Aims. Treatment of end-stage anteromedial osteoarthritis (AMOA) of the knee is commonly approached using one of two surgical strategies: medial unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). In this study we aim to investigate if there is any difference in outcome for patients undergoing UKA or TKA, when treated by high-volume surgeons, in high-volume centres, using two different clinical guidelines. The two strategies are ‘UKA whenever possible’ vs TKA for all patients with AMOA. Methods. A total of 501 consecutive AMOA patients (301 UKA) operated on between 2013 to 2016 in two high-volume centres were included. Centre One employed clinical guidelines for the treatment of AMOA allowing either UKA or TKA, but encouraged UKA wherever possible. Centre Two used clinical guidelines that treated all patients with a TKA, regardless of wear pattern. TKA patients were included if they had isolated AMOA on preoperative radiographs. Data were collected from both centres’ local databases. The primary outcome measure was change in Oxford Knee Score (OKS), and the proportion of patients achieving the patient-acceptable symptom state (PASS) at one-year follow-up. The data were 1:1 propensity score matched before regression models were used to investigate potential differences. Results. The matched cohort included 400 patients (mean age 67 years (SD 9.55), 213 (53%) female, mean BMI 30.2 kg/m. 2. , 337 (84%) American Society of Anesthesiologists grade ≤ 2). We found a mean adjusted difference in change score of 3.02 points (95% confidence interval (CI) 1.41 to 4.63; p < 0.001) and a significantly larger likeliness of achieving PASS (odds ratio 3.67 (95% CI 1.73 to 8.45); p = 0.001) both in favour of the UKA strategy. Conclusion. UKA and TKA are both good strategies for treating end-stage AMOA. However, when compared as a strategy, UKA achieved larger improvements in OKS, and were more likely to reach the PASS value at one-year follow-up. Cite this article: Bone Jt Open 2022;3(5):441–447

Purpose: Talipes equinus is a frequent deformity observed in patients with central nervous disease. The surgical strategy is based on an assessment of the spasticity and retraction elements in the deformity and the presence or not of antagonistic muscles. We propose a codified treatment strategy and present results obtained over the last two years. Material and methods: All patients who underwent surgical treatment for central neurological talipes equinus between 1998 and 1999 were included in this study. All patients were seen by the orthopaedic surgeon and the physical education and rehabilitation physician at the preoperative consultation. Selective neuromotor nerve blocks completed the physical exam in order to assess spasticity and retractions (soleus, gastocnemius, flexor digitalis). Functional antagonistic or transferable muscles were identified. A function contract was established with the patient. All patients were operated on by the same surgeon and were reviewed late after surgery by an independent clinician. Gain in joint movement and function were recorded as well as any complications. Results: Thirty-five patients underwent surgery (42 feet). The analytic results were good: mean gain in joint movement = 37.5°. The functional objectives (walking for 31 patients, verticalisation for ten, comfort for one) were achieved in all patients except five. There was one taluseversus, one anterior subluxation of the talus, one persistent stepping. For two patients underlying neurological disorders did not allow fulfilment of the contract. There were also three cases of claw toes with moderate functional impact. Discussion: Preponderant retraction makes it difficult to assess antagonistic and intrinsic muscles, leading to the complications observed. A dynamic EMG recording might provide a solution. Functional outcome depends on correct assessment of the underlying neurological status. Conclusion: The good results achieved in this series of patients validates the proposed decisional algorithm. The surgical strategy must be inscribed within a functional contract established with each individual patient

Aim. A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated. Method. Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis. Results. Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly plurimicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p=0.022). An increased prevalence of coagulase negative Staphylococci (p=0.017) and Candida (p=0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p=0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p=0.025) and Actinomyces infection (OR, 9.5; p=0.027). Conclusions. Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. Carbapenem should be reserved for ESBL at-risk patients only, including those with previous fluoroquinolone use. The uncorrelation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment

Purpose of the study: The surgical technique for thoracolumbar scoliosis and T11-L3 lumbar scoliosis with a lumbosacral counter curvature (neutral L4) does not raise any particular problem in terms of the length of the instrumentation and the choice of the vertebral bodies to include in the fusion. The strategy is however more difficult to establish when the iliolumbar angle is closed and L4 is included in the curvature.

