Objectives:. To gain an understanding of the current issues surrounding falls prevention across Europe and to embrace at national and international level, the different political and health service agendas in each country such that recommendations can ultimately be translated into working models of practice in each country. To establish a robust network of key members across Europe to facilitate the effective and efficient promulgation of evidence likely to influence service developments at national and local level. To derive a consensus approach to assessment and management of older people at risk of falling in a variety of clinical settings using the existing evidence base as well as experts in the field. To ultimately facilitate a pan-European approach to assessment and management of falls whilst minimising impact on clinical autonomy and paving the way for further research activity within member states. Description of work: This work package focuses on the development of a consensus approach to the assessment and management of falls in older people across Europe. Fundamental to this process is the development of a clear understanding of how services across Europe are currently configured and what the national and international drivers for change might be over the next 5–10yrs. The ultimate aim is to be able to facilitate the development of a set of comparable assessment and outcome measures to be used in a large randomised controlled trial with fracture as the primary outcome measure. Year 1. Whilst undertaking the networking exercise in year 1, members had the opportunity to visit key individuals in European countries and anticipate the potential opportunities and constraints of developing and delivering falls services in a co-ordinated and comprehensive fashion. Year 2 focuses on the development of assessment tools, which can be tailored so as to be applied in a variety of clinical settings from community based assessment to the highly specialised investigation units. The work package links closely with other work packages on balance and gait and psychology to ensure consensus in recommendations. In addition to the recommendations for clinical assessment and management, the work package also provides advice and guidance on evaluation and audit of services and as such links closely with the taxonomy work. Recommendations are to be peer reviewed. Year 3 entails the collation of agreed assessment and evaluation methods and the translation of the recommendations into a format for dissemination including written documentation translated into a number of different languages and an interactive website with links to relevant organisation across Europe and the rest of the world. Year 4. During the final year, members of the work package take responsibility for the dissemination of the work to clinical colleagues

Few previous studies showed that the conventional total knee replacement (TKR) has affection to the same side of talar tilt (TT). We expected to prevent this problem by the computer-assisted (CAS) TKR. The purpose of this study was to compare between pre and post-operative talar tilt and ankle clinical assessment on the CAS TKR and the Conventional TKR in 28 patients (56 knees) whom underwent bilateral TKR. 28 patients, 56 knees, whom underwent both CAS total knee replacement (TKR) and conventional total knee replacement (TKR), in both knees, with the combination of Gap Balance and Measurement Resection techniques performed by one surgeon (P. Sriphirom) at Rajavithi Hospital, Bangkok. The post-operative has a 12 months follow-up for ankle radiographic finding by tibiotalar angle (TTA), tibial articular surface angle (TAS), and talar tilt (TT) = (TAS-TTA) and for ankle clinical assessment by foot functional index (FFI) from pre-operation and post-operation from both groups. The study also compares the CAS TKR with the Conventional TKR for pre-operation and post-operation. 56 knees, 28 patients, mean age = 67.79 years whom underwent bilateral TKR by the Conventional group and the CAS group had pre-operative TT (TT = TAS − TTA). The Conventional group = 1.5 (−5, 8), the CAS group = 0.5 (−5, 8), P value = 0.65. On post-operative TT the Conventional group = 0.0 (−5, 3), the CAS group = 1.0 (−3, 8), the P value = 0.4. The comparison of pre-operative TT and post-operative TT in the Conventional group, the P value = 0.01. On pre-operative TT and post-operative TT in the CAS group, the P value = 0.65. TT was significantly different in the Conventional group but was not significantly different in the CAS group. The ankle clinical assessment by foot functional index (FFI), which are (1) Pain, (2) Difficulty living, and (3) Daily life activity limitation. The pre-operative FFI in the Conventional group = 1.85 (0.81, 6.88) and pre-operative FFI in the CAS group = 1.91 (0.24, 66.5), the P value = 0.57. The post-operative FFI in the Conventional group = 1.68 (0.24, 7.0) and post-operative FFI in the CAS group = 1.65 (0.24, 6.76), the P value = 0.04, which showed a significantly different between the post-operative FFI from both groups. In the Conventional group the post-operative FFI was not significantly different from pre-operative FFI, the P value = 0.2 but for the CAS group the post-operative FFI was not significantly different from pre-operative FFI, the P value = 0.04. This study showed that the conventional TKR effected to post-operative talar, tilt but CAS TKR has less effect and was not significantly different to ankle joint. Finally, the study needs to be conducted on more patients and to be observed on a longer term follow-up

