no statistical difference in preoperative MOxFQ scores between the groups (p=0.2039). Preoperative EQ5D-TTO scores were statistically different (mean mechanical 0.58 vs functional 0.26, p=0.0162) but not EQ5D-VAS scores (mean mechanical 77 vs functional 53, p=0.0806).

Mechanical group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 57.88, 22.13, 18.5. Mean EQ5D-TTO= 0.58, 0.78, 0.84. EQ5D-VAS= 77, 82, 82.5.

Functional group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 71.87, 37.75, 23. Mean EQ5D-TTO 0.26, 0.63, 0.76. EQ5D-VAS 53, 80, 88.

This trend of improvement in PROMs was not reflected in patient satisfaction scores. 75% of respondents in the functional group reported dissatisfaction at 26 weeks versus no dissatisfaction in the mechanical group. We should consider counselling patients accordingly when offering surgery.

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion.

Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion.

Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion.

Gram staining is used as an initial indicator of synovial joint infection but has widely varied false negative rates in the literature. Clinical decisions are often made on the basis of gram stain results, such as whether a patient requires urgent surgery, and therefore it is important to understand the tests efficacy.

A retrospective review of synovial fluid aspirates in NHS Tayside for the years 2017 and 2018 was performed from the departmental microbiology database. Aspirates of large joints were included (hip, knee, shoulder, wrist, elbow, ankle). Any joints with prosthesis were excluded, including fixation metalwork. Any abscess overlying a joint that was not proven to penetrate the joint was also excluded. Initial gram stain results and formal culture results were reviewed. Final culture results were considered to be the gold standard to compare gram stain results to.

2167 samples were reviewed. Of these 1552 were excluded base on inclusion criteria. Of the remaining 615, 120 (19.5%) were culture positive. There were 33 positive gram stain results, 1 false positive and 32 true positive results. The sensitivity was 26.67% with a specificity of 99.80% (p=0.0001). The negative predictive value is 84.88% (CI 83.44% – 86.21%).

These results show that gram stain tests of native joints have a low sensitivity and poor negative predictive value. This is reflected in the current literature with prosthetic joints. Based on this study caution should be used when interpreting a negative gram stain result with appropriate safety netting and follow up required alongside clinical assessment.

This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions.

Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or non-operative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year using the Disabilities of the Arm, Shoulder and Hands (DASH), Oxford Shoulder Scores (OSS) and Short Form (SF-12). Reduction was evaluated using radiographs. Complications were recorded, and an economic evaluation performed.

There was no significant difference in DASH or OSS at one year between non-operative and ORTSD groups (DASH score, 4.67 versus 5.63; OSS, 45.72 versus 45.63). Patients undergoing surgery had inferior DASH scores at 6 weeks (p<0.01). Five patients who failed non-operative management subsequently received surgery. Overall cost of treatment was significantly greater after ORTSD fixation (£796.22 vs £3359.73 (p<0.01)).

ORTSD fixation confers no functional benefit over non-operative treatment at one year. While patients managed non-operatively generally recover faster, a significant group remain dissatisfied following non-operative treatment requiring delayed surgical reconstruction.

Though knee osteoarthritis (OA) is diagnosed and monitored radiographically, full thickness cartilage loss (FTCL) has rarely been correlated with radiographic classification. This study aims to analyse which classification system correlates best with FTCL and assessing their reliability.

Prospective study of 300 consecutive patients undergoing total knee arthroplasty (TKA) for OA. Two blinded examiners independently graded preoperative radiographs using 5 systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlback. Interobserver agreement was assessed using the intraclass correlation coefficient. Intraoperatively, anterior cruciate ligament (ACL) status and FTCL in 16 regions of interest were recorded. Radiographic classification and FTCL were correlated using the Spearman correlation coefficient.

On average, each knee had 6.8±3.1 regions of FTCL, most common medially. The commonest patterns of FTCL were medial with patellofemoral (48%) and tricompartmental (30%). ACL status was associated with pattern of FTCL (p=0.02). All classification systems demonstrated moderate ICC, but this was highest for IKDC: whole knee 0.68 (95%CI 0.60–0.74); medial compartment 0.84 (0.80–0.87); and lateral compartment 0.79 (0.73–0.83). Correlation with FTCL was strongest for Ahlback (Spearman rho 0.27–0.39) and KL (0.30–0.33), though all systems demonstrated medium correlation. The Ahlback was the most discriminating in severe OA. Osteophyte presence in the medial compartment had high positive predictive value for FTCL, but not in the lateral compartment.

The Ahlback and KL systems had the highest correlation with confirmed cartilage loss. However, the IKDC system displayed best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, though less discriminating in severe disease.

