With the rising rates, and associated costs, of total knee arthroplasty (TKA), enhanced clarity regarding patient appropriateness for TKA is warranted. Towards addressing this gap, we elucidated in qualitative research that surgeons and osteoarthritis (OA) patients considered TKA need, readiness/willingness, health status, and expectations of TKA most important in determining patient appropriateness for TKA. The current study evaluated the predictive validity of pre-TKA measures of these appropriateness domains for attainment of a good TKA outcome. This prospective cohort study recruited knee OA patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those receiving primary, unilateral TKA completed questionnaires pre-TKA assessing TKA need (WOMAC-pain, ICOAP-pain, NRS-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, prior OA treatment), TKA readiness/willingness (Patient Acceptable Symptom State (PASS), willingness to undergo TKA), health status (PHQ-8, BMI, MSK and non-MSK comorbidities), TKA expectations (HSS KR Expectations survey items) and contextual factors (e.g., age, gender, employment status). One-year post-TKA, we assessed for a ‘good outcome’ (yes/no), defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with TKA results. Multiple logistic regression, stepwise variable selection, and best possible subsets regression was used to identify the model with the smallest number of independent variables and greatest discriminant validity for our outcome. Receiver Operating Characteristic (ROC) curves were generated to compare the discriminative ability of each appropriateness domain based on the ‘area under the ROC curve’ (AUC). Multivariable robust Poisson regression was used to assess the relationship of the variables to achievement of a good outcome. f 1,275 TKA recipients, 1,053 (82.6%) had complete data for analyses (mean age 66.9 years [SD 8.8]; 58.6% female). Mean WOMAC pain and KOOS-PS scores were 11.5/20 (SD 3.5) and 52.8/100 (SD 17.1), respectively. 78.1% (95% CI 75.4–80.5%) achieved a good outcome. Stepwise variable selection identified optimal discrimination was achieved with 13 variables. The three best 13-variable models included measures of TKA need (WOMAC pain, KOOS-PS), readiness/willingness (PASS, TKA willingness), health status (PHQ-8, troublesome hips, contralateral knee, low back), TKA expectations (the importance of improved psychological well-being, ability to go up stairs, kneel, and participate in recreational activities as TKA outcomes), and patient age. Model discrimination was fair for TKA need (AUC 0.68, 95% CI 0.63-0.72), TKA readiness/willingness (AUC 0.61, 95% CI 0.57-0.65), health status (AUC 0.59, 95% CI 0.54-0.63) and TKA expectations (AUC 0.58, 95% CI 0.54-0.62), but the model with all appropriateness variables had good discrimination (AUC 0.72, 95% CI 0.685-0.76). The likelihood of achieving a good outcome was significantly higher for those with greater knee pain, disability, unacceptable knee symptoms, definite willingness to undergo TKA, less depression who considered improved ability to perform recreational activities or climb stairs ‘very important’ TKA outcomes, and lower in those who considered it important that TKA improve psychological wellbeing or ability to kneel. Beyond surgical need (OA symptoms) and health status, assessment of patients’ readiness and willingness to undergo, and their expectations for, TKA, should be incorporated into assessment of patient appropriateness for surgery

Freehand distal interlocking of intramedullary nails remains a challenging task. If not performed correctly it can be a time consuming and radiation expensive procedure. Recently, the AO Research Institute developed a new training device for Digitally Enhanced Hands-on Surgical Training (DEHST) that features practical skills training augmented with digital technologies, potentially improving surgical skills needed for distal interlocking. Aim of the study: To evaluate weather training with DEHST enhances the performance of novices without surgical experience in free-hand distal nail interlocking compared to a non-trained group of novices. 20 novices were assigned in two groups and performed distal interlocking of a tibia nail in an artificial bone model. Group 1: DEHST trained novices (virtual locking of five nail holes during one hour of training). Group 2: untrained novices without DEHST training. Time, number of x-rays, nail hole roundness, critical events and success rates were compared between the groups. Time to complete the task (sec.) and x-ray exposure (µGcm2) were significantly lower in Group1 414.7 (290–615) and 17.8 (9.8–26.4) compared to Group2 623.4 (339–1215) and 32.6 (16.1–55.3); p=0.041 and 0.003. Perfect circle roundness (%) was 95.0 (91.1–98.0) in Group 1 and 80.8 (70.1–88.9) in Group 2; p<0.001. In Group 1 90% of the participants achieved successful completion of the task (hit the nail with the drill), whereas only 60% of the participants in group 2 achieved this; p=0.121. Training with DEHST significantly enhances the performance of novices without surgical experience in distal interlocking of intramedullary nails. Besides radiation exposure and operation time the com-plication rate during the operation can be significantly reduced