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Instrumented fusion for lumbar degenerative spondylolisthesis (LDS) has been challenged recently with high impact trials demonstrating similar changes in health-related quality of life (HRQOL) and less morbidity/cost with laminectomy alone. Randomized trials often fail, however, to evaluate a heterogeneous population of patients. A standardized clinical assessment and management plan (SCAMP) was created as a decision aid for surgeons based on the radiographic stability and clinical presentation of patients. The purpose of this study was to compare outcomes of those patients who followed the decision aid with respect to fusion/no fusion to those who did not. Patients were prospectively enrolled from eleven different Canadian institutions and followed from 2015–2019. A degenerative spondylolisthesis instability classification system (DSIC) was created using best available evidence stratifying patients into three different subtypes (1. stable degenerative spondylolisthesis, 2. potentially unstable spondylolisthesis and 3. unstable spondylolisthesis). The decision aid recommends laminectomy alone for group 1 patients, posterolateral fusion with pedicle screws in type 2 patients and pedicle screw and interbody fusion for type 3 patients. One year changes in HRQOL, length of hospital stay (LOS), medication use and surgical time were compared between each group and in context of whether the treatment fell within the decision aid recommendation. Statistics were performed with STATA software. There were 394 patients initially enrolled and 334 (84.8%) with full one year data available for comparison. There were 95 type 1 (stable), 224 type 2 (potentially unstable) and 75 type 3 (unstable) patients initially classified. Baseline Ostwestry disability index (ODI), EQ-5D, and SF-12 MCS scores were significantly worse for type 3 patients versus type 1 patients. One hundred and eight patients were treated within the recommendations of the DSIC system (108/334, 32.3%). Surgeons performed interbody fusions in 141 patients (42%) rather than follow DSIC recommending a less invasive approach. There were no significant differences EQ-5D, SF-12 PCS/MCS, PHQ-9 or ODI at one year between patient groups. There was a trend towards shorter operating times for those patients following the DSIC system (195 minutes non-followers versus 180 followers, p=0.078) and reduced hospital stay (4.46 days non-followers versus 3.98 followers, p=0.065). There were no significant clinical differences in outcome at 1 year whether patients underwent decompression alone, decompression/posterolateral fusion or interbody fusion regardless of the stability classification. Surgeons were more likely to perform potentially unnecessary interbody fusions even in those patients with stable or potentially unstable spondylolisthesis. Although not statistically significant, there is some suggestion that following the DSIC system based on best evidence recommendations leads to more judicious/responsible use of hospital resources. Further study is required to determine why surgeons are more likely to choose more invasive, higher rigidity constructs in patients with LDS

Purpose: The diagnosis and treatment of superior labral antero posterior (SLAP) lesions is a controversial subject in shoulder pathology. The aim of this retrospective study was to evaluate the strength of association between clinical assessment (O’Brien test), standard MRI, and arthroscopic identification of a SLAP lesion. Method: Patients who underwent isolated arthroscopic treatment of a SLAP lesion by two senior orthopaedic surgeons between 2004 and 2007 were included in this study. Pre-operatively, all had a standard MRI and the outcome of O’Brien test had been documented. Sensitivity of these measures in detecting a SLAP lesion confirmed through arthroscopy were calculated independently and combined. The relationship between O’Brien test and standard MRI are also presented. Results: Forty-five patients were included in this study. The O’Brien test demonstrated a sensitivity of 42% (true positive) in detecting a SLAP lesion while sensitivity of the standard MRI was only 13%. The sensitivity of the O’Brien test and standard MRI when considered together was 47%, only slightly higher than the O’Brien test alone. The association between the O’Brien test and standard MRI in identifying a SLAP lesion as measured by the phi correlation coefficient was −0.19 which suggests little to no relationship (p = 0.095). Conclusion: The current study illustrates the difficulties in accurately diagnosing a SLAP lesion pre-operatively. Previously documented sensitivity of the O’Brien test in identifying a SLAP lesion was not replicated herein. Furthermore, this study draws into question the practice of patient’s undergoing a standard MRI for SLAP lesion identification because the added value from this investigation was nominal. A standard MRI is often requested when the diagnosis is not certain or to exclude other shoulder pathology. If, however, a SLAP lesion is suspected clinically in absence of other shoulder pathology, then a diagnostic tool other than standard MRI may be more meaningful. Some literature suggests MRI arthrogram may be useful in diagnosing a SLAP lesion but access to this tool can be limited