Glenohumeral dislocation is complicated with a greater tuberosity fracture in 16% of cases. Debate regarding the safety of closed reduction in the emergency department exists, with concerns over fracture propagation during the reduction manoeuvre. The study aim was to report the results of closed reduction, identify complications and define outcome for these injuries.

188 consecutive glenohumeral dislocations with a tuberosity fracture were identified from a prospective database from 2014–2017. 182 had an attempted closed reduction under appropriate sedation using standard techniques, five were manipulated in theatre due to contra-indications to sedation. Clinical, radiographic and patient reported outcomes, in the form of the QuickDASH and Oxford Shoulder Score (OSS), were collected.

A closed reduction in the emergency department was successful in 162 (86%) patients. Two iatrogenic fractures of the proximal humerus occurred, one in the emergency department and one in theatre, representing a 1% risk. 35 (19%) of patients presented with a nerve lesion due to dislocation. Surgery was performed in 19 (10%) cases for persistent or early displacement (< 2 weeks) of the greater tuberosity fragment. Surgery resulted in QuickDASH and OSS scores comparable to those patients in whom the tuberosity healed spontaneously in an anatomical position (p=0.13). 18 patients developed adhesive capsulitis (10%).

Glenohumeral dislocation with greater tuberosity fracture can be safely treated by closed reduction within the emergency department with a low risk of humeral neck fracture. Persistent or early displacement of the tuberosity fragment will occur in 10% of cases and is an indication for surgery.

Successful return to work (RTW) is a crucial outcome after primary total knee arthroplasty (TKA) in patients under 65 years old. We aimed to determine whether TKA facilitated RTW in patients <65 years, whose intention was to return preoperatively.

We prospectively assessed 106 TKA patients under 65 years over a 1 year period both preoperatively and at 1 year following surgery. Patient demographics were collected including Oxford knee score, Oxford-APQ, VAS pain/health scores and EQ-5D. A novel questionnaire was distributed to delineate pre-operative employment status and post-operative intentions. This included questions on nature of pre and post-operative occupation, whether joint disease affected their ability to work and details of retirement plans and how this was affected by their knee.

69 patients intended to return to work following their TKA. Following arthroplasty, 57/69 patients (82.6%) returned to work at a mean of 16.4 weeks (SD 16.6). Univariate analysis showed significant factors facilitating RTW included, pre-operative oxford knee score, pre-operative Oxford-APQ score and pre-operative EQ-5D score. These were not predictive on multivariate analysis.

This study finds that TKA facilitates return to work in 83% of those who intend to return to work following their surgery. This could have significant positive and health and financial cost implications for the individual, health system and society.

We report a cost-effectiveness analysis of Primary Total Ankle Replacements (TAR). In addition, we looked for factors that could be predictors of increased gain in Quality-Adjusted Life Years (QALYs).

Pre-operative and six-month post-operative data for TAR was obtained over seven-and-a-half-years in NHS Lothian. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and Deprivation category. Continuous variables were assessed with Pearson correlation coefficients, Deprivation and BMI categories with Boxplots and gender with the Mann-Whitney U test.

The 74-patient cohort [Mean age 68.03 (SD 8.61), 60.8% male] had 49% classed as obese or higher. Cost per QALY gained was £3841, rising to £9202 when annual 3.5% reduction in health gains and 1.9% revision rates were included. Lower pre-operative EQ-5D-3L index correlated significantly with increased QALYs gained (p <0.01), all other predictors returned insignificant results (p >0.05).

Primary TAR has proven very cost-effective in treating end-stage ankle arthritis. Pre-operative EQ-5D-3L is the most promising predictor of QALYs gained identified.

To evaluate if clinical recovery following midshaft clavicle fracture is associated with nonunion and determine if this has superior predictive value compared to estimation at time of injury.

A prospective study of all patients (≥16 years) who sustained a displaced midshaft clavicle fracture was performed. We assessed patient demographics, injury factors, functional scores and radiographic predictors with a standardized protocol at six-weeks. Conditional-stepwise regression was used to assess which factors independently predicted nonunion at six-months post-injury determined by CT. The nonunion predictor six-week model (NUP6) was compared against a previously validated model based on factors available at time of injury (NUP0-smoking, comminution and fracture displacement).

200 patients completed follow-up at six months. The nonunion rate was 14% (27/200). Of the functional scores, the QuickDASH had the highest accuracy on receiver-operator-characteristic (ROC) curve analysis with a 39.8 threshold, above which was associated with nonunion (Area Under Curve (AUC) 76.8%, p<0.001).

On regression modelling QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort (n=80/200). Conversely if two or more were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%.

The NUP6 model appeared to have superior accuracy when compared to the NUP0 model on ROC curve analysis (AUC 87.3% vs 64.8% respectively).

Delayed assessment at six-weeks following displaced clavicle fracture enables a more accurate prediction of fracture healing.