Aim. Early fracture-related infections (FRIs) are a common entity in hospitals treating trauma patients. It is important to be aware of the consequences of FRI in order to be able to counsel patients about the expected course of their disease. Therefore, the aims of this study were to evaluate the recurrence rate, to establish the number of secondary surgical procedures needed to gain control of the initial infection, and to identify predictors for recurrence in patients with early FRI. Method. A retrospective multicentre cohort study was conducted in two level 1 trauma centres. All patients between January 1st 2015 to July 1st 2020 with confirmed FRI with an onset of <6 weeks after initial fracture fixation were included. Recorded data included patient demographics, trauma mechanism, clinical and laboratory findings, surgical procedure, microbiology, and follow-up. Univariate and multivariate logistic regression analyses were performed to assess predictors for recurrent FRI. Results. A total of 166 patients were included in this study with a median age of 54.0 years (IQR 33.0–64.0). The cohort consisted of a majority of males (66.3%). Recurrence of FRI at one year follow-up was 11.4% and the overall recurrence rate within a median follow-up time of 24.0 months (IQR 15.4–36.9) was 18.1%. A total of 49.4% of patients needed at least one secondary procedure in order to treat the ongoing FRI, of whom 12.6% required at least three additional procedures. Predictors for recurrent FRI were use of an intramedullary nail during index operation (OR 4.343 (95% CI 1.448–13.028), p=0.009), need for at least one additional washout and debridement (OR 1.908 (95% CI 1.102–3.305), p=0.021), and a decrease in Injury Severity Score (ISS) (inverted OR 1.058 (95% CI 1.002–1.118), p=0.042). Conclusions. An FRI recurrence rate of 18.1% and need for at least one additional surgical procedure to gain control of the initial infection of 49.4% were seen in our cohort. Predictors for recurrent FRI were respectively the use of an intramedullary nail during index operation, need for secondary procedures, and a decrease in ISS. Results of this study can be used for preoperative counselling of early FRI patients

Aims

As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA).

Purpose: Uncertainty around back pain management results in large volumes of patients with back related complaints being referred to orthopaedic surgeons for direction. The vast majority of these referrals are non surgical leading to unacceptable wait times (T1) across Canada. This reservoir delays not only those who are disabled with problems requiring a surgical remedy but also those who only require direction to appropriate conservative care. Physiotherapists with advanced training in orthopaedics possess skills in musculoskeletal interview, exam and Orthopaedic residents on the other hand must acquire spine specific skills in interview and exam, interpretation of radiographic exams, surgical decision making as well as surgical technique in a 2–3 month residency rotation. Our question was „Can an Experienced Physiotherapist Become Proficient in Triaging for Surgically Appropriate Patients After a 2–3 month „Residency „. Method: Following a 3 month clinical residency an experienced physiotherapist and a spine surgeon independently interviewed, physically examined and reviewed diagnostic imaging of 31 patients. It was then independently concluded whether the patients were candidates for surgical treatment, required conservative management or whether further investigations were necessary to make the final determination. The level of agreement was calculated using Chance Corrected Agreement or Kappa values. Operational definitions were reviewed and a second group of 29 patients were assessed. Results: The initial Kappa score was .68 (considered good clinical agreement) and the final Kappa score was 0.84 (considered virtually interchangeable). Conclusion: A 3 month period can prepare an experienced orthopaedic physiotherapist to triage a waiting list for surgical candidates. The therapist can add value through being better prepared to direct conservative options. Expediting triage will facilitate the right person getting to the right intervention within a reasonable time frame. Addressing the backlog of referrals will also help identify the magnitude of surgical need

