THA in patients with acetabular bone defects is associated with a high risk of dislocation. Dual mobility (DM) cups are known to prevent and treat chronic instability. The aim of this study was to evaluate the dislocation rate and survival of jumbo DM cups.

This was a retrospective, continuous, multicenter study of all the cases of jumbo DM cup implantation between 2010 and 2017 in patients with acetabular bone loss (Paprosky 2A: 46%, 2B: 32%, 2C: 15% and 3A: 6%). The indications for implantation were revisions for aseptic loosening of the cup (n=45), aseptic loosening of the femoral stem (n=3), bipolar loosening (n=11), septic loosening (n=10), periprosthetic fracture (n=5), chronic dislocation (n=4), intraprosthetic dislocation (n=2), cup impingement (n=1), primary posttraumatic arthroplasty (n=8), and acetabular dysplasia (n=4). The jumbo cups used were COPTOS TH (SERF), which combines press-fit fixation with supplemental fixation (acetabular hook, two superior flanges with one to four screws, two acetabular pegs). A bone graft was added in 74 cases (80%). The clinical assessment consisted of the Harris hip score. The primary endpoint was surgical revision for aseptic acetabular loosening or the occurrence of a dislocation episode.

In all, 93 patients were reviewed at a mean follow-up of 5.3 ± 2.3 years [0, 10]. As of the last follow-up, the acetabular cup had been changed in five cases: three due to aseptic loosening (3.2%) and two due to infection (2.1%). The survivorship free of aseptic loosening was 96.8%. Three patients (3%) suffered a dislocation. At the last follow-up visit, the mean HSS scores were 72.15, (p < 0.05).

Use of a jumbo DM cup in cases of acetabular bone defects leads to satisfactory medium-term results with low dislocation and loosening rates.

Aim

Musculoskeletal infection is a serious complication, however literature is lacking prospective data on its impact on mental health. The study aimed to assess mental health in patients with musculoskeletal infections and how they experience the possible mental and physical impairment.

Aims

Fracture-Related Infection (FRI) is a severe complication caused by microbial infection of bone. It is imperative to gain more insight into the potentials and limitations of Debridement, Antibiotics and Implant Retention (DAIR) to improve future FRI treatment. The aims of this study were to: 1) determine how time to surgery affects the success rate of DAIR procedures of the lower leg performed within 12 weeks after the initial fracture fixation operation and 2) evaluate whether appropriate systemic antimicrobial therapy affects the success rate of a DAIR procedure.

Aim

There is growing evidence that bacteria encountered in periprosthetic joint infections (PJI) form surface-attached biofilms on prostheses, as well as biofilm aggregates embedded in synovial fluid and tissues. However, models allowing the investigation of these biofilms and the assessment of their antimicrobial susceptibility in physiologically relevant conditions are currently lacking. To address this, we developed a synthetic synovial fluid (SSF) model and we validated this model in terms of growth, aggregate formation and antimicrobial susceptibility testing, using multiple PJI isolates.

A hip fracture represents the extreme end of osteoporosis, placing a significant burden on secondary care, society, and the individual patient. The National Hip Fracture Database (NHFD) reports each hospital's attainment of the BPT with other measures, along with reporting outcomes. There is clearly wide variability in provision of orthogerriatrician (OG) services across the dataset. Unfortunately, despite overwhelming evidence that provision of an OG service is of benefit, it is presently challenging to recruit to this important specialty within the UK.

Publicly available reports from the NHFD were obtained for each of the 177 participating hospitals for 2017. This was matched with information held within the annual NHFD Facilities Audit for the same period, which include hours of OG support for each hospital. This information was combined with a Freedom of Information request made by email to each hospital for further details concerning OG support. The outcome measures used were Length of Stay (LoS), mortality, and return to usual residence. Comparison was made with provision of OG services by use of Pearson's correlation coefficient. In addition, differences in services were compared between the 25% (44) hospitals delivering outcomes at the extremes for each measure.

Attainment of BPT correlated fairly with LoS (−0.48) and to less of a degree with mortality (−0.1) and return home (0.05). Perioperative medical assessment contributed very strongly with BPT attainment (0.75). In turn perioperative medical assessment correlated fairly with LoS (−0.40) and mortality (−0.23) but not return home (0.02). Provision of perioperative medical assessment attainment was correlated fairly with total OG minutes available per new patient (0.22), total OG minutes available per patient per day (0.29) and number of days per week of OG cover (0.34); with no link for number of patients per orthogeriatrician (0.01). Mortality for the best units were associated with 30% more consultant OG time available per patient per day, and 51% more OG time available per patient. Units returning the most patients to their usual residence had little association with OG time, although had 59% fewer patients per OG, the best units had a 19% longer LoS. For all three measures results for the best had on average 0.5 days per week better routine OG access.

There is no doubt that good quality care gives better results for this challenging group of patients. However, the interaction of BPT, other care metrics, level of OG support and patient factors with outcomes is complex. We have found OG time available per patient per day appears to influence particularly LoS and mortality. Options to increase OG time per patient include reducing patient numbers (ensuring community osteoporosis/falls prevention in place, including reducing in-patient falls); increasing OG time across the week (employing greater numbers/spreading availability over 7 days per week); and reducing LoS. A reduction in LoS has the largest effect of increasing OG time, and although it is dependent on OG support, it is only fairly correlated with this and many other factors play a part, which could be addressed in units under pressure.

Trauma patients present with different injuries and some of them require emergency surgical procedures. Orthopaedic department at Steve Biko Academic Hospital (SBAH) have seen an increasing number of patients presenting with serious orthopaedic injuries due to Delivery Motorbike Accidents (DMBA). The aim of the study was to establish the epidemiology and pattern of orthopaedic injuries sustained following Delivery Motorbike Accident.

Motor Vehicle Accident (MVA) administration office at SBAH in emergency department was approached for patients registers used between 1 January 2020 and 31 December 2022. There patients were registered as Motor Vehicle Accident (MVA), Motorbike Accident (MBA) and Pedestrian Vehicle Accident (PVA) by the administration office. The details of patients classified as MBA were collected and used to obtain clinical data from medical and radiological records in the form of patient's files and PACS respectively.