Osteoinductive bone substitutes are in their developmental infancy and a paucity of effective grafts options persists despite clinical demand. Bone mineral substitutes such as hydroxyapatite cause minimal biological activity when compared to osteoinductive systems present biological growth factors in order to drive bone regeneration. We have previously demonstrated the in-vitro efficacy of a bioengineered system at presenting growth factors at ultra low-doses. This study aimed to translate this growth factor delivery system towards a clinically applicable implant.

Osteoinductive surfaces were engineered using plasma polymerisation of poly(ethyl acrylate) onto base materials followed by adsorption of fibronectin protein and subsequently growth factor (BMP-2). Biological activity following ethylene oxide (EO) sterilisation was evaluated using ELISAs targeted against BMP-2, cell differentiation studies and atomic force microscopy. Scaffolds were 3D printed using polycaprolactone/hydroxyapatite composites and mechanically tested using a linear compression models to calculate stress/strain. In-vivo analysis was performed using a critical defect model in 23 mice over an 8 week period. Bone formation was assessed using microCT and histological analysis. Finally, a computer modelling process was developed to convert patient CT images into surface models, then formatted into 3D-printable scaffolds to fill critical defects.

Following EO sterilisation, there was no change in scaffold surface and persistent availability of growth factors. Scaffolds showed adequate porosity for cell migration with mechanical stiffness similar to cancellous bone. Finally, the in vivo murine model demonstrated rapid bone formation with evidence of trabecular remodelling in samples presenting growth factors compared to controls.

National guidelines encourage the use of total hip arthroplasty (THA) to treat intracapsular neck of femur fractures. There have been no population based studies appraising the surgical outcomes for this indication across an entire population. This study aims to calculate the complication rates for THA when performed for a fractured neck of femur and compare them to THA performed for primary osteoarthritis in the same population.

The Scottish Arthroplasty Project identified all THAs performed in Scotland for neck of femur fracture and osteoarthritis between 1st of January 2009 and 31st December 2014. Dislocation, periprosthetic infection and revision rates at 1 year were calculated.

The rate of dislocation, periprosthetic infection and revision at 1 year were all significantly increased among the fracture neck of femur cohort. In total 44046 THAs were performed, 38316 for OA and 2715 for a neck of femur fracture. 2.1% of patients (n=57) who underwent a THA for a neck of femur fracture suffered a dislocation in the 1st year postoperatively, compared to 0.9% (n=337) when the THA was performed for osteoarthritis. Relative Risk of dislocation: 2.4 (95% C.I. 1.8077–3.1252, p value <0.0001). Relative Risk of infection: 1.5 (95% C.I. 1.0496–2.0200, p value 0.0245) Relative Risk of revision: 1.5 (95% C.I. 1.0308–2.1268, p value 0.0336).

This is the first time a dislocation rate for THA performed for a neck of femur fracture has been calculated for an entire population. As the number of THAs for neck of femur fracture increases this dislocation rate will have clinical implications.

Fractures of the lateral clavicle with complete displacement have a high non-union rate and are associated with poor functional outcomes following non-operative treatment. Various operative techniques are available but preliminary studies of open reduction and tunnelled suspensory device (ORTSD) fixation report good early functional outcomes with a low rate of complications. This study assesses the functional outcomes in a large series of patients treated using ORTSD.

After surgical reconstruction in 67 patients, outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Oxford score at six weeks, and three, six and twelve months post-operatively. 55 of 64 surviving patients were contacted at a mean of 69 (27–120) months to complete DASH and Oxford scores, evaluate overall satisfaction, and document any complications.

At one year post-operatively, the mean Oxford score was 46.4 and mean DASH score was 2.4 points (59/67 patients assessed). At a mean of 69 months after surgery, the mean Oxford score was 46.5 and mean DASH score was 2.2 (55 surviving and contactable patients). There were no significant differences between the one-year functional scores and those at the latest follow-up. Two patients developed symptomatic non-union requiring re-operation, and two developed an asymptomatic fibrous union not requiring surgery. The five-year survival when considering only obligate revision for implant-related complications was 97.0%.

ORTSD fixation for isolated displaced lateral-end clavicle fractures in medically-fit patients is associated with good functional outcomes, and a low rate of medium-term complications. Routine removal of the implant was not necessary.

We report on the 5 year results of a randomized study comparing TKR performed using conventional instrumentation versus electromagnetic computer-assisted surgery.

This study analysed patient reported outcome measures (PROMs) at 5 years utilising the American Knee Society Score (AKSS), Oxford Knee Score (OKS), the Short Form 36 score and range of motion (ROM). Of the 200 patients enrolled 125 completed 5 year follow up, 62 in the navigated group and 63 in the conventional group. There were 28 deceased patients, 29 withdrawals and 16 lost to follow-up.