INTRODUCTION. Important surgical requirements for optimal function are accurate bone cut alignments and soft tissue balancing. From an unbalanced state, balancing can be achieved by Surgical Corrections including soft tissue releases, bone cut modifications, and changing tibial insert thickness. Surgical balancing can now be quantified using an instrumented tibial trial, but the procedures and results need further investigation. Our major purpose was to determine the initial balancing after making the bone cuts, and the final accuracy of balancing after Surgical Corrections. A related purpose was to determine the number and effectiveness of different Corrections in achieving balancing. METHODS. During 101 surgeries of a PCL-retaining TKA, screen capture software recorded the video feed of surgery, angular data from the navigation system, and lateral and medial contact forces from the instrumented tibial trial. Initial bone cuts were made using navigation based on measured resection. The instrumented tibial trial measured the magnitudes and locations of the contact forces on the lateral and medial sides throughout flexion. The Heel Push Test (Walker 2014) determined the initial balancing, defined as a ratio of the medial/total force at 0, 30, 60 and 90 degrees flexion. A balanced knee with equal lateral and medial forces would show a value of 0.5. Surgical Corrections were then performed with the goal of achieving balancing. The most common Corrections were soft tissue releases (total 63 incidences), including MCL, postero-lateral corner, postero-medial corner; and increasing/decreasing tibial insert thicknesses (34 incidences). RESULTS. After the bone cuts and inserting the trials, the average medial/total force ratio was 0.49 +/− 0.27. After final balancing, the ratio was 0.52 +/− 0.14 (Figure 1). The initial data was scattered between 0.0 (lateral force only) and 1.0 (medial force only). The final data showed a clear narrowing of the range of imbalance. The different Surgical Corrections achieved an improvement of the medial/total ratio between 0.11–0.18. A 2mm insert increase increased the total force by 106 Newtons. A final medial/total ratio between 0.35–0.65 was achieved in 80% of cases from 0–30 degrees; 77% from 0–90 degrees. In 84% of the cases, 0–2 Corrections were required. The average total force on the condyles from 0–90 degrees was 290.5+/−166.8 Newtons initially and 215.3+/−86.3 Newtons after balancing, the large range due to patient variations in ligament stiffness. DISCUSSION. Acceptable balancing was achieved in the majority of cases with only 0–2 Surgical Corrections. The sensitivity of the balancing values to the Surgical Corrections was consistent with a previous study showing that changes of 2mm or 2 degrees could correct most imbalanced states (Walker 2014), related to collateral stiffness being in the region of 50N/mm (Wilson 2012, Robinson 2005). With only 2 Surgical Corrections needed in the majority of cases, no additional time was needed compared with qualitative methods. The acceptable level in our study from 0.35–0.65 medial/total force ratio was based on what could readily be achieved, consistent with a previous study (Gustke 2014). An IRB study is now underway to determine the ideal balancing ratio and the effect on functional outcome

Methods. A pericapsular approach was used with capsulotomy and then correction of the lesions both in the pelvic and in the femoral aspects. The traction times and total surgery times for the conventional method and the new out-inside technique were compared. Results. Conventional Hip Arthroscopy. –. 61 Hips done. –. Total surgery time was 110 minutes. –. Traction time was 50 minutes. –. 6 Weeks non weight bearing. New out-inside technique of hip arthroscopy. –. 24 Hips done. –. Total surgery time was 90 minutes. –. Traction time was 20 minutes. –. 4 weeks non weight bearing. New out-inside technique – E Margalet results. –. 68 Hips done. –. Total surgery time was 80.5 minutes. –. Traction time was 18.2 minutes. –. 3-4 weeks non weight bearing. Conclusion. Hip arthroscopy for femoral-acetabular impingement involves time spent working on the central and peripheral compartment. This new therapeutic approach requires a less aggressive exposure and is technically easier than conventional arthroscopy. A 30 degree optic system and shoulder and knee arthroscopic instruments were used without the need for fluoroscopy and the 70 degree optic was only used in the central compartment. No new surgical portals are used but rather a new surgical approach. It is important to note that new surgical complications need to be considered in this method. Outcomes are variable regarding pain and full recovery to normal previous activity of each patient. NO DISCLOSURES