Material and methods: We report 11 cases of type II scoliosis, all in girls aged 15.5 years on average (range 12–18 years). These girls presented an imbalanced trunk with lumbar asymmetry. Mean lumbar curvature was 51° (range 41–72°), and, for patients with a double curvature, the mean thoracic counter curvature was 28° (range 21–45°). Lateral lumbar displacement was 4.2 cm (3–4.9 cm), and in double curvatures the thoracic displacement was 3.1 cm (1.7–4.2 cm). Mean lumbar lordosis was −41° (range −38° to −46°). Mean thoracic kyphosis was +13° (range −2° to +22°). Anterior instrumentation was used for all curvatures. For six patients, five levels, from T11 to L3 were instrumented and in five patients, four levels from T12 to L3. For the double scoliosis cases, in situ rod bending was necessary to balance the lumbar curvature with the thoracic curvature.

Results: Mean follow-up was 42 months (range 14–79). One revision was required for rupture of a corporeal screw with L4–L5 nonunion. Trunk imbalance was corrected in all patients. The iliolumbar angle was opened with a mean L3–L4 inclination of 11° (range 0–18°). Mean Cobb angle was 22° in the lumbar region (range 17–30°). For the double curvatures, the mean residual thoracic curvature was 27.6° (range 17–44°). Mean residual lateral displacement was 0.2 cm in the lumbar region (range 0–0.3 cm) and 0.8 cm (range 0.3–2.2 cm) in the thoracic region. Mean thoracic kyphosis was 13° (range +10–25°). Mean lumbar lordosis was −51° (range −49° to +44°).

Discussion: In the literature, a posterior approach has been proposed for curvatures with a closed iliolumbar angle and inclusion of L4. The assembly includes L4 and often L5, extending as high as T5–T6 in the cases with double curvatures. We have chosen a completely different strategy and propose short anterior instrumentation. The spinal balance obtained appears to be as good with a better functional result due to the preservation of spinal motion and posterior muscle function. Longer follow-up will be necessary to assess the effect on the discs above and below the fusion.

Purpose: All displacements can be described with x, y, z coordinates. We propose an anterior view of the first metatarsal associated with a peroperative test to determine the precise position in the frontal plane, both statically and dynamically. Lateral release is an important step in surgical treatment of hallux valgus. Both the extent of release and the potential benefit of no release must be carefully evaluated. We propose a view allowing an assessment of the metatarsophalangeal reducibility.

Material and method: Peroperative test. This test explores cuneometatarsal laxity. We conducted a prospective study in 100 cases. A 12/100 pin was used to immobilise the first cuneiform and a 20/100 pin was placed in the base of the first metatarsal. A third distal pin in the neck was used to pivot the bone on its axis. A small protractor was used to measure the angle by projection with ±2.5° precision.

Modified Guntz view. This is a weight-bearing anterior view of the first metatarsal. The cassette is positioned posteriorly. The patient stands with the heal raised 40 mm on a 20mmx20mm plexiglass bar. The metatarsal diaphysis must appear perfectly vertical. An isosceles triangle is constructed on the articular facets; the base of the triangle is perfectly horizontal and defines the pronation-supination angle. We made 100 measurements and checked correlation with the peroperative test.

Reduction view. A Zimmer brace was used to reduce the varus metatarsus and adduct the toe. The metatarsophalangeal angle and the position of the sesamoids were used to assess reducibility.

Results: Pronation and/or pronation instability was = 10° in 96% of the patients. The reduction view enabled classifiation by three grades of reducibility.

Discussion: Our contribution is determining for correction of displacements taking into account the frontal plane. No other study has shown so clearly the existence of metatarsal pronation. We also confirmed the presence of a large proportion of cuneometatarsal instability. The extent of lateral release or the potential benefit of no release can now be assessed.

Conclusion: A certain number of failures have undoubtedly been related to neglect of the parameters studied here. It is indispensable to explore the frontal plane and the dynamic parameters before establishing indications for new flat-oblique metatarsal osteotomies using conventional or minimally invasive techniques.

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Introduction Circumferential fusion is becoming increasingly popular and has been advocated by many authors to improve the fusion rates and clinical outcomes of the degenerative lumbosacral spine. Anterior lumbar interbody fusion (ALIF) with posterolateral fusion does provide direct access to the disc via a separate incision/ approach but has inherent neurovascular risks. Posterior lumbar interbody fusion (PLIF) with posterolateral fusion mandates bilateral exposure with significant retraction of neural elements with higher incidence of postoperative radiculitis. PLIF also reduces surface area for fusion and disrupts the posterior tension band. TLIF allows for a circumferential fusion through a single posterior incision with only slight retraction of the thecal sac and nerve roots, with much less morbidity and costs as compared to traditional PLIF and ALIF techniques. To our knowledge, there are no studies that report radiographic and clinical results of using recombinant human bone morphogenic protein (rhBMP-2) and allograft in a TLIF setting. The purpose of this study was to assess clinical & radiographic outcomes of patients treated with one or two level instrumented transforaminal lumbar interbody fusions (TLIF) performed with allograft and rh-BMP2 for treatment of symptomatic spondylolisthesis or degenerative disc disease.