There was improvement in clinical function in most PROMs from 1-5 year follow up across both groups. OKS improved from a mean of 26.6 (12–55) to 35.1 (5–48). AKSS increased from 75.3 (0–100) to 78.4 (−10–100), SF36 from 58.9 (2.5–100) to 53.2 (0–100). ROM improved by an average 7 degrees from 110 degrees to 117 degrees (80–135). There was no statistically significant difference in PROMs between the groups at 5 years.

Patients undergoing revision surgery were identified from the dataset and global PACS. There were no revisions within 5 years in the navigated group and 3 revisions in the conventional group, two for infection and one for mid-flexion instability, giving an all cause revision rate of 3.06% at 5 years for this group.

There appears to be no significant advantage in clinical function for patients undergoing TKR for OA of the knee with electromagnetic navigation when compared to conventional techniques. There may be an advantage in reducing early revision rates using this technology.

Elevated fat pads on a paediatric elbow radiograph may represent an intraarticular fracture. If no obvious fracture is visible, the injury may be treated with a collar and cuff until discomfort resolves. In some centres these patients are discharged directly from A&E, easing the load on fracture clinics and reducing the number of visits required by the patient.

A retrospective study was carried out to review patient journey for children referred to clinic with elevated fat pads only and to investigate whether such a protocol could be established locally. Notes for all children attending fracture clinic in May 2018 were reviewed. X-rays for patients with any elbow injury were then reviewed. Patients with raised fat pads only were included in the study. Outcome following clinic review was recorded.

818 patients (315 new referrals) attended 15 clinics. 31 were referred with raised fat pads only. Mean age was 7.7 years with mean time to clinic of 4 days. 74.2% required no further treatment and were discharged at first clinic appointment. 8 patients were kept in cast for another 1–2 weeks due to parental apprehension, patient apprehension or patient being uncomfortable without cast. None of our patients required surgical intervention or re-attended following discharge.

This study showed that patients with raised fat pads only can be treated with collar and cuff, analgesia and discharged from A&E with an advice leaflet. This would reduce the number of patients unnecessarily attending clinics thereby reducing patient distress and enabling more efficient use of clinic appointments.

The burden of osteoporosis (OP), and its accompanied low energy fractures, is ever increasing. Targeted therapies are under development to stem the tide of the disease, with microRNAs identified as biomarkers and potential targets. Assessing the functional capacity of bone marrow mesenchymal stromal cells (BMSC) from patients with low energy neck of femur fractures (NOF) will identify the expected outcomes to be achieved from new, targeted osteogenic therapies.

Two patient groups were assessed; low energy NOF and osteoarthritic. Bone marrow aspirates were taken at time of arthroplasty surgery. The adherent fraction was cultured and assessed by flow cytometry, microRNA expression and differentiation functionality.

Both patient groups demonstrated characteristic extracellular markers of BMSCs. 3 key markers were significantly reduced in their expression in the NOF group (CD 90, 13, 166 P=0.0286). Reduced differentiation capacity was observed in the NOF group when cultured in osteogenic and adipogenic culture medium. 105 microRNAs were seen to be significantly dysregulated, with microRNAs known to be crucial to osteogenesis and disease process such as osteoporosis abnormally expressed.

This data demonstrates the impaired functional capacity of BMSCs and their abnormal microRNA expression in patients who suffer a low energy NOF. Future targeted therapies for OP must address this to maximise their restorative effect on diseased bone. The important role microRNAs can play as biomarkers and target sites has been further reinforced.

MOXIMED KineSpring® Knee Implant System is an Orthopaedic device designed for younger or highly active patients with osteoarthritis. The device is placed under the skin, is attached to the tibia and femur, and contains springs which help limit some of the forces that are transmitted through the knee during activities such as walking or running and thereby relieve pain that may be experienced by patients with early arthritis of the knee. The aim of this study is to determine the long term safety and efficacy of the KineSpring knee implant system.

This is a prospective case series involving two centres in Glasgow. 29 patients (mean age of 45.1 years and range 18-65 years) were recruited into the study between 2011 and 2016. The Primary outcome measure was Oxford knee score (OKS) at 2, 5 and 10 years post-operatively. Secondary outcome measures include device related complications and survival, patient reported functional outcome measures, patient satisfaction, pain levels and change in radiographic classification of osteoarthritis

At 2-year follow-up, 7 implants were removed (74.1% survival). Complications include deep infection, requiring removal in 1 patient, 2 implant failures requiring removal and one spring breakage. In comparison to pre-operative measures there was an improvement in the pain (3.58 vs. 5.20, p=0.02), stiffness (4.16 vs. 4.47, p=0.6) and OKS (32.4 vs. 36.9, p=0.03).