Introduction. Total hip arthroplasty (THA) using the direct anterior approach (DAA) in a supine position is a minimally invasive surgery that reduces postoperative dislocation. Excellent exposure of both the acetabulum and proximal femoral part is important to reduce intraoperative complications. Generally, two surgical assistants need to hold four retractors to maintain excellent exposure of the acetabulum. We examined intra- and postoperative complications as indicators of the efficiency of using the “Magic Tower” (MT) device compared with a non-MT group. Material and Method. Twenty consecutive DAA THAs using MT were analyzed, and 20 DAA THAs not using MT were also analyzed. MT is a retractor-holding device, and has an arm structure that can be moved in a wide variety of directions. This device holds a retractor stably, and each movement of the arm can be locked by one click. Operating time, blood loss, length of skin incision, intraoperative complications, and number of assistants were recorded. Postoperative radiographs were obtained to evaluate implant position. Results. Mean operating time was 105 min in the MT group and 118 min in the non-MT group. Mean blood loss was 232 g in the MT group and 233 g in the non-MT group. Mean length of skin incision was 80 mm in the MT group and 85 mm in the non-MT group. Mean cup inclination was 45.8° in the MT group and 47.3° in the non-MT group. Postoperative implant position was also excellent in both groups. In all comparisons, no significant differences were seen between groups. No intraoperative complications were encountered. Two assistants were required in the non-MT group, and one in the MT group. Discussion. A majority of the complications reported with THA can be attributed to access issues, i.e., difficulties in exposure and accurate component implantation. To achieve excellent exposure at the acetabulum, four retractors (anterior, posterior, cranial, and caudal) are desirable. In such procedures, two surgical assistants are needed to hold retractors. One of these assistants needs to hold the anterior retractor and cranial/caudal retractor from the opposite side of the surgery beyond the abdomen of the patient. However, the assistant on the opposite side cannot achieve good exposure, as strong retraction of the anterior part of the acetabulum may cause complications of femoral nerve palsy. The MT is able to hold a retractor firmly by applying pressure toward the acetabulum instead of traction, and also reduces the number of surgical assistants required. While preparing the femur, exposure of the femoral canal was also better than in the non-MT group. Conclusion. In primary DAA THA, no significant differences between groups were identified. However, the MT is clearly a useful device that allows maintenance of excellent exposure, reducing the number of surgical assistants required

Introduction of new surgical intervention need assessment of the true results by eliminating cognitive dissonance and the placebo effect. Significant time must elapse since the procedure to derive conclusions. With the initial gratifying results of Endoscopic Foraminoplasty a retrospective analysis of the data was performed to identify if the outcome was accurate and not a placebo effect. Early postoperative Data (6 weeks and 6 months) derived from questionnaires on 91 patients with Endoscopic Foraminoplasty (April 1997 and November 1998), which included the Oswestry Disability Scale and a Visual Analogue Pain Scale was compared with the data at 2 years (late). A t-test was used to assess the difference between the Oswestry Disability scores from the two questionnaires and a Wilcoxon Signed Rank test for the Visual Analogue Pain Scale. No significant difference between the Visual Analogue Pain Scores at 6 weeks to 6 months and 2 years post-operation was noted. There was however, a marginal improvement (p= 0.05) in Oswestry Index over two years period. The initial outcome of Endoscopic Laser Foraminoplasty was sustained or improved at the end of two years and was not a placebo effect

The author presents his experience over twenty three years as visiting orthopaedic specialist in the early management of neonatal and infantile clubfoot with annual visits to the Kingdom of Tonga, S.W. Pacific. This has involved three hundred and seventy two infants with five hundred and fifty eight feet. The relative ease of assisting surgically those least able to afford treatment overseas in their own country where such treatment may not be available in their own country is discussed. The equipment required; the surgical skills needed; the importance of safe anaesthesia; the importance in gaining the confidence of family, local medical, nursing and administration staff is emphasized. The high incidence of clubfoot in Polynesians is noted. The incidence in Tonga approaches one per hundred live births ie. 1% so for Tonga where there are approximately 2500 live births per annum – this means an annual case load of 25 babies with upto 40 feet to correct on an annual basis: a formidable annual caseload. Three orthopaedic visiting surgeons with one visiting anaesthetist plus another local anaesthetist utilizing two theatres can successfully complete this caseload in 3–4 days of operating. In the absence of such visiting teams many of these babies would remain untreated or inadequately treated and would commence walking at 12–18 months on uncorrected feet with disastrous results. Early soft tissue correction in a baby under 12 months of age is highly desirable to ensure a corrected plantargrade foot before walking commences. Clubfoot is therefore especially common in Tonga; Samoa; Tahiti; Hawaii and amongst Maoris in New Zealand yet it still occurs in Melanesians in Fiji; Papua New Guinea; Solomon Islands; Vanuatu; New Caledonia and in the Micronesian states in the Caroline Islands; Marshall and Mariana Islands. There is a need for visiting orthopaedic teams to visit and surgically treat clubfoot on an annual basis. The author in co-operation seeks to establish an Asian Pacific Foundation to ensure this important surgery is delivered annually to our near neighbours

In a global environment of rising costs and limited funds, robotic and computer-assisted orthopaedic technologies could provide the means to drive a necessary revolution in arthroplasty productivity. Robots have been used to operate on humans for 20 years, but the adoption of the technology has lagged behind that of the manufacturing industry. The use of robots in surgery should enable cost savings by reducing instrumentation and inventories, and improving accuracy. Despite these benefits, the orthopaedic community has been resistant to change. If the ergonomics and economics are right, robotic technology just might transform the provision of joint replacement.