Methods During a consecutive 13 month period, 77 patients underwent TLIF procedures utilizing rhBMP-2 by one spine surgeon for lumbosacral degenerative and deformity conditions with simultaneous posterolateral fusions with allograft. Pedicle screw instrumentation (Monarch, DePuy Spine) provided distraction and a carbon-fiber curvilinear cage (Leopard, Depuy Spine) packed with rhBMP-2 (Large II Kit, total graft volume 8ml onto 77.4 sq. cm collagen sponge; Infuse: Medtronic Sofamor Danek) was placed into the disk space after hemifacetectomy and discectomy. The patients were followed at two weeks and three, six, 12 and 24 months after surgery patients were followed with several functional parameters such as the visual analog scale (VAS), SF-36 and Oswestry Disability Index (ODI) questionnaires. Fusion was assessed by static and dynamic radiographs at 6, 12, and 24 months as well as CT scans at 24 months.

Results 71 patients were available for follow-up (92%) evaluation (mean 16 months; range 6–24 months). At 24 months, 85 percent and 81 percent of patients had improvement over preoperative ODI and SF-36 measures respectively. At 24 months, 70% of patients had good to excellent outcomes by both ODI and SF-36. We achieved 94% fusion rate with only four pseudarthroses. There was one wound infection treated with hardware removal and intravenous antibiotics. One patient had excessive bone growth into the foramen, necessitating surgical decompression with subsequent excellent clinical outcome. Ten patients had paresthesias on the side of the TLIF, all of which resolved by three weeks. There were no permanent neurologic deficits.

Discussion The use of rhBMP-2 inside the cage, in combination with posterolateral allograft, can provide a high fusion rate and good clinical outcomes in a TLIF setting. The morbidity associated with iliac crest bone graft is avoided, with fusion rates approaching that of a true anterior/posterior circumferential fusion. Complications were few, with no significant neurologic sequelae from the placement of a structural graft into the anterior column through a posterior approach. Overgrowth of bone into the neural foramen, likely related to the residue of rhBMP-2 at the TLIF entry site, can occur. Care must be taken to place the TLIF cage device and the contained rhBMP-2 into the anterior half of the disk space to minimize the risk of this complication.

Surgical planning is the first step in operative fracture management. Complex situations are often faced which pose difficulties on both technical and logistic fronts. Surgical planning is the first step in operative fracture management. The degree of planning that is required is therefore determined by a number of factors including: the nature of the injury mechanism and its concomitant physiological insult, complexity of the fracture and region, expertise of the surgical team and equipment limitations. This paper explores a novel planning process in orthopaedic trauma surgery based upon British Military Doctrine. The seven questions of surgical planning represent a novel method that draws inspiration from the combat estimate process. It benefits from a global approach that encompasses logistic as well as surgical constraints. This, in turn, allows the surgical team to form an understanding of the nature of the fracture in order to develop, document and deliver a surgical plan. This has benefits for the operating surgeon, operating room practitioners and trainees alike and ultimately can result in improved patient care.

Aims. Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications. Methods. Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected. Results. Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported. Conclusion. Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction. Cite this article: Bone Jt Open 2024;5(1):28–36

Partial thickness abductor tendon tears are a significant source of recalcitrant laterally based hip pain. For those that fail conservative treatment, the results of endoscopic repair are highly successful with minimal morbidity. The principal burden is the protracted rehabilitation that is necessary as part of the recovery process. There is a wide gap between failed conservative treatment and successful surgical repair. It is hypothesized that a non-repair surgical strategy, such as a bioinducitve patch, could significantly reduce the burden associated recovery from a formal repair. Thus, the purpose of this study is to report the preliminary results of this treatment strategy. Symptomatic partial thickness abductor tendon tears are treated conservatively, including activity modification, supervised physical therapy and ultrasound guided corticosteroid injections. Beginning in January 2022, patients undergoing hip arthroscopy for intraarticular pathology who also had persistently symptomatic partial thickness abductor tendon tears, were treated with adjunct placement of a bioinducitve (Regeneten) patch over the tendon lesion from the peritrochanteric space. The postop rehab protocol is dictated by the intraarticular procedure performed. All patients are prospectively assessed with a modified Harris Hip Score (mHHS) and iHOT and the tendon healing response examined by ultrasound. Early outcomes will be presented on nine consecutive cases. Conclusions - Will be summarized based on the preliminary outcomes to be reported