The KineSpring improves overall pain, stiffness and functional outcome at 2 years following surgery, however there was a high rate of removal and further long-term follow up analysis is required regarding its effectiveness.

Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

Reduced length of stay (LOS) is logistically, economically and physiologically beneficial. Although a high proportion of total joint arthroplasty (TJA) patients are suitable for same day admission (SDA), removable barriers persist in many centres. This study aimed to determine factors limiting SDA and quantify the impact of implementing both SDA and a targeted enhanced recovery programme on length of stay.

This single-centre retrospective cohort study collected data on elective TJA patients aged <60. Qualitative service reviews identified opportunities for optimisation. Improvements were implemented in 2017, including: obtaining consent at the pre-assessment clinic and robustly assessing suitability for SDA. A targeted rapid recovery program was implemented in June 2018. Data was collected prior to changes in 2017, and following changes in 2018.

106 of 108 screened patients were eligible for inclusion. There were no significant between-year differences in baseline health characteristics. Significantly greater proportions of 2018 patients were consented at their pre-assessment clinic (56% vs 8.9%, p<0.001) and assessed as suitable for SDA (94% vs 57.1%, p<0.001). Pre-operative LOS was significantly reduced in 2018 for both total hip replacements (median [IQR]: 0[0,0] vs 1[1,1], p<0.001) and total knee replacements (median [IQR]: 0[0,0] vs 0[0,1], p=0.002). The departmental mean LOS improved from 4.7 days to 3.7 days following SDA. This was further shortened to 3.2 days after introduction of the rapid recovery program.

When a larger proportion of patients were deemed suitable for SDA, this correlated with reduction of LOS. The department now performs above national standards in both of these parameters.

Combined glenoid and humeral bone loss has been identified as an important factor in predicting recurrence after arthroscopic shoulder stabilisation. The “glenoid track” concept is proposed to predict recurrent instability by comparing the relative size of the glenoid to the humeral bone defect. The aim of this study was to investigate whether assessment of the glenoid track on a pre-operative MR arthrogram could be used to predict subsequent instability in a typical UK population.

A retrospective study was undertaken of 175 primary arthroscopic stabilisation procedures of which 82% (n=143) were men. The median age was 26 years (IQR 22 to 32, range 16 to 77). The median follow-up was 76 months (range 21 to 125). A pre-operative MR arthrogram was used to determine if the shoulder was on-track or off-track. The endpoint of recurrent dislocation was examined.

The prevalence of “off-track” bone loss in this group was 14.2% (n=25). There were 6 (24%) dislocations in the off-track group compared with 5 (3.33%) dislocations in the on-track group (RR 7.2, 95% CI 2.45 to 20.5, p=0.001). At 5 years, the cumulative redislocation rate was 26.1% in the off-track group compared with 8.7% in on-track group. The rate of any recurrent instability was 60% (n=15) v 18% (n=27) (RR 3.33, 95% CI 2.02 to 5.20, p<0.0001). Glenoid track (on v off) was not predicted by gender (p=0.411).

In a typical UK population assessment of the glenoid track on an MR arthrogram can be used to risk stratify patients with shoulder instability.

The treatment of massive rotator cuff tears remains controversial. There is lack of studies comparing patient-reported outcomes (PROM) of arthroscopic massive rotator cuff repairs (RCR) against large, medium and small RCRs. Our study aims to report the PROM for arthroscopic massive RCR versus non-massive RCR.

Patients undergoing an arthroscopic RCR under a single surgeon over a 5-year period were included. Demographic data were recorded. Pre-operative Quick-DASH and Oxford Shoulder Score (OSS) were prospectively collected pre-operatively and at final review (mean of 18 months post-operatively). The scores were compared to a matched cohort of patients who had large, medium or small RCRs. A post-hoc power analysis confirmed 98% power was achieved.

82 patients were included in the study. 42 (51%) patients underwent massive RCR. The mean age of patients undergoing massive RCR was 59.7 and 55% (n=23) were female. 21% of massive RCRs had biceps augmentation. Quick-DASH improved significantly from a mean of 46.1 pre-operatively to 15.6 at final follow-up for massive RCRs (p<0.001). OSS improved significantly from a mean of 26.9 pre-operatively to 41.4 at final follow up for massive RCRs (p<0.001). There was no significant difference in the final Quick-DASH and OSS scores for massive and non-massive RCRs (p=0.35 and p=0.45 respectively). No revision surgery was required within the minimum one year follow up timescale.

Arthroscopic massive rotator cuff repairs have no functional difference to non-massive rotator cuff repairs in the short term follow up period and should be considered in appropriate patient groups.