Aim: This study was designed to investigate the association between clinical assessment International Clubfoot Study Group (ICFSG) and quantitative gait data of the children. Methods: Nineteen patients with 30 surgically treated clubfoot were included in this study. Bilateral involvement was present in 11. Average age was 9 years (range 6–14 years) at the time of last follow-up. Patients were treated with different surgical techniques at early childhood period. At the final follow-up they were evaluated according to ICFSG clinical scale. This rating system is based on three main subgroups of evaluation as morphologic evaluation, functional evaluation and radiological evaluation. The maximum score is 12 in morphologic evaluation, 36 in functional evaluation and 12 in radiological evaluation. The total score is from 0 for a perfect result to 60 for the worst result. Further, a total score of 0–5 is rated as excellent, 6–15 as good, 16–30 as fair and over 30 as poor. Quantitative gait data was collected with the Vicon 370 (Oxford Metrics, Oxford, UK). Two force plates (Bertec, Colombus, Ohio, USA) were used for kinetic analysis. All time-distance (walking velocity, cadence, step time, step length, double support time), kinematic (joint rotation angles of pelvis, hip, knee and ankle in sagittal, coronal and transverse planes) and kinetic (ground reaction forces, moments and powers of hip, knee and ankle) data were processed using Vicon Clinical Manager software package. Spearman correlation analysis was used to evaluate if there is a correlation between total clinical score and gait parameters. Results: Average ICSG score was 8.63 (range 1–29). Outcome was excellent in 16, good in 8 and fair in 6 patients according to ICSG. There was a significant correlation between total ICSG score and walking velocity (rs=−0.195, p=0.004), step length (rs=−0.476, p=0.019), pelvic excursion in sagittal plane (rs=−0.429, p=0.026), hip excursion in sagittal plane (rs=−0.511, p=0.006), knee excursion in sagittal plane (rs=−0.486, p=0.019), Ankle excursion in sagital plane (rs=−0.413, p=0.040), peak ankle plantar flexion moment (rs=−0.600, p=0.039), peak ankle plantar flexion power (rs=−0.487, p=0.025). When we compare the gait parameters between groups only foot progression angle showed a significant difference (p=0.031). Conclusion: ICFSG score is a successful method to follow outcome in patients with surgically treated clubfoot. ICFSG score is correlated with many kinematic and kinetic gait data however foot progression angle is the only parameter predicting outcome in children with surgically treated idiopathic clubfoot. Quantitative gait analysis may help to define the liable factors of the functional deficits, and to prescribe novel rehabilitation techniques to enable better outcome for children with clubfeet

Knee dislocations are a rare but serious cause of trauma. The aim of this study was to establish current demographics and injury patterns/associations in multi-ligament (MLI) knee injuries in the United Kingdom.

A National survey was sent out to trauma & orthopaedic trainees using the British Orthopaedic Trainees Association sources in 2018. Contributors were asked to retrospectively collect a data for a minimum of 5 cases of knee dislocation, or multi-ligament knee injury, between January 2014 and December 2016. Data was collected regarding injury patterns and surgical reconstructions.