Introduction. Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction. Materials and Methods. Nine patients underwent this treatment between 2020–2023. Initial deformity correction by Ilizarov or hexapod butt frame was followed by internal beaming with a mean follow up of 11 months. A retrospective analysis of radiographs and electronic records was performed. Meary's angle, calcaneal pitch, cuboid height, hindfoot midfoot angle and AP Meary's angle were compared throughout treatment. Complications, length of stay and the number of operations are also described. Results. Mean age was 53 years (range:40–59). Mean frame duration was 3.3 months before conversion to beaming. Prior frame-assisted deformity correction resulted in consistently improved radiological parameters. Varying degrees of subsequent collapse were universal, but 5 patients still regained mobility and a stable, plantargrade, ulcer-free foot. Complications were common, including hardware migration (N=6,66%), breakage (N=2,22%), loosening (N=3,33%), infection (N=4,44%), 1 amputation and an unscheduled reoperation rate of 55%. Mean cumulative length of stay was 42 days. Conclusions. Aggressive deformity correction and internal fixation for Charcot arthropathy requires strategic and individualised care plans. Complications are expected for each patient. Patients must understand this is a limb salvage scenario. This management strategy is resource heavy and requires timely interventions at each stage with a well-structured MDT delivering care. The departmental learning points are to be discussed

Aims. This study aimed to develop and validate a fully automated system that quantifies proximal femoral bone mineral density (BMD) from CT images. Methods. The study analyzed 978 pairs of hip CT and dual-energy X-ray absorptiometry (DXA) measurements of the proximal femur (DXA-BMD) collected from three institutions. From the CT images, the femur and a calibration phantom were automatically segmented using previously trained deep-learning models. The Hounsfield units of each voxel were converted into density (mg/cm. 3. ). Then, a deep-learning model trained by manual landmark selection of 315 cases was developed to select the landmarks at the proximal femur to rotate the CT volume to the neutral position. Finally, the CT volume of the femur was projected onto the coronal plane, and the areal BMD of the proximal femur (CT-aBMD) was quantified. CT-aBMD correlated to DXA-BMD, and a receiver operating characteristic (ROC) analysis quantified the accuracy in diagnosing osteoporosis. Results. CT-aBMD was successfully measured in 976/978 hips (99.8%). A significant correlation was found between CT-aBMD and DXA-BMD (r = 0.941; p < 0.001). In the ROC analysis, the area under the curve to diagnose osteoporosis was 0.976. The diagnostic sensitivity and specificity were 88.9% and 96%, respectively, with the cutoff set at 0.625 g/cm. 2. . Conclusion. Accurate DXA-BMD measurements and diagnosis of osteoporosis were performed from CT images using the system developed herein. As the models are open-source, clinicians can use the proposed system to screen osteoporosis and determine the surgical strategy for hip surgery. Cite this article: Bone Joint Res 2023;12(9):590–597

Genetic skeletal disorders constitute a rare and heterogeneous bone diseases often leading to poor quality of life. Several surgical options are available. The surgeon must deal with specific features (bone deformity, previous procedures, abnormal bone quality, stiffness or instability, muscle weakness). The questions concern the feasibility of the procedures and the surgical strategy. 55 patients (26 W, 29 M) were reviewed between 2016 and 2022. The mean age of the patients was 35 years (17–71). The diagnosis included 9 hereditary multiple exostoses, 8 osteogenesis imperfecta, 6 multiple epiphyseal dysplasia congenita, 6 achondroplasia, 4 osteopetrosis, 3 pycnodysostosis, 3 hypophosphatemic rickets, 3 fibrous dysplasia, 2 mucopolysaccharidosis, and 10 miscellaneous. 25 patients were referred for hip problems (40 hips). 4 patients (7 hips) requiring a THA have not been operated (4 planned). 4 patients (6 hips) had a proximal femoral fixation (2 osteotomies, 4 fracture fixations). 17 patients (27 hips) sustained a THA (25 primary, 2 revisions). All of them were operated by one operator, using a posterolateral approach and standard implants (including 7 dysplastic and 2 short stems). No customized implant has been used. As regard the 27 THAs, the mean follow up was 4.2 years (1–12). The early complications included 2 femoral cracks and 1 femur fracture. There were 2 revisions (1 cup loosening at 2 years, 1 stem loosening at 4 years). No infection nor dislocation occurred. All the patients were satisfied with their treatment and regain some autonomy. 3 THA were considered as unfeasible. Constitutional bone diseases need a multidisciplinary program of care. The indication for surgery is based on a mutual trust patient/surgeon, a careful evaluation of benefits/risks, and an accurate imaging to anticipate the difficulties. The expected results are a better function and quality of life, and a stability over time