Approximately 240 patients presented to Emergency department with orthopaedic injuries following a motorbike accident. About 78 files could not be retrieved from the patient's records department. About 74patients had their occupation recorded as unknown or unemployed. Approximately 70 patients had their occupation indicated in the file by the Clinicians or Administration Clerks. About 40 patients had their occupation as delivery man or working for a delivery company. 16 patients did not have images on the PACS system. Most of the patients were males, presented after hours and sustained multiple injuries that were managed surgically. Very few patients had their helmet status indicated in the file.

The study suggests that accidents due to delivery motorbikes are prevalent at SBAH and result in orthopaedic injuries. Almost 50% of patients who had their occupation indicated in the file were delivery employees. A follow up prospective study is recommended to ensure complete collection of data from patients at presentation to ED.

Aim

Treatment algorithms for fracture-related nonunion depend on the presence or absence of bacterial infection. However, the manifestation of septic nonunion varies. Low-grade infections, unlike manifest infections, lack clinical signs of infection and present similarly to aseptic nonunion. The clinical importance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the clinical relevance of low-grade infection in the development and management of femoral or tibial nonunion.

Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection that typically starts in the dermis and epidermis and spreads along soft tissue planes, penetrating subdermal layers and can lead to massive tissue necrosis resulting in severe morbidity and mortality. The aim of this case series was to describe the epidemiology and burden of NSTI's at a District Hospital servicing a South African urban settlement.

This retrospective case series was performed at a single centre. Consecutive patients were identified following a clinical diagnosis for NSTI. Further laboratory pre-operative work up was standardized including: use of validated Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC scores) and Human Immunodeficiency Virus (HIV) status. All patients who underwent surgical debridement were captured on the Theatre Database (www.medwebtools.org™). All patients received standardized perioperative, intra-operative and post-operative protocols for antibiotics, debridement and soft tissue closure or cover based on the severity of disease. Medical records, theatre notes, National Health Laboratory Service (NHLS) results and radiological results were captured for every patient.

28 patients (14 male, 14 female) presented with NSTI over a 3 year period (2021–2023). The mean age was 39.5 years. The most common organisms cultured were Streptococcus pyogenes (10 patients), Staphylococcus aureus (9 patients), Bacillus cereus (3 patients).

This retrospective case series is an important study because it demonstrates some of the highest incidence of NSTI globally; however, the cause of this is yet to be determined. Our results show that having a high clinical index of suspicion; using the LRINEC score to assess severity and using a standardized antibiotic and peri-operative protocol with early soft tissue cover that NSTI's can be managed effectively with a reduction in patient morbidity and overall length of hospital stay.

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR).

Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients.

The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients.

For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR.

Aim

To classify Fracture-related Infection (FRI) allowing comparison of clinical studies and to guide decision-making around the main surgical treatment concepts.

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect.

A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score.

There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05).

The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score.

The bone-patellar tendon-bone (BTB) autograft has a lower rate of graft failure but a higher rate of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction. Subsequent contralateral injury may be a marker of success of the BTB graft, but it is unclear whether the type of graft influences the rate of return to sport. This study aimed to compare the rates of return to weekly sport and return to preinjury activity levels between the BTB and hamstring tendon autografts following primary ACL reconstruction.

Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014-November 2019 were analyzed. The primary outcome was return to weekly sport, defined as a Marx activity score of 8, at 2-year follow-up. The secondary outcome was return to preinjury activity level, defined as a post-operative Marx activity score that was equal or greater to the patient's preinjury Marx score. Return to sport was compared between the BTB and hamstring tendon autografts via multivariate binary logistic regression with adjustment for patient demographics.

4259 patients were analyzed, of which 50.3% were playing weekly sport (n = 2144) and 28.4% had returned to their preinjury activity level (n = 1211) at 2-year follow-up. A higher rate of return to weekly sport was observed with the BTB autograft compared to the hamstring tendon autograft (58.7% versus 47.9%, adjusted odds ratio = 1.23, p = 0.009). Furthermore, the BTB autograft had a higher rate of return to preinjury activity levels (31.5% versus 27.5%, adjusted odds ratio = 1.21, p = 0.025).

The BTB autograft is associated with a higher return to sport and may explain the higher rate of contralateral ACL injury following primary ACL reconstruction.

Aim

Polypropylene (PPE) synthetic mesh is increasingly used in knee arthroplasty surgery to salvage a disrupted extensor mechanism. Despite its clinical success, it is associated with a high rate of periprosthetic joint infection (PJI), which is hypothesized to be caused by bacterial biofilm. The purpose of the current study is to describe the progression of PPE-based biofilm formation over time and to determine if intraoperative antiseptic solutions could be used to effectively remove biofilm when treating PJI.

Aim

Infections represent a serious threat to the successful utilization of implants in modern medicine. Implant-associated infections are difficult to treat, because they involve biofilms that protect bacteria from the immune system and harbour antibiotic-tolerant persister cells.

In this work, we developed an antibody-drug conjugate (ADC) containing the anti-neoplastic drug mitomycin C (MMC) as a novel treatment paradigm for implant-associated infections. MMC was chosen as it is a potent antimicrobial against biofilms and its synthesis into an ADC was chosen to alleviate toxicity. Following development and synthesis of the ADC, stability and release of MMC was measured. We then used the ADC to kill bacteria in suspension and in biofilms, in vitro and in vivo.

Minimally displaced paediatric proximal humerus fractures (PHFs) can be reliably managed non-operatively, however there is considerable debate regarding the appropriate management of severely displaced PHFs, particularly in older children and adolescents with limited remodelling potential. The purpose of this study was to perform a systematic review to answer the questions: “What are the functional and quality-of-life outcomes of paediatric PHFs?” and “What factors have been associated with a poorer outcome?”

A review of Medline and EMBASE was performed on 4^th July 2021 using search terms relevant to PHFs, surgery, non-operative management, paediatrics and outcomes. Studies including ≥10 paediatric patients with PHFs, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes.

Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favourable outcome scores were found for patients with minimally displaced fractures, and for children aged less than ten years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score.

An excellent functional outcome can be expected following non-operative management for minimally displaced paediatric PHFs. Prospective trials are required to establish a guideline for the management of severely displaced PHFs in children and adolescents according to fracture displacement and the degree of skeletal maturity.

Background and aim

In 2019, specific diagnostic and antibiotic treatment recommendations for diabetic foot infection (DFI) and osteomyelitis (DFO) were introduced in our institution. They include principles on numbers of biopsies to obtain for microbiological/histopathological examinations, labeling anatomic localization, and antibiotic treatment (ABT) duration based on the aforementioned findings. ABT should be stopped after complete resection of infected bone. In case of incomplete resection, treatment is continued for 4–6 weeks. Two years after the introduction of these recommendations, we investigated the degree of implementation for hospitalized patients.

Introduction

Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome.

Excessive postoperative opioid prescribing is a significant contributor to the opioid crisis. Prescribing in orthopaedic surgery is often further complicated by high use of opioid-based preoperative analgesia. ‘Opioid PrEscRiptions and usage After Surgery’ (OPERAS) is an international multicentre prospective student- and trainee-led collaborative study which aims to quantify the amount of opioids prescribed at discharge after common orthopaedic surgeries against what is consumed by patients at 7-days, and assess the impact of opioids on patient-reported outcomes.

Data is being collected over 6 14-day periods on consecutive adult patients undergoing shoulder arthroplasty, rotator cuff repair, shoulder labral repair, anterior cruciate ligament repair, hip arthroplasty, and knee arthroplasty, with follow-up via telephone call at 7-days after discharge. The primary outcome is the proportion of oral morphine equivalents (OME) of prescribed opioids versus consumed opioids at 7-days post-discharge.

This ongoing study is actively recruiting in over 20 countries. Globally, 65 centres are collecting orthopaedic, including 10 New Zealand centres and 17 Australian centres. To date, 284 orthopaedic patients have been prospectively enrolled with complete data (mean age 59.6 ± 16.7 years; 51.6% female). Overall, 77% and 89% of patients were prescribed opioids on discharge in New Zealand and Australia respectively. On average, 60% of prescribed opioids were consumed at 7-days post-discharge globally (150 OME (75-500) vs. 90 OME (15-200); p<0.01). In New Zealand and Australia, 42.1% (285 OME (150-584) vs. 120 OME (6-210); p<0.01) and 63.3% (150 OME (86-503) vs. 95 OME (28-221); p<0.01) of prescribed opioids were consumed at 7-days, respectively.

OPERAS will provide the first high-quality global data on opioid prescription and consumption patterns with patient perspectives. These data can inform prescribing practice and inform guidelines. The growing interest in New Zealand and Australia in student- and trainee-led orthopaedic collaborative research, as evidenced by this study should be actively encouraged and fostered.

Patient-reported outcome measures (PROMs) have failed to highlight differences in function or outcome when comparing knee replacement designs and implantation techniques. Ankle-worn inertial measurement units (IMUs) can be used to remotely measure and monitor the bi-lateral impact load of patients, augmenting traditional PROMs with objective data. The aim of this study was to compare IMU-based impact loads with PROMs in patients who had undergone conventional total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and robotic-assisted TKA (RA-TKA).

77 patients undergoing primary knee arthroplasty (29 RA-TKA, 37 TKA, and 11 UKA) for osteoarthritis were prospectively enrolled. Remote patient monitoring was performed pre-operatively, then weekly from post-operative weeks two to six using ankle-worn IMUs and PROMs. IMU-based outcomes included: cumulative impact load, bone stimulus, and impact load asymmetry. PROMs scores included: Oxford Knee Score (OKS), EuroQol Five-dimension with EuroQol visual analogue scale, and the Forgotten Joint Score.

On average, patients showed improved impact load asymmetry by 67% (p=0.001), bone stimulus by 41% (p<0.001), and cumulative impact load by 121% (p=0.035) between post-operative week two and six. Differences in IMU-based outcomes were observed in the initial six weeks post-operatively between surgical procedures. The mean change scores for OKS were 7.5 (RA-TKA), 11.4 (TKA), and 11.2 (UKA) over the early post-operative period (p=0.144). Improvements in OKS were consistent with IMU outcomes in the RA-TKA group, however, conventional TKA and UKA groups did not reflect the same trend in improvement as OKS, demonstrating a functional decline.

Our data illustrate that PROMs do not necessarily align with patient function, with some patients reporting good PROMs, yet show a decline in cumulative impact load or load asymmetry. These data also provide evidence for a difference in the functional outcome of TKA and UKA patients that might be overlooked by using PROMs alone.

Materials & Methods

Chronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures.

Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores.

A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated.

There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, p= <0.001), with no significant difference between groups (3.3 points, p=0.50). Among the PKIP sub-scores, there was a significant improvement in knee confidence (3.5±2 vs 7.7±2; p<0.001), stability (3.4±2 vs 7.4±3; p<0.001) and satisfaction (2.5±1.7 vs 6.6±3, p<0.001). Between group differences in PKIP sub-scores one year after surgery were small and non-significant. For all patients, the OKS and PKIP scores were moderately correlated before surgery (r=0.64, p=<0.05), and at 1 year after surgery (r=0.61, p= <0.001).

Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort.

Aim

The aim of this investigation was to compare risk of infection in both cemented and cementless hemiarthroplasty (HA) as well as total hip arthroplasty (THA) following femoral neck fracture.

This study aimed to identify the success rate of debridement, antibiotics and implant retention (DAIR) for prosthetic joint infection (PJI) in a large prospective cohort of patients undergoing total knee arthroplasty (TKA). The ability for different PJI classification systems to predict DAIR success was assessed.

A prospective, multicenter study of PJIs occurring between July 2014 and December 2017 in 27 hospitals across Australia and New Zealand was performed. First time PJIs following primary TKA that were managed with DAIR were analyzed. DAIR success was defined as the patient being alive with documented absence of clinical or microbiological evidence of infection and no ongoing antibiotics for the index joint at 2-year follow-up. Multivariate analysis was performed for multiple PJI classification systems to assess their ability to predict DAIR success using their respective definitions of “early” PJI (Coventry ≤1 month, International Consensus Meeting ≤90 days or Auckland <1 year), or as hematogenous versus chronic PJI (Tsukayama).