The arrival of major trauma centres (MTC) to Scotland highlights the need for structured management of polytrauma patients. The aim was to report the epidemiological profile of polytrauma patients (Injury Severity Score (ISS) 15) admitted to a large trauma unit in the UK and gather information about the initial management of this severely injured cohort.

Prospectively collected data from the Scottish Trauma Audit Group (STAG) database of 366 polytrauma patients (ISS <15 & aged ≥13 years) admitted to a single trauma unit, from 1st January 2013 to 31st October 2017 was analysed. Data included patient demographics, injury characteristics, length of stay (LOS) and survivorship.

The median age was 49 years (range 13–93) and females made up 31.1% of the population. There was a mean ISS of 25.7 (range 15–75) and mean LOS of 19 days. The overall mortality rate was 21%. Higher mortality occurred among females (p<0.001), patients ≥60 years age (p<0.001), patients who sustained their injury at home (p<0.0001), and those with head injuries (p<0.01). Orthopaedic injuries were present in 187 patients (51.1%) with a mortality rate of 10.7%. The most common mechanism of injury was road traffic collision (41.5%) and these patients had a significantly higher ISS (p<0.01). A fall from height <2m was associated with higher mortality (p=0.01).

This study is the largest of its kind and presents a detailed epidemiological profile of patients attending a large UK trauma unit. This knowledge will help guide initial management and aid in resource and capacity planning for the future.

The objective of this study was to compare differences in alignment following robotic arm-assisted bi-unicompartmental knee arthroplasty (Bi-UKA) and conventional total knee arthroplasty (TKA).

This was a prospective, randomised controlled trial of 70 patients. 39 TKAs were implanted manually, as per standard protocol at our institution, and 31 Bi-UKA patients simultaneously received fixed-bearing medial and lateral UKAs, implanted using robotic arm-assistance. Preoperative and 3-month postoperative CT scans were analysed to determine hip knee ankle angle (HKAA), medial distal femoral angle (MDFA), and medial proximal tibial angle (MPTA). Analysis was repeated for 10 patients by a second rater to validate measurement reliability by calculating the intra-class correlation coefficient (ICC).

Mean change in HKAA towards neutral was 2.7° in TKA patients and 2.3° in Bi-UKA patients (P=0.6). Mean change in MDFA was 2.5° for TKA and 1.0° for Bi-UKA (P<0.01). Mean change in MPTA was 3.7° for TKA and 0.8° for Bi-UKA (P<0.01). Mean postoperative MDFA and MPTA for TKAs were 89.8° and 89.6° respectively, indicating orientation of femoral and tibial components perpendicular to the mechanical axis. Mean postoperative MDFA and MPTA for Bi-UKAs were 91.0° and 86.9° respectively, indicating a more oblique joint line orientation. Inter-rater agreement was excellent (ICC>0.99). Early functional activities, according to the new Knee Society Scoring System, favoured Bi-UKAs (P<0.05).

Robotic arm-assisted, cruciate-sparing Bi-UKA better maintains the natural anatomy of the knee in the coronal plane and may therefore preserve normal joint kinematics, compared to a mechanically aligned TKA. This has been achieved without significantly altering overall HKAA.

Aims

Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control.

Prosthetic joint infections provide complex management, due to often-difficult diagnosis, need for multiple surgeries and increased technical and financial requirements. “2 in 1” single stage approaches have been advocated due to reduction in risks, costs and complications. This study aimed to investigate the results of single stage revision using metaphyseal sleeves for infected primary Total Knee Replacement (TKR).

Prospective data was collected on all patients presenting with an infected primary TKR over an 8-year period (2009–17). All revision procedures were undertaken in a single stage using metaphyseal sleeves.

26 patients were included, 2 of which had previously failed 2 stage revision and 3 failed DAIR procedures. Mean age was 72.5. Mean BMI was 33.4. Median ASA 2. Mean time to revision was 3.5 years range 3 months to 12 years. Six patients had actively discharging sinuses at the time of surgery. Only 4 of the 26 patients had no positive microbiological cultures from deep tissue samples or joint aspirates.

Only one patient has a recurrence of infection. This patient did not require further surgery and is treated on long term antibiotic suppression and is systemically well.

There were statistically significant improvements in both the pain and function component of AKSS scores. There was no significant improvement in flexion, however mean extension and total range of movement both showed statistically significant improvements.

Using Metaphyseal sleeves in single stage revision for infected TKR are safe and lead to an improvement in pain, function and have excellent efficacy for eradication of infection.

The aim of our study was to compare the incidence of post-operative anterior knee discomfort after anterograde tibial nailing by suprapatellar and infrapatellar approaches.