Introduction. Unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) present significant challenges for both patients and surgeons. Understanding the specific UROs types is crucial for improving patient outcomes and refining surgical strategies in ASD correction. Method. This retrospective analysis utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database spanning from 2017 to 2021. Patient information was extracted using specific CPT codes related to posterior pedicle fixation. Result. In a cohort of 1088 patients undergoing posterior spinal deformity corrections, we examined various preoperative factors to discern their correlation with reoperation prevalence. Our analysis revealed no statistically significant differences in reoperation prevalence concerning gender (male: 4.0%, p=0.131) or ethnicity (Hispanic: 4.2%, p=0.192). Similarly, no notable associations were identified for diabetes mellitus, smoking status, dyspnea, history of severe COPD, hypertension, ASA classification, or functional health status before surgery, with reoperation prevalences ranging from 3.2% to 8.8% and p-values spanning from 0.146 to 0.744. Overall, the reoperation prevalence within the entire cohort stood at 5.2% (55 cases). In terms of the types of reoperations investigated, spinal-related procedures emerged as the most prevalent, accounting for 43.7% (24 cases), followed closely by wound site revisions at 23.6% (13 cases). Additionally, gastrointestinal-related procedures and various other miscellaneous interventions, such as uroscopy, demonstrated reoperation prevalences of 7.2% (4 cases) and 25.5% (14 cases), respectively. Conclusion. our findings highlight the diverse spectrum of reoperation procedures encountered following posterior spinal deformity corrections, with wound site revisions and spinal-related interventions being the most prevalent categories. These results emphasize the complexity of managing UROs in spinal surgery and the need for tailored approaches and infection/incision protocols to address the specific challenges associated with each type of reoperation

Management of complex posterior malleolar fractures requires a detailed appreciation of ligamentous and bony anatomy for optimal fracture fixation and restoration of articular congruency. Pre operative planning is vitally important to determine the surgical strategy for complex ankle fractures. We evaluated pre operative planning strategy pre and post implementation of BOAST 12 guidelines (2016) focussing on pre operative CT scans prior to definitive fixation at a major trauma centre. A multi-surgeon retrospective review of prospectively collected data from 2013 to 2018 was performed at a major trauma centre. Patients who had sustained a posterior malleolar fracture and definitive fixation were identified. Information was collated from PICS, PACS, the trauma database and operative notes. 134 patients were identified over a 5 year period who had sustained a posterior malleolar fracture and had definitive fixation. (Pre BOAST guidelines = 61, Post BOAST guidelines = 73). Prior to the implementation of BOAST guidelines ¼ with posterior malleolar fractures did not have a pre operative CT scan (15/61). Post implementation of BOAST 12 90% (66/73)patients with fixation of posterior malleolus fractures had a pre operative CT scan. Posterior malleolus surgery most commonly took place In patients between 18–30 years. Following implantation of BOAST 12 guidelines there was a 15% increase in pre operative CT scanning for ‘complex ankle fractures'. Changes in national guidelines have heavily influenced pre operative planning strategy for ankle fractures at University Hospitals Birmingham. A detailed appreciation of fracture pattern pre operatively helps guide surgical strategy

Aims. The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). Methods. This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define ‘at risk’. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. Conclusion. The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519–528