189 PJIs were managed with DAIR, with an overall success rate of 45% (85/189). Early PJIs had a higher rate of DAIR success when analyzed according to the Coventry system (adjusted odds ratio = 3.85, p = 0.008), the ICM system (adjusted odds ratio = 3.08, p = 0.005) and the Auckland system (adjusted odds ratio = 2.60, p = 0.01). DAIR success was lower in both hematogenous (adjusted odds ratio = 0.36, p = 0.034) and chronic PJIs (adjusted odds ratio = 0.14, p = 0.003) occurring more than one year since the primary TKA.

DAIR success is highest when performed in infections occurring within one year of the primary TKA. Late infections had a high DAIR failure rate irrespective of their classification as hematogenous or chronic. Time since primary is a useful predictor of DAIR success.

The optimal timing of when to perform manipulation under anesthesia (MUA) for stiffness following total knee arthroplasty (TKA) is unclear. This study aimed to identify the risk factors for MUA following primary TKA and whether performing an “early” MUA within 3 months results in a greater improvement in range of motion.

Primary TKAs performed between January 2013 and December 2018 at three tertiary New Zealand hospitals were reviewed. International Classification of Diseases discharge coding was used to identify patients who underwent an MUA. Multivariate Cox regression was performed to identify patient and surgical risk factors for MUA. Pre- and post-MUA knee flexion angles were identified through manual review of operation notes. Multivariate linear regression was performed to compare the mean flexion angles pre- and post-MUA, as well as the mean gain in flexion, between patients undergoing “early” (<3 months) versus “late” MUA (>3 months).

7386 primary TKAs were analyzed in which 131 underwent subsequent MUA (1.8%). Patients aged <65 years were two times more likely to undergo MUA compared to patients aged ≥65 years (2.5% versus 1.3%, adjusted hazard ratio = 2.1, p<0.001). Gender, body mass index, patient comorbidities or a history of cancer were not associated with the risk of MUA. There was no difference in the final post-MUA flexion angle between patients who underwent early versus late MUA (104.7 versus 104.1 degrees, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3 versus 79.6 degrees, p = 0.012), and subsequently had a greater overall gain in flexion compared to patients who underwent late MUA (mean gain 33.1 versus 24.3 degrees, p<0.001).

Younger age was the only patient risk factor for MUA. A greater overall gain in flexion was achieved in patients who underwent early MUA within 3 months.

The aim was to predict the number and incidence of distal radius fractures in Scotland over the next two decades according to age group, categorised into under 65yrs(<65) and 65yrs and older (≥65), and estimate the potential increased operative burden of this.

The number of distal radius fracture in Scotland was isolated from the Global Burden of Disease database and this was used, in addition to historic population data and population estimates, to create a multivariable model allowing incorporation of age group, sex and time. A Negative Binomial distribution was used to predict incidence in 2030 and 2040 and calculate projected number of fractures according to the population at risk. A 20.4% operative intervention rate was assumed in the ≥65 group (local data).

In terms of number of fractures, there was a projected 61% rise in the ≥65 group with an overall increase of 2099 fractures per year from 3417 in 2020 (95% confidence interval (CI) 2960 – 3463) to 5516 in 2040 (95% CI 4155–5675). This was associated with 428 additional operative interventions per year for those ≥65yrs. The projected increase between 2020 and 2040 was similar in both sexes (60% in females, 63% in males), however the absolute increase in fracture number was higher in females (2256 in 2020 [95% CI 1954–2287] to 3620 in 2040 [95% CI 2727–3721]) compared to males (1160 [95% CI 1005–1176] to 1895 [95% CI 1427–1950]). There was a 4% projected fall in the number of fractures in those <65.

Incidence of distal radius fractures is expected to considerably increase over the next two decades due to a projected increase in the number of fractures in the elderly. This has implications for the associated morbidity and healthcare resource use.

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand

Outcomes following knee arthroplasty are typically defined as implant survivorship at defined timepoints, or revision incidence over time. These estimates are difficult to conceptualise, and lack context for younger patients with more remaining years of life. We therefore aimed to determine a ‘lifetime’ risk of revision as a more useful metric for total (TKA) and unicompartmental knee arthroplasty (UKA).

The New Zealand Joint Registry was used to identify 96,497 primary TKAs and 13,481 primary UKAs performed between 1999 and 2019. Patient mortality and revision incidence were also extracted. Estimates of lifetime risk were calculated using an actuarial lifetable method. The estimates were stratified by age and gender. Reasons for revision were categorised using previously published standardised definitions.

The lifetime risk of UKA revision was two-fold higher than TKA across all age groups (range 3.7-40.4% UKA, 1.6-22.4% TKA). Revision risk was higher for males with TKA (range 3.4%-25.2% males, 1.1%-20% females), but higher for females with UKA (range 4.3%-43.4% vs. 2.9%-37.4% for males). Revision due to infections were higher for TKA (1.5% males, 0.7% females) compared with UKA (0.4% males, 0.1% females). The increased risk in younger UKA patients was associated with higher incidence of aseptic loosening (UKA 2%, TKA 1%) and ‘unexplained pain’ (UKA 2%, TKA 0.2%).

The risk for UKA was two-fold higher than TKA, and this was partially explained by a higher proportion of revisions due to ‘unexplained pain’. For TKA, males had higher risk of revision, in contrast to UKA where females had higher risk; this gender difference was associated with higher incidence of infections with TKA. Younger age, gender and higher ASA status were also associated with increased lifetime risk of UKA revision. Lifetime risk of revision can provide a meaningful measure of arthroplasty outcomes to aid patient counselling.

The 2021 Australian Orthopaedic Association National Joint Replacement Registry report indicated that total shoulder replacement using both mid head (TMH) length humeral components and reverse arthroplasty (RTSA) had a lower revision rate than stemmed humeral components in anatomical total shoulder arthroplasty (aTSA) - for all prosthesis types and diagnoses. The aim of this study was to assess the impact of component variables in the various primary total arthroplasty alternatives for osteoarthritis in the shoulder.