73 cases were available for analysis across 11 acute care NHS Trusts. 77% were male. Mean age was 31.9 (SD 12.4; range 16–69). Mean Body Mass Index (BMI) was 28.3 (SD 7.0; range 19–52). Early (<3 weeks) reconstruction was performed in 53% with 9 (23%) patients under-going procedures for arthrofibrosis. Late (>12 weeks) reconstruction took place in 37% with one (3.7%) patient under-going arthroscopic arthrolysis. 4% had delayed surgery (3–12 weeks) and 5% had early intervention with delayed ACL reconstruction. For injuries involving 3 or more ligament injuries graft choices were ipsilateral hamstring (38%), bone-patella tendon-bone (20%), allograft (20%), contralateral hamstring (17%) and synthetic grafts in 18%.

Multi-ligament knee injuries are increasingly being managed early with definitive reconstructions. This is despite significant risk of arthrofibrosis with early surgery. Ipsilateral and contralateral hamstring grafts make up the bulk of graft choice however allograft (20%) and synthetic grafts (18%) remain popular.

Background: Morton’s Neuroma is most likely a mechanically induced degenerative neuropathy, presenting as forefoot pain.

Methods: The authors retrospectively reviewed clinical notes, imaging and histology from 71 consecutive patients (75 feet) treated operatively for Morton’s Neuroma between January 2006 and April 2009 and a control group of 20 patients (20 feet) undergoing MRI for other forefoot pathology. 7 feet were excluded from the surgical group due to recurrent disease or missing data.

Results: 84% of the surgical group were female. Mean age was 52. 97.4% of the surgical group presented with pain. 50% described pain in the plantar aspect of the forefoot and 85% reported that their pain was worse in shoes. Web space tenderness was positive in 95%, foot squeeze test 88%, plantar percussion 61% and toe tip sensation deficit 67%. Any two tests were positive in 92% of this group. In the control group any two tests were positive in only 39% – this difference was statistically significant (p< 0.0001 chi-squared test). MRI identified a neuroma in 97% of the surgical group (mean size 8mm) and 50% of the control group (mean size 6mm). 68% were in the 3rd web space; the remainder were in the 2nd web space. Histology confirmed neuroma in 99%.

Discussion: This cohort is larger than any other published series and is further strengthened by both the consistency of clinical testing and the independence of radiological and histological assessment.

Conclusion: We found that diagnosis of Morton’s neuroma was accurate. MRI correctly identified the neuromata in 97% and at least two clinical tests were present in 92%.

Aims: The symptoms of aseptic and septic prosthetic joint loosening may be similar, and identification of low-grade prosthetic infection based only on clinical history and physical examination has a reported low sensitivity. In a prospective study we explored to what extent a thorough examination of the patient’s history of sickness and a standardized preoperative clinical examination could help the surgeon to identify cases of septic loosening.

Methods: We included 54 patients undergoing revision surgery due to loosening of a total hip or knee prosthesis. Preoperatively a standardized form which included data regarding the patient’s history of sickness was obtained and a physical examination was performed.

Postoperatively a final diagnose was made based on microbiological testing, which in addition to routine culture, included sonication of the prosthesis and nucleic acid based diagnostics (PCR). Data from the preoperative examination was evaluated in relation to the final diagnose (chi-square test and Student’s t-test), and the sensitivity and specificity for diagnosing a septic loosening was calculated for each preoperative finding.

Results: According to the final diagnose, 21 patients had a septic loosening and 33 patients had an aseptic loosening. In the septic group and aseptic group the following anamnestic data was registered: Pain during rest: 16/21 vs. 7/33 (p < 0.001). Prior history of soft tissue debridement: 11/21 vs. 4/33 (p = 0.001). Prior prosthetic revision surgery: 13/21 vs. 8/33 (p = 0.006). Time from index operation to revision: 45 (5 – 144) moths vs. 159 (22–390) moths, (p = 0.02). Time from index operation to debut of prosthetic assosiated dyscomfort: 10 (0–110) moths vs. 120 (0–240) moths, (p < 0.001). The calculated sensitivity (se) and spesifisity (sp) for the pre-operative findings were: Existence of prosthetic related pain during rest: 79% se, 79% sp; history of soft tissue revision in the affected joint 52% se, 88% sp; history of prior exchange prosthetic revision in the affected joint 62% se, 76% sp, respectively.