95 subjects presenting with a tibial fracture requiring an intramedullary nail were randomised to treatment using a suprapatellar (SP) or infrapatellar (IP) approach. Anterior knee discomfort was assessed at 4 months, 6 months and 1 year post operatively using the Aberdeen Weightbearing Test-Knee (AWT-K), knee specific patient reported outcome measures and the VAS pain score. The AWT-K is an objective measure which uses weight transmitted through the knee when kneeling as a surrogate for anterior knee discomfort.

53 patients were randomised to an SP approach and 42 to an IP approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared to the uninjured leg when kneeling in the SP group compared to the IP group at all time points at all follow-up visits. This reached significance at 4 months for all time points except 30 seconds. It also reached significance at 6 months at 0 seconds and 1 year at 60 seconds.

We conclude that the SP approach for anterograde tibial nailing reduces anterior knee discomfort post operatively compared to the IP approach.

The primary aim of this study was to undertake a cost-effectiveness analysis (CEA) of acute fixation versus conservative management of displaced midshaft clavicle fractures. The secondary aim was to conduct a sensitivity analysis of patient characteristics that may influence a threshold of £20,000 per quality-adjusted life year gained (QALY).

A CEA was conducted from a randomised control trial comparing conservative management (n=92) to acute plate fixation (n=86) of displaced midshaft clavicle fractures. The incremental cost effectiveness ratio (ICER) was used to express the cost per QALY. The short form 6-dimensional (SF-6D) score was the preference based index to calculate the cost per QALY.

The 12-month SF-6D advantage of acute fixation over conservative management was 0.0085 (p=0.464) with a mean cost difference of £4,096.22 and resultant ICER of £481,908.24/QALY. For a threshold of £20,000/QALY the benefit of acute fixation would need to be present for 24.1 years. Linear regression analysis identified nonunion as the only independent factor to influence the SF-6D at 12-months (p<0.001). Conservatively managed fractures that resulted in a nonunion (n=16) had a significantly worse SF-6D compared to acute fixation (0.0723, p=0.001) with comparable healthcare cost at 12-months (£170.12 difference). Modelling the ICER of acute fixation against those complicated by a nonunion proved to be cost effective at £2,352.97/QALY at 12-months.

Routine plate fixation of displaced midshaft clavicle fractures is not cost-effective. Patients with nonunion after conservative management have increased morbidity with comparable expense to those undergoing acute fixation which suggests targeting these patients is a more cost-effective strategy.

Hip fracture care is complex multi-disciplinary. We hypothesise that quality of care is affected by variance in resources between ‘in-hours’ (Monday-Friday, 0800–1700) and ‘out-of-hours’ services.

This prospective multicentre national cohort study assessed quality of care by evaluating adherence to the evidence-based Scottish Standards of Care for Hip Fracture Patients. Data was collected by the Scottish Hip Fracture Audit for 15174 patients admitted to any of 22 Scottish hospitals from January 2014-April 2018.

11197/15174 (73.8%) patients were admitted out-of-hours. They were significantly less likely to meet the following Standards: ED Big-6-Bundle (OR 0.85, p= 0.002); Time in ED <4 hours (OR 0.76, p< 0.001); avoidance of repeated fasting (OR 0.80, p< 0.001), and avoidance of prolonged fluid fasting (OR 0.83, p< 0.001). Out-of-hours admissions were more likely to receive: geriatric assessment <3 days (OR 1.16, p< 0.001); OT input <3 days (OR 1.10, p= 0.013), and PT input <2 days (OR 1.44, p< 0.001). There were no significant differences for: Time to Theatre <36 hours; Inpatient Care Bundle <24 hours, and Post-op Day 1 Mobilisation.

Quality of hip fracture care is affected by time of admission. ED care is poorer out-of-hours, which may reflect limited resources, and out-of-hours admissions are more likely to be excessive fasted excessively. Weekday in-hours admissions are less likely to receive geriatric and allied health professional input in the days following admission, which may reflect the reduced weekend services. Examination of out-of-hours service organisation is required for the pursuit of consistent, equitable care for hip fracture patients.

There is currently no information regarding long-term outcomes following total hip replacement (THR) for hip fracture in patients selected in accordance with national guidelines. We define the long-term outcomes and compare these to short-term outcomes in the same previously reported cohort.

We prospectively identified patients who underwent THR for a displaced hip fracture over a 3-year period from 2007–2010. These patients were followed up at 10 years using the Oxford hip score(OHS), the Short-form 12(SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously assessed at 2 years. We identified 128 patients. Mean follow up was 10.4 years. 60 patients(48%) died by the time of review and 5 patients(4%) developed dementia and were unable to respond. 3 patients were untraceable. This left a study group of 60 patients with a mean age of 81.2.

Patients reported excellent outcomes at 10 year follow up and, when compared with short-term outcomes, there was no statistically significant change in levels of satisfaction, OHS, or SF-12. The rates of dislocation(2%), deep infection(2%) and revision(3%) were comparable to those in the literature for elective THR. Mortality in the hip fracture group at 10 years is lower than that of elective registry data.