Data from a large national arthroplasty registry were analysed for the period April 2004 to December 2020. The study population included all primary aTSA, RTSA, and TMH shoulder arthroplasty procedures undertaken for osteoarthritis (OA) using either cross-linked polyethylene (XLPE) or non-cross-linked polyethylene (non XLPE). Due to the previously documented and reported higher revision rate compared to other anatomical total shoulder replacement options, those using a cementless metal backed glenoid components were excluded. The rate of revision was determined by Kaplan-Meir estimates, with comparisons by Cox proportional hazard models. Reasons for revision were also assessed.

For a primary diagnosis of OA, aTSA with a cemented XLPE glenoid component had the lowest revision rate with a 12-year cumulative revision rate of 4.7%, compared to aTSA with cemented non-XLPE glenoid component of 8.7%, and RTSA of 6.8%. The revision rate for TMH was lower than aTSA with cemented non-XLPE, but was similar to the other implants at the same length of follow-up. The reason for revision for cemented aTSR was most commonly component loosening, not rotator cuff deficiency.

Long stem humeral components matched with XLPE in aTSA achieve a lower revision rate compared to shorter stems, long stems with conventional polyethylene, and RTSA when used to treat shoulder OA. In all these cohorts, loosening, not rotator cuff failure was the most common diagnosis for revision.

Escalating health care expenditure worldwide is driving the need for effective resource decision-making, with medical practitioners increasingly making complex resource decisions within the context of patient care. Despite raising serious legal and ethical issues in practice, this has attracted little attention in Australia, or internationally. In particular, it is unknown how orthopaedic surgeons perceive their obligations to the individual patient, and the wider community, when rationing care, and how they reconcile competing obligations. This research explores legal and ethical considerations, and resource allocation by Australian orthopaedic surgeons, as a means of achieving public health cost containment driven by macro-level policy and funding decisions.

This research found that Australian orthopaedic surgeon's perceptions, and resource allocation decision making, can be explained by understanding how principles of distributive justice challenge, and shift, the traditional medical paradigm. It found that distributive justice, and challenges of macro level health policy and funding decisions, have given rise to two new medical paradigms. Each which try to balance the best interests of individual patients with demands in respect of the sustainability of the health system, in a situation where resources may be constrained. This research shows that while bedside rationing has positioned the medical profession as the gate keepers of resources, it may have left them straddling an increasingly irreconcilable void between the interests of the individual patient and the wider community, with the sustainability of the health system hanging in the balance.

Introduction

Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS.

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in a motor impairment affecting the upper limbs more than the lower limbs, with occasional sensory impairment and urinary retention seen. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study is to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Introduction

Anterior cruciate ligament (ACL) injuries represent a significant burden of disease to the orthopaedic surgeon and often necessitate surgical reconstruction in the presence of instability. The hamstring graft has traditionally been used to reconstruct the ACL but the quadriceps tendon (QT) graft has gained popularity due to its relatively low donor site morbidity.

Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition.

603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³.

Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European.

This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation.

In 2021, Vigdorchik et al. published a large multicentre study validating their simple Hip-Spine Classification for determining patient-specific acetabular component positioning in total hip arthroplasty (THA). The purpose of our study was to apply this Hip-Spine Classification to a sample of Australian patients undergoing THA surgery to determine the local acetabular component positioning requirements. Additionally, we propose a modified algorithm for adjusting cup anteversion requirements.

790 patients who underwent THA surgery between January 2021 and June 2022 were assessed for anterior pelvic plane tilt (APPt) and sacral slope (SS) in standing and relaxed seated positions and categorized according to their spinal stiffness and flatback deformity. Spinal stiffness was measured using pelvic mobility (PM); the ΔSS between standing and relaxed seated. Flatback deformity was defined by APPt <−13° in standing. As in Vigdorchik et al., PM of <10° was considered a stiff spine. For our algorithm, PM of <20° indicated the need for increased cup anteversion. Using this approach, patient-specific cup anteversion is increased by 1° for every degree the patient's PM is <20°.

According to the Vigdorchik simple Hip-Spine classification groups, we found: 73% Group 1A, 19% Group 1B, 5% Group 2A, and 3% Group 2B. Therefore, under this classification, 27% of Australian THA patients would have an elevated risk of dislocation due to spinal deformity and/or stiffness. Under our modified definition, 52% patients would require increased cup anteversion to address spinal stiffness.

The Hip-Spine Classification is a simple algorithm that has been shown to indicate to surgeons when adjustments to acetabular cup anteversion are required to account for spinal stiffness or flatback deformity. We investigated this algorithm in an Australian population of patients undergoing THA and propose a modified approach: increasing cup anteversion by 1° for every degree the patient's PM is <20°.

Pelvic tilt (PT) is always described as the pelvic orientation along the transverse axis, yet four PT definitions were established based on different radiographic landmarks: anterior pelvic plane (PT_a), the centres of femoral heads and sacral plate (PT_m), pelvic outlet (PT_h), and sacral slope (SS). These landmarks quantify a similar concept, yet understanding of their relationships is lacking. Some studies referred to the words “pelvic tilt” for horizontal comparisons, but their PT definitions might differ. There is a demand for understanding their correlations and differences for education and research purposes.

This study recruited 105 sagittal pelvic radiographs (68 males and 37 females) from a single clinic awaiting their hip surgeries. Hip hardware and spine pathologies were examined for sub-group analysis. Two observers annotated four PTs in a gender-dependent manner and repeated it after six months. The linear regression model and intraclass correlation coefficient (ICC) were applied with a 95% significance interval.

The SS showed significant gender differences and the lowest correlations to the other parameters in the male group (−0.3< r <0.2). The correlations of SS in scoliosis (n = 7) and hip implant (female, n = 18) groups were statistically different, yet the sample sizes were too small. PT_m demonstrated very strong correlation to PT_h (r > 0.9) under the linear model PT_m = 0.951 × PT_h - 68.284.