Conclusion: We advise a carefully obtained history from every patient presenting with loosening of implanted prosthetic components for identification of a potential low grade infection. In particular, pain during rest has a notable sensitivity and specificity. A prior history of soft tissue revision also strongly indicates a septic prosthetic loosening.

A randomised prospective study of 4 bearing surfaces in hip replacements is being conducted. The primary objective is to identify the best long term bearing surface clinically and radiographically, and metal ion levels have been measured in all cases.

Patieents have been randomised to the 4 bearing surfaces viz. Ceramic on XLinked Poly, Ceramic on Ceramic, Metal on Metal and Ceramic on Metal. Pre operative blood samples and follow up blood samples for metal ion analysis using the ICPMS method have been taken in all patients. As at February 2008 187 patients have been recruited, and metal ion levels at 1 year are available in 52 patients.

Metal ion levels are not increased with Ceramic on XLinked Poly or Ceramic on Ceramic bearings. At 1 year follow up the metal ion levels in Ceramic on Metal bearings is half that of Metal on Metal bearings using the mean levels, and one third using the madian levels. Of note is that the chromium levels in Ceramic on Metal bearings is the least elevated.

Due to laboratory evidence that Ceramic on Metal bearings have the best surface wear characteristics with no head stripe wear, and laboratory and clinical evidence of lower metal ion blood levels, Ceramic on Metal hip replacements could be a bearing surface of the future.

Background and Purpose of Study: The SCAS assesses patients with spinal pain who have failed routine conservative treatment and/or whose referral details indicate secondary care opinion may be necessary. Patients are assessed by Advanced Musculoskeletal Physiotherapy Practitioners (AMPs) working under the supervision of a Consultant Rheumatologist. Although a rare occurrence, the early detection of spinal metastases in this patient population is essential. The purpose of this study was to retrospectively assess the case notes of those patients with an eventual diagnosis of spinal metastases to evaluate early indicators of the disease.

Methods: The reports of all spinal MRI scans requested by the SCAS over a two year period were reviewed for the presence of spinal metastases. On those patients whose MRI results were positive the incidence and frequency of ‘red flags’ documented in the patients case notes was recorded. Results of recent blood tests, Xrays and bone scans were also reviewed.

Results: A total of 16 patients with spinal metastases were diagnosed over a two year period from a patient population of 3200, a prevalence of 0.5%. The most commonly occurring red flags were first onset of spinal symptoms over the age of 50 (81%), progressive pain unresponsive to conservative intervention (57%), previous history of cancer (38%) and unexplained weight loss (38%). 9 patients had undergone previous Xray, 4 of which were suggestive of metastatic disease. 3 patients had undergone previous bone scan, 2 of which were suggestive of metastatic disease.

Conclusion: Findings suggest that for spinal patients presenting with the most commonly occurring red flags, urgent MRI scan should be requested. Xray and ESR levels were not useful in the definitive differential diagnosis of spinal metastases.

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips.

Materials/Methods: Of the 30585 births (over a 6 year period) in the population served by our hospital, 2742 babies (8.96percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive).

Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans.

Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings.

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips.

Materials and Methods: Of the 30585 births (from 1997–2002) in the population served by our hospital, 2742 babies (8.96 percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive).

Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45 percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38 percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans.

Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings.

Aim of the study: Impaction bone grafting is examined and published by numerous authors in the literature, however possible correlation between bone remodeling at the site of revision hip arthroplasty and bone turnover markers is not well known yet.

Materials and method: 22 patients undergoing revision hip arthroplasty with impaction bone grafting were enrolled in a prospective study. Bone turnover markers and bone mineral density (DXA) were measured preoperatively. WOMAC and Harris Hip Score (HHS) were evaluated pre- and postoperatively. During a one-year-period the same tests were performed after 6 weeks, 3 months, 6 months, 12 months respectively. The data were analyzed using logistic regression.

Results: Significant bone remodeling was observed at the site of revision hip arthroplasty at the 6 month follow up. WOMAC and HHS improved significantly after surgery. One deep wound infection occurred due to MRSE, removal of the prosthesis was performed.