Long-term outcomes for THR after hip fracture in selected patients are excellent and the early proven benefits are sustained. Our data validates the selection process of national guidelines and confirms low complication rates. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Anterior knee pain (AKP) is the commonest complication of total knee arthroplasty (TKA). This study aims to assess whether sagittal femoral component position is an independent predictor of AKP after cruciate retaining single radius TKA without primary patellofemoral resurfacing.

From a prospective cohort of 297 consecutive TKAs, 73 (25%) patients reported AKP and 89 (30%) reported no pain at 10 years. Patients were assessed pre-operatively and at 1, 5 and 10 years using the short form 12 and Oxford Knee Score (OKS). Variables assessed included demographic data, indication, reoperation, patella resurfacing, and radiographic criteria.

Patients with AKP (mean age 67.0 (38–82), 48 (66%) female) had mean Visual Analogue Scale (VAS) Pain scores of 34.3 (range 5–100). VAS scores were 0 in patients with no pain (mean age 66.5 (41–82), 60 (67%) female). Femoral component flexion (FCF), anterior femoral offset ratio, and medial proximal tibial angle all differed significantly between patients with AKP and no pain (p<0.001), p=0.007, p=0.009, respectively). All PROMs were worse in the AKP group at 10 years (p<0.05). OKSs were worse from 1 year (p<0.05). Multivariate analysis confirmed FCF and Insall ratio <0.8 as independent predictors of AKP (R² = 0.263). Extension of ≥0.5° predicted AKP with 87% sensitivity.

AKP affects 25% of patients following single radius cruciate retaining TKA, resulting in inferior patient-reported outcome measures at 10 years. Sagittal plane positioning and alignment of the femoral component are important determinants of long-term AKP with femoral component extension being a major risk factor.

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR.

From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD).

The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05).

This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures.

Revision hip arthroplasty presents a challenge in the setting of femoral bone loss. Tapered stems are susceptible to subsidence which leads to leg length inequality, hip instability and may necessitate repeat femoral revision surgery.

The purpose of this study was to compare radiographic outcomes in two modular tapered revision systems with different distal stem geometries. We sought to establish the minimum postoperative stem bi-cortical contact length that predicts subsidence for tapered stems.

This study examined revision total hip arthroplasties between 2009 and 2016 in a European university affiliated major trauma center. Modular stem A has a taper of 3 degrees whereas modular stem B has a taper of 2 degrees. Radiologic assessment compared x-rays at two time points: immediately post-surgery and most recent x-ray available at a minimum follow up of two years. Leg length discrepancy, subsidence and postoperative bi cortical contact was assessed. Descriptive summary statistics calculated clinical factors (i.e. age, gender, Paprosky classification).

122 arthroplasties were completed. Complete data was available for 112. Revisions were carried out for Paprovski grade 3a/ 3b femoral deficits. Post-operative bi-cortical contact of the proximal stem < 20mm was associated with higher subsidence rates (P = 0.047). Subsidence rates for implant A and B system were 4.27mm (0.12–25.62mm) and 3.43 mm (0.3–11.1 mm) respectively. Significant subsidence was noted in 9.8% (n=8) in implant A and 5.2%(n=2) in implant B.

We conclude that immediate postoperative bi-cortical stem contact of <20mm was associated with significantly higher subsidence rates in this study.

International literature reports a 30% lifetime prevalence of intimate partner violence (IPV, domestic abuse). Many of those affected have little interaction with healthcare. Since a third of abused patients sustain musculoskeletal injuries, the fracture clinic has potential for identifying victims of abuse. The aim was to identify the proportion of fracture clinic patients who had suffered IPV within the past year.

A prospective questionnaire study of patients in three UK adult fracture clinics was conducted. There were no gender/age exclusions and the target sample size was 278. This study had ethics approval and the questionnaire used is validated in this population.

Of 336 respondents, 46% were females with 63% aged over 40 (212/336). The total prevalence of IPV within the preceding 12 months was 9% (29/336). The lifetime prevalence of IPV amongst respondents was 20% (68/336). 38% of patients suffering from IPV had been physically abused by their partner (11/29 vs. 7% in controls, p<0.001). None of the patients were being seen for an injury related to abuse. Two thirds of respondents thought that staff should ask routinely about IPV (64% 216/336) but only 5% had been asked about abuse (18/336).

This is the first study in the UK investigating prevalence of IPV in orthopaedics. There is a high lifetime prevalence of abuse in fracture clinic patients. Patients are willing to disclose abuse within the fracture clinic setting and are supportive of staff asking about abuse. This presents an opportunity to identify those at risk in this vulnerable population.