The PT_m and PT_h are interchangeable under a simple linear regression model, which enables study comparisons between them. In the male group, SS is more of a personalised spinal landmark independent of the pelvic anatomy. Female patients with hip implant may have more static spinopelvic relationships following a certain pattern, yet a deeper study using a larger dataset is required. The understanding of different PTs improves anatomical education.

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting times

The principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products.

We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool.

We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present.

The aim of this study was to examine the incidence of obesity in patients undergoing primary total shoulder replacement (TSR) (stemmed and reverse) for osteoarthritis (OA) in Australia compared to the incidence of obesity in the general population.

A 2017-18 cohort of 2,621 patients from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) who underwent TSR, were compared with matched controls from the Australian Bureau of Statistics (ABS) National Health Survey from the same period. The two groups were analysed according to BMI category, sex and age.

According to the 2017-18 National Health Survey, 35.6% of Australian adults are overweight and 31.3% are obese. Of the primary TSR cases performed, 34.2% were overweight and 28.6% were obese. The relative risk of requiring TSR for OA increased with increasing BMI category. Class-3 obese females, aged 55-64, were 8.9 times more likely to require TSR compared to normal weight counterparts. Males in the same age and BMI category were 2.5 times more likely. Class-3 obese patients underwent TSR 4 years (female) and 7 years (male) sooner than their normal weight counterparts.

Our findings suggest that the obese population is at risk for early and more frequent TSR for OA. Previous studies demonstrate that obese patients undergoing TSR also exhibit increased risks of longer operative times, higher superficial infection rates, higher periprosthetic fracture rates, significantly reduced post-operative forward flexion range and greater revision rates.

Obesity significantly increases the risk of requiring TSR. To our knowledge this is the first study to publish data pertaining to age and BMI stratification of TSR Societal efforts are vital to diminish the prevalence and burden of obesity related TSR.

There may well be reversible pathophysiology in the obese population to address prior to surgery (adipokines, leptin, NMDA receptor upregulation). Surgery occurs due to recalcitrant or increased pain despite non-op Mx.

Total Joint Arthroplasty (TJA) is a successful orthopaedic procedure allowing dramatic clinical and functional improvements. Globally, there's been an increase in demand and performed cases associated with an increase in complications. Subsequently, focus on the prevention of complications has become important worldwide. The incidence of venous-thrombolic events (VTE) despite great attention has not diminished despite much investigation. A balance between efficacy and safety from the available agents is essential. Low molecular weight heparin (LMWH) has been commonly used, but oral anti-coagulants have become more popular. The aim of this study was to assess the adherence LMWH and the effectiveness and safety of preventing VTE in post-operative arthroplasty patients in a South African setting.

We conducted a prospective cohort study that included hip and knee, primary and revision, arthroplasty patients who received thromboprophylaxis with one daily injection of LMWH for 14 days post discharge. Patients who omitted 1 or more doses during the follow up period were classified as “non adherent”. A questionnaire was used at follow up visits at least 6 weeks post-operatively.

100 consecutive patients were followed up. The mean age of patients was 63.45 years. There were 68 % female patients. There was a 92% compliance rate. 60 % of patients had the injection administered by a family member, 38 % administered it themselves and 2 % had the injection administered by health professionals. Venous thromboembolic events were confirmed in 5 % at 7.86 days after surgery. Three patients had persistent wound drainage after surgery, however, none required reoperation or readmission.

Compliance with LMWH is high and is comparable with oral agents. It is effective in preventing VTE and safe with regards to bleeding and wound complications in a South African setting. Patient education regarding medications may improve compliance of the medication.

Periprosthetic joint infection (PJI) in geriatric and/or multimorbid patients is an enormous challenge for orthopaedic surgeons. Revision procedures have also been demonstrated to expose patients to higher infection risks. Prior patient stratification according to presumed infection risks, followed by a more potent local antibiotic prophylaxis protocol with selective use of DALBC, is an interesting strategy to decrease the burden of PJI in high risk patients.

The PubMed & EMBASE databases were screened for publications pertaining to the utilization of DALBC in cement for infection prophylaxis & prosthesis fixation. 6 preclinical & 7 clinical studies were identified which met the inclusion criteria and were stratified by level of clinical evidence. Only those studies were considered which compared the PJI outcome in the DALBC vs the SALBC group.

Use of DALBC is likely to be more effective in preventing PJI in high risk patients. The preliminar findings so far may encourage clinicians to consolidate this hypothesis on a wider clinical range.

Cementless fixation is an alternative to cemented unicompartmental knee replacement (UKR), with several advantages over cementation. This study reports on the 15-year survival and 10-year clinical outcomes of the cementless Oxford unicompartmental knee replacement (OUKR).

This prospective study describes the clinical outcomes and survival of first 693 consecutive cementless medial OUKRs implanted in New Zealand.

The sixteen-year survival was 89.2%, with forty-six knees being revised. The commonest reason for revision was progression of arthritis, which occurred in twenty-three knees, followed by primary dislocation of the bearing, which occurred in nine knees. There were two bearing dislocations secondary to trauma and a ruptured ACL, and two tibial plateau fractures. There were four revisions for polyethylene wear. There were four revisions for aseptic tibial loosening, and one revision for impingement secondary to overhang of the tibial component. There was only one revision for deep infection and one revision where the indication was not stated. The mean OKS improved from 23.3 (7.4 SD) to 40.59 (SD 6.8) at a mean follow-up of sixteen years.

In conclusion, the cementless OUKR is a safe and reproducible procedure with excellent sixteen-year survival and clinical outcomes.

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children. Contemporary research aims to identify predictors of acute and chronic complications. Trends in C-reactive protein (CRP) following treatment initiation may predict disease course. We have sought to identify factors associated with acute and chronic complications in the New Zealand population.

A retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral centre between 2008-2018 was performed. Multivariate was analysis used to identify factors associated with an acute or chronic complication. An “acute” complication was defined as need for two or more surgical procedures, hospital stay longer than 14-days, or recurrence despite IV antibiotics. A “chronic” complication was defined as growth or limb length discrepancy, avascular necrosis, chronic osteomyelitis, pathological fracture, frozen joint or dislocation. 151 cases met inclusion criteria. The median age was 8 years (69.5% male). Within this cohort, 53 (34%) experienced an acute complication and 18 (12%) a chronic complication.