Conclusion: Cancellous bone grafting secures primary stability for the hip implants, and after a period of 12 months proper bone remodeling is achieved.

Introduction There is no consensus on the superiority of either Chevron or Mitchell osteotomy in the treatment of hallux valgus. In the literature Chevron osteotomy is recommended for the mild and Mitchell’s for the moderate hallux valgus (HV) deformities. We reviewed outcomes of two of the most common distal first metatarsal osteotomies.

Aims To compare the results of Chevron vs Mitchell osteotomy in the treatment of HV.

To evaluate the co-relation between clinical outcome and radiological correction achieved after the two osteotomies.

Method We reviewed clinical notes and pre- and postoperative radiographs of a total of 111 operations including 61 Chevron and 50 Mitchell osteotomies in 90 patients.

We designed a patient-focused questionnaire to evaluate clinical outcomes that addressed the main functional outcomes concerning patients after bunion surgery. These included pain, usage of footwear postoperatively, cosmoses, development of transfer metatarsalgia and the repeatability of the procedure they had undergone. These questions were point based and a final clinical score was calculated for comparison with the radiological correction. This was also used as a measure of success of the procedure.

Conclusion There is a statistically significant radiological difference in HV angle correction and the loss of first metatarsal height as seen post-operatively between patients treated with Chevron and Mitchell osteotomies for HV correction (p=0.03 and p=0.0004 respectively). There is no statistically significant difference (p=0.6) in the clinical outcomes based on the newly designed patient-focused questionnaire with either Chevron or Mitchell osteotomies at a mean follow-up of 27 months post-operatively. Clinical outcome determined by patient-focused questionnaire remains the same in-spite of radiological differences noticed post-operatively between the two osteotomies.

Introduction: In clinical orthopaedics questionnaire based outcome scores such as the DASH shoulder score suffer from a ceiling effect, subjectivity and the dominance of pain perception over functional capacity. As a result it has becomes increasingly difficult to clinically validate medical innovations in therapy or implants and to account for rising patient demands. Thus, objective functional information needs to be added to routine clinical assessment. Motion analysis with opto-electronic systems, force plates or EMG is a powerful research tool but lab-based, too expensive and time consuming for routine clinical use. Inertia sensor based motion analysis (IMA) can produce objective motion parameters while being faster, cheaper and easier to operate. In this study a simple IMA shoulder test is defined and. its reliability tested,. its diagnostic power to distinguish healthy from pathological shoulders is measured and. it is validated against gold standard clinical scores. Methods: An inertia sensor (41x63x24mm3, 39g) comprising a triaxial accelerometer (±5g) and a triaxial gyroscope (±300°/sec) was taped onto the humerus in a standardised position. One-hundred healthy subjects without shoulder complaints (40.6 ±15.7yrs) and 40 patients (55.4 ±12.7yrs) with confirmed unilateral shoulder pathology (29 subacromial impingement, 9 rotator cuff pathology, 2 other) were measured. Two motion tasks (‘hand behind the head’ and ‘hand to the back’) based on the Simple Shoulder Test (SST) were performed on both shoulders (three repetitions at self selected speed). Motion parameters were calculated as the surface area described by combing two angular rate signals of independent axes (ARS) or by combing the angular rate and the acceleration of a single axis (COMP score). The relative asymmetry between two sides was scored. Results: The test produced high intra-(r2≥0.88) and inter-observer reliability (r2≥0.82). Healthy subjects scored a mean asymmetry of 9.6% (ARS) and 14.6% (Comp). Patients with shoulder complaints showed > 3× higher asymmetry (ARS: 34.1%, Comp: 42.7%) than the healthy controls (p< 0.01). Using thresholds (ARS: 16%, Comp 27%) healthy and pathological subjects could be distinguished with high diagnostic sensitivity (e.g. ARS: 97.5% [CI: 85.3–99.9%]) and specificity (e.g. COMP: 85.5% [CI: 76.1–91.1%]). Both asymmetry scores were strongly intercorrelated (r2=0.76) as were the clinical scores (r2=0.62, DASH-SST). Asymmetry and clinical scores were hardly correlated (r2< 0.14). Discussion: The IMA shoulder test and asymmetry scores showed high reliability meeting or exceeding common clinical scores. With a fast assessment of a simple ADL tasks (test duration < 60s) it was possible to provide diagnostic power at clinically usable level making routine clinical application feasible even by nonspecialist personnel. Weak correlations with the clinical scores show that the new test adds an objective functional dimension to outcome assessment which may have the potential to differentiate new treatments or implants required to trigger new therapeutic innovation cycles. Similar motion tests and parameters could also serve lower extremity outcome assessment