Abstract. Introduction. COMPOSE describes the demographics, fracture characteristics, management and associated outcomes of knee femoral periprosthetic fractures (KFPPF). Methods. Multicentre retrospective cohort study conducted 01/01/2018-31/12/2018. Data collected included: patient demographics, social and mobility characteristics, fracture characteristics, management strategy and post-treatment outcomes (length of stay, reoperation, readmission, 30-day and 12-month mortality). Results. 785 PPFs from 27 NHS sites were included in the COMPOSE cohort. Of these 162 (21%) were related to an isolated knee prosthesis (151 femur, 10 tibia and 1 patella). The KFPPF group had a mean age of 81.1 years, 127 (84%) female, 114 (76%) living in their own home, with 99 (63%) reliant on walking aids/bedbound. Most fractures were B (58%) or C (35%) type and occurred around a primary cemented replacement (141,94%) at a mean of 8.2 years after surgery. 116 (76.8%) KFPPFs were treated operatively. Mean time to surgery was 5 days and the commonest surgical strategy was fixation alone (64%) vs revision+/-fixation (36%). Mean operative time was 126 minutes and 11 (10%) patients required ITU/HDU admission after surgery. Mean LOS was 22 days and 47 patients (31%) experienced a complication prior to discharge. Overall, 5 patients (3%) had a further operation within 12 months, 7 (5%) were readmitted within 30 days and the 30-day and 12-month mortality were 6.6% and 23.2% respectively. Conclusions. KFPPF patients are elderly and frail and have mortality, re-operation and readmission rates comparable to hip fracture patients. However, they wait longer for surgery and surgical treatment is more complex

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures

Several preoperative planning tools in computer-assisted surgery in acetabular fractures have been proposed. Moreover, all these preoperative planning tools are based on geometrical repositioning with their own limitations. The aim of this study was to evaluate the value of our prototype virtual planning tool using a rigid biomechanical model to predict failure in fracture reduction. Between November of 2015 and June of 2016, 10 patients were operated by the main author for acetabular fracture in our institution. To validate our biomechanical model planning tool, biomechanical simulation was performed for each patient immediately after the surgery. Reduction quality was assessed on post-operative CT scans. A 3D model of the acetabular fracture was build out of the CT images using the non-commercial software Itksnap. Then a biomechanical model implemented within the non-commercial Artisynth framework was used to perform virtual reduction. Surgical approach and surgical strategy according to the operative report were simulated. The simulated reductions and the surgical reductions were compared. The same reductions were obtained during surgery and biomechanical simulation in the 10 cases. For 7 cases, reduction was achieved by anterior surgical approach and so was the simulation. For 3 cases, reduction was achieved by posterior surgical approach and so was the simulation. The biomechanical simulation found similar results using the same surgical strategy with 9 anatomical reductions (90%) and one imperfect reduction (10%). The mean duration to perform acetabular planning surgery was 24 +/− 9 min [16–38]. Our virtual planning tool using a rigid biomechanical model can predict success or failure in fracture reduction according to the surgical approach and the surgical strategy

Aims. Current antibiotic treatment strategies for prosthetic joint infection (PJI) are based mostly on observational retrospective studies. High-quality data from prospective cohorts using identical treatment strategies may improve current clinical practice. We developed a regional network of collaborating hospitals and established a uniform treatment protocol. Data from all patients diagnosed with a PJI are prospectively registered in a an online database. With this quality registry we aim to study the outcome of antibiotic and surgical strategies while adhering to a pre-established treatment protocol. Methods. A working group of orthopaedic surgeons, infectious disease specialists and microbiologists was established. The working group reached consensus on definition of PJI and a uniform treatment protocol, based on current guidelines and expert-based clinical experience. A website was built to communicate information to colleagues and patients (. www.protheseinfectie.nl. ). In each participating hospital weekly multidisciplinary meetings were started to discuss all PJI cases. All patients are included in an online quality registry and followed for at least two years. We aim to enroll >600 patients with a knee or hip PJI. Research will focus on the duration of antibiotic treatment, antibiotic suppressive therapy and comparison of different oral antibiotic treatment strategies in relation to successful treatment outcomes. Results. Currently, four regional hospitals are included in the partnership. Multidisciplinary meetings have lowered the threshold to discuss patients, and the adherence to the PJI treatment protocol has improved steadily. Complicated cases are discussed between colleagues from collaborating centers. The collaboration has been perceived as very successful by the participating hospitals. Since 2015, over 300 patients have been included, of whom 52% were male. In 26%, PJI occurred after revision surgery. Staphylococcus aureus was involved in 25% of cases, coagulase-negative Staphylococci in 23%, Streptococci in 13% and Gram-negative micro-organisms in 15%. Conclusions. In this project, collaboration between different medical specialties through multidisciplinary meetings was the key to the improvement of patient care The regional collaborative project led to the implementation of a uniform treatment protocol for PJI. With this prospective project we aim to improve patient care by providing evidence for optimal antibiotic and surgical strategies for PJI. Ideally, countries should have hospital networks and a uniform method of data collection to make it easy to share data for scientific research