Regression analysis showed that contiguous disease, delayed presentation, and failure to reduce CRP by 50% at day 4/5 predicted an acutely complicated disease course. Chronic complication was predicted by need for surgical management and failed CRP reduction by 50% at day 4/5. We conclude that CRP trends over 96 hours following commencement of treatment differentiate patients with AHO likely to experience severe disease.

The posterior compartments of the knee are currently accessed arthroscopically through anterior, posteromedial or posterolateral portals. A direct posterior portal to access the posterior compartments has been overlooked due to a perceived high-risk of injury to the popliteal neurovascular structures. Therefore, this study aimed to investigate the safety and accessibility of a direct posterior portal into the knee.

This cross-sectional study comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16mm from the vertical plane between the medial epicondyle of the femur and medial condyle of the tibia and 8 and 14mm (females and males respectively) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen in 90-degree flexion. Posterior aspects of the knees were dissected from superficial to deep, to assess potential damage caused by cannula insertion. Incidence of neurovascular damage was 9.6% (n=10); 0.96% medial cannula and 8.7% lateral cannula. The medial cannula damaged one small saphenous vein (SSV) in a male specimen. The lateral cannula damaged one SSV, 7 common fibular nerves (CFN) and both CFN and lateral cutaneous sural nerve in one specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens.

A medial-lying direct posterior portal into the knee is safe in 99% of occurrences. The lateral-lying direct posterior portal is of high risk to the CFN.

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention.

127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. p<0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI).

The number of columns involved in the injury best predicts functional outcomes (FFI, P <0.05, AOFAS, p<0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group.

We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes.

Rates of prosthetic joint infection in megaprostheses are high. The application of silver ion coating to implants serves as a deterrent to infection and biofilm formation.

A retrospective review was performed of all silver-coated MUTARS endoprosthetic reconstructions (SC-EPR) by a single Orthopaedic Oncology Surgeon. We examined the rate of component revision due to infection and the rate of infection successfully treated with antibiotic therapy. We reviewed overall revision rates, sub-categorised into the Henderson groupings for endoprosthesis modes of failure (Type 1 soft tissue failure, Type 2 aseptic loosening, Type 3 Structural failure, Type 4 Infection, Type 5 tumour progression).

283 silver-coated MUTARS endoprosthetic reconstructions were performed for 229 patients from October 2012 to July 2022. The average age at time of surgery was 58.9 years and 53% of our cohort were males. 154 (71.3%) patients underwent SC-EPR for oncological reconstruction and 32 (14.8%) for reconstruction for bone loss following prosthetic joint infection(s). Proximal femur SC-EPR (82) and distal femur (90) were the most common procedures. This cohort had an overall revision rate of 21.2% (60/283 cases). Component revisions were most commonly due to Type 4 infection (19 cases), Type 2 aseptic loosening/culture negative disease (15 cases), and Type 1 dislocation/soft tissue (12 cases).

Component revision rate for infection was 6.7% (19 cases). 15 underwent exchange of implants and 4 underwent transfemoral amputation due to recalcitrant infection and failure of soft tissue coverage. This equates to a limb salvage rate of 98.3%. The most common causative organisms remain staphylococcus species (47%) and polymicrobial infections (40%).

We expand on the existing literature advocating for the use of silver-coated endoprosthetic reconstructions. We provide insights from the vast experience of a single surgeon when addressing patients with oncological and bone loss-related complex reconstruction problems.

The introduction of robotics for total knee arthroplasty (TKA) into the operating theatre is often associated with a learning curve and is potentially associated with additional complications. The purpose of this study was to determine the learning curve of robotic-assisted (RA) TKA within a multi-surgeon team.

This prospective cohort study included 83 consecutive conventional jig-based TKAs compared with 53 RA TKAs using the Robotic Surgical Assistant (ROSA) system (Zimmer Biomet, Warsaw, Indiana, USA) for knee osteoarthritis performed by three high-volume (> 100 TKA per year) orthopaedic surgeons. Baseline characteristics including age, BMI, sex and pre-operative Kellgren-Lawrence grade were well-matched between the conventional and RA TKA groups. Cumulative summation (CUSUM) analysis was used to assess learning curves for operative times for each surgeon. Peri-operative and delayed complications were reviewed.

The CUSUM analysis for operative time demonstrated an inflexion point after 5, 6 and 15 cases for each of the three surgeons, or 8.7 cases on average. There were no significant differences (p = 0.53) in operative times between the RA TKA learning (before inflexion point) and proficiency (after inflexion point) phases. Similarly, the operative times of the RA TKA group did not differ significantly (p = 0.92) from the conventional TKA group. There was no discernible learning curve for the accuracy of component planning using the RA TKA system. The average length of post-operative follow-up was 21.3 ± 9.0 months. There was no significant difference (p > 0.99) in post-operative complication rates between the groups.

The introduction of the RA TKA system was associated with a learning curve for operative time of 8.7 cases. Operative times between the RA TKA and conventional TKA group were similar. The short learning curve implies this RA TKA system can be adopted relatively quickly into a surgical team with minimal risks to patients.

Distal radius fractures (DRFs) are one of the most common types of fracture and one which is often treated surgically. Standard X-rays are obtained for DRFs, and in most cases that have an intra-articular component, a routine CT is also performed. However, it is estimated that CT is only required in 20% of cases and therefore routine CT's results in the overutilisation of resources burdening radiology and emergency departments. In this study, we explore the feasibility of using deep learning to differentiate intra- and extra-articular DRFs automatically and help streamline which fractures require a CT.

Retrospectively x-ray images were retrieved from 615 DRF patients who were treated with an ORIF at the Royal Brisbane and Women's Hospital. The images were classified into AO Type A, B or C fractures by three training registrars supervised by a consultant. Deep learning was utilised in a two-stage process: 1) localise and focus the region of interest around the wrist using the YOLOv5 object detection network and 2) classify the fracture using a EfficientNet-B3 network to differentiate intra- and extra-articular fractures.