Osteoarthritis is a joint condition affecting an estimated eight million people in the UK. The kinematics of walking and the impact experienced are thought to play an important role in the initiation and progression of the disease. Previous studies have looked the effect of osteoarthritis on the kinematics of walking in a laboratory environment. This work is part of the Newcastle Thousand Families Study which has followed a cohort of 1142 members since birth in 1947. Optoelectronic gait analysis methods are unsuitable for this environment, so inertial measurement units are being used. This study focuses on the validation of a protocol using inertial sensors to assess gait in the clinical environment. The sensors measure orientation in three dimensions. Our hypothesis was that an attachment position that minimises the movement of the sensor relative to the segment during gait was more important than the proximity of the sensor to anatomical landmarks. The effect of sampling rate, fatty tissue movement and material type were also tested Seven sensors (Xsens, Netherlands) were attached to participants on top of the foot, on the tibial plateau, on the lateral surface of the femur 10cm proximal to the lateral epicondyle, and over the sacrum. Attachment is by Velcro straps over the top of clothing for the waist, thigh and shank sensors, and with double-sided hypoallergenic tape on the foot. Four calibration movements are performed followed by a walking trial of ten paces down a corridor at a self-selected speed. Data is recorded wirelessly at a sampling rate of 50Hz. The calibration movements and trials are repeated twice and the time taken is 20 minutes. Measurement of the joint angles in the sagittal plane was used to assess the effect of changing the sensor position, simulating fatty tissue movement, and variation of material type underneath the sensor. The foot and thigh sensors were displaced in the distal direction by up to 10cm, the shank and waist sensors were displaced in the proximal direction by 5cm. Material types of different elasticity were tested. Fatty tissue movement beneath the straps was simulated using hydration gel packs. Each attachment scenario was repeated five times on a single subject. A “normal” attachment scenario was used to establish a baseline for repeatability of hip, knee and ankle angle measurement (mean±standard deviation of 49±1.28°, 61.5±1.28° and 33.5±0.69° respectively). Repeatability is comparable to that reported for an opto-electronic system (45±1.8°, 63±1.9° and 36±1.5°). Displacement of the foot, shank and waist sensors had no effect on the repeatability. Displacement of the thigh sensor decreased the repeatability for the knee and hip joint angles (52±3.22° and 62.5±2.91°). As the thigh sensor moved closer to the knee the movement artefact experienced increased. Altering sampling rate and simulated fatty tissue did not decrease repeatability. Of the materials tested, denim had the greatest affect, decreasing hip and knee angle repeatability (50.0±2.04° and 61.0±1.75°). A sensor attachment position that minimises sensor movement relative to the segment has been shown to produce the greatest repeatability, irrespective of their proximity to bony landmarks. This is particularly true for the femur sensor.

Conventional proximal tibial osteotomy is a widely successful joint-preserving treatment for osteoarthritis; however, conventional procedures do not adequately control the posterior tibial slope (PTS). Alterations to PTS can affect knee instability, ligament tensioning, knee kinematics, muscle and joint contact forces as well as range of motion. This study primarily aimed to provide a comprehensive investigation of the variables influencing PTS during high tibial osteotomy using a 3D surgical simulation approach. Secondly, it aimed to provide a simple means of implementing the findings in future 3D pre-operative planning and /or clinically. The influence of two key variables: the gap opening angle and the hinge axis orientation on PTS was investigated using three independent approaches: (1) 3D computational simulation using CAD software to perform virtual osteotomy surgery and simulate the post-operative outcome. (2) Derivation of a closed-form mathematical solution using a generalised vector rotation approach (3) Clinical assessment of synthetically generated x-rays of osteoarthritis patients (n=28; REC reference: 17/HRA/0033, RD&E NHS, UK) for comparison against the theoretical/computational approaches. The results from the computational and analytical assessments agreed precisely. For three different opening angles (6°, 9° and 12°) and 7 different hinge axis orientations (from −30° to 30°), the results obtained were identical. A simple analytical solution for the change in PTS, ΔP. s,. based on the hinge axis angle, α, and the osteotomy opening angle, θ, was derived:. ΔP. s. =sin. -1. (sin α sin θ). The clinical assessment demonstrated that the absolute values of PTS, and changes resulting from various osteotomies, matched the results from the two relative prediction methods. This study has demonstrated that PTS is impacted by the hinge axis angle and the extent of the osteotomy opening angle and provided computational evidence and analytical formula for general use