The distal radius region of interest (ROI) detection stage using the ensemble model of YOLO networks detected all ROIs on the test set with no false positives. The average intersection over union between the YOLO detections and the ROI ground truth was Error! Digit expected.. The DRF classification stage using the EfficientNet-B3 ensemble achieved an area under the receiver operating characteristic curve of 0.82 for differentiating intra-articular fractures.

The proposed DRF classification framework using ensemble models of YOLO and EfficientNet achieved satisfactory performance in intra- and extra-articular fracture classification. This work demonstrates the potential in automatic fracture characterization using deep learning and can serve to streamline decision making for axial imaging helping to reduce unnecessary CT scans.

Long femoral nails for neck of femur fractures and prophylactic fixation have a risk of anterior cortex perforation. Previous studies have demonstrated the radius of curvature (ROC) of a femoral nail influencing the finishing point of a nail and the risk of anterior cortex perforation. This study aims to calculate a patients femoral ROC using preoperative XR and CT and therefore nail finishing position.

We conducted a retrospective study review of patients with long femoral cephalomedullary nailing for proximal femur fractures (OTA/AO 31(A) and OTA/AO 32) or impending pathological fractures at a level 1 trauma centre between January 1, 2015 and December 31, 2020 with both full length lateral X-ray and CT imaging. Femoral ROC was calculated on both imaging modalities. Outcomes measured including nail finishing position, anterior cortex encroachment and impingement. The mean femoral ROC was 1026mm on CT and 1244mm on XR. CT femoral ROC strongly correlated with nail finishing point with a spearmans coefficient of 0.77. Additionally, femurs with a ROC <1000mm were associated with a higher risk of anterior encroachment (OR 6.12) and femurs with a ROC <900mm were associated with a higher risk of anterior cortex impingement (OR 6.47).

To our knowledge this is the first study to compare a measured femoral ROC to nail finishing position. The use of CT to measure femoral ROC and to a lesser extent XR was able to predict both nail finishing position and risk of anterior cortex encroachment. Preoperative XRs and CTs were able to identify patients with a small femoral ROC. This predicted patients at risk of anterior cortex impingement, anterior cortex encroachment and nail finishing position. We may be able to select femoral nails that resemble the native femoral ROC and mitigate the risk of anterior cortex perforation.

Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT.

Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint.

Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears.

Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%.

At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%.

Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes.

Introduction: The mechanobiology and response of bone formation to strain under physiological loading is well established, however investigation into exceedingly soft scaffolds relative to cancellous bone is limited. In this study we designed and 3D printed mechanically-optimised low-stiffness implants, targeting specific strain ranges inducing bone formation and assessed their biological performance in a pre-clinical in vivo load-bearing tibial tuberosity advancement (TTA) model. The TTA model provides an attractive pre-clinical framework to investigate implant osseointegration within an uneven loading environment due to the dominating patellar tendon force.

A knee finite element model from ovine CT data was developed to determine physiological target strains from simulated TTA surgery. We 3D printed low-stiffness Ti wedge osteotomy implants with homogeneous stiffness of 0.8 GPa (Ti1), 0.6 GPa (Ti2) and a locally-optimised design with a 0.3 GPa cortex and soft 0.1 GPa core (Ti3), for implantation in a 12-week ovine tibial advancement osteotomy (9mm). We quantitatively assessed bone fusion, bone area, mineral apposition rate and bone formation rate.

Optimised Ti3 implants exhibited evenly high strains throughout, despite uneven wedge osteotomy loading. We demonstrated that higher strains above 3.75%, led to greater bone formation. Histomorphometry showed uniform bone ingrowthin optimised Ti3 compared to homogeneous designs (Ti1 and Ti2), and greater bone-implant contact. The greatest bone formation scores were seen in Ti3, followed by Ti2 and Ti1.

Results from our study indicate lower stiffness and higher strain ranges than normally achieved in Ti scaffolds stimulate early bone formation. By accounting for loading environments through rational design, implants can be optimised to improve uniform osseointegration. Design and 3D printing of exceedingly soft titanium orthopaedic implants enhance strain induced bone formation and have significant importance in future implant design for knee, hip arthroplasty and treatment of large load-bearing bone defects.

Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity.

Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week.

Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages.

New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance.

Clinical success of prostheses in joint arthroplasty is ultimately determined by survivorship and patient satisfaction. The purpose of this study was to compare (non-inferiority) a new morphometric designed stem for total hip arthroplasty (THA) against an established comparator.

A prospective randomised multi-centre study of 144 primary cementless THA performed by nine experienced orthopaedic surgeons was completed (70 received a fully coated collarless tapered stem and 74 received a morphometric designed proximally coated tapered stem). PROMs and blood serum markers were assessed preoperatively and at intervals up to 2-years postoperatively. In addition, measures of femoral stem fit, fill and subsidence at 2-years post-operatively were measured from radiographs by three observers, with an intra-class correlation coefficient of 0.918. A mixed effects model was employed to compare the two prosthesis over the study period. A p-value <0.05 was considered statistically significant.

Demographics, Dorr types and blood serum markers were similar between groups. Both stems demonstrated a significant improvement in PROMs between the pre- and post-operative measurements, with no difference at any timepoint (p > 0.05). The fully coated tapered collarless femoral stem had a non-significantly higher intra-operative femoral fracture rate (5.8% vs 1.4%, p = 0.24), with all patients treated with cable fixation and partial weight bearing. The mean subsidence at 2-years was 2.5mm +/− 2.3mm for the morphometric stem and 2.4mm +/− 1.8mm for the fully coated tapered collarless femoral stem (p = 0.879). There was one outlier in each group with increased subsidence (fully coated tapered collarless femoral stem 6.9mm, morphometric wedge stem 7.4mm), with both patients reporting thigh pain at 2 years.

When compared with an established stem, the newer designed morphometric wedge stem performed well with comparable radiological and PROM outcomes at 2 year follow up. Continued follow-up is required for long term benchmarking.