Introduction. Treatment of non-union in open tibial fractures Gustilo-Anderson(GA)-3A/3B fractures remains a challenging problem. Most of these can be dealt using treatment methods that requires excision of the non-union followed by bone grafting, masquelet technique, or acute shortening. Circular fixators with closed distraction or bone transport also remains a useful option. However, sometimes due to patient specific factors these cannot be used. Recently antibiotic loaded bone substitutes have been increasingly used for repairing infected non-unions. They provide local antibiotic delivery, fill dead space, and act as a bone conductive implant, which is resorted at the end of a few months. We aimed to assess the outcome of percutaneous injection of bone substitute while treating non-union of complex open tibial fractures. Materials & Methods. Three cases of clinical and radiological stiff tibial non-union requiring further intervention were identified from our major trauma open fracture database. Two GA-3B cases, treated with a circular frame developed fracture-related-infection(FRI) manifesting as local cellulitis, loosened infected wires/pins with raised blood-markers, and one case of GA-3A treated with an intramedullary nail. At the time of removal of metalwork/frame, informed consent was obtained and Cerament-G. TM. (bone-substitute with gentamicin) was percutaneously injected through a small cortical window using a bone biopsy(Jamshedi needle). All patients were allowed to weight bear as tolerated in a well-fitting air-cast boot and using crutches. They were followed up at 6 weekly intervals with clinical assessment of their symptoms and radiographs. Fracture union was assessed using serial radiographs with healing defined as filling of fracture gap, bridging callus and clinical assessment including return to full painless weight bearing. Results. Follow-up at 6 months showed all fractures had healed with no defect or gaps with evidence of new trabecular bone and significant resorption of Cerament-G. TM. at final follow-up. There was no evidence of residual infection with restoration of normal limb function. Fractures with no internal fixation showed a mild deformity that had developed during the course of the healing, presumed due to mild collapse in the absence of fixation. These were less than 10 degrees in sagittal and coronal planes and were clinically felt to be insignificant by the patients. Conclusions. Cerament-G's unique combination of high dose antibiotics and hydroxy apatite matrix provided by calcium sulphate might help provide an osteoconductive environment to allow these stiff non-unions to heal. The matrix appears to provide a scaffold-like structure that allows new bone in-growth with local release of antibiotics helping reduce deep-seated infections. The final deformation at fracture site underlines the need for fixation- and it is very unlikely that this technique will work in mobile nonunions. Whilst similar fractures may heal without the use of bone substitute injections, the speed of healing in presence of significant fracture gap suggests the use of these bone substitutes did help in our cases. Further studies with a larger cohort, including RCTs, to evaluate the effectiveness of this technique compared to other methods are needed

Aims. A core outcome set for adult, open lower limb fracture has been established consisting of ‘Walking, gait and mobility’, ‘Being able to return to life roles’, ‘Pain or discomfort’, and ‘Quality of life’. This study aims to identify which outcome measurement instruments (OMIs) should be recommended to measure each core outcome. Methods. A systematic review and quality assessment were conducted to identify existing instruments with evidence of good measurement properties in the open lower limb fracture population for each core outcome. Additionally, shortlisting criteria were developed to identify suitable instruments not validated in the target population. Candidate instruments were presented, discussed, and voted on at a consensus meeting of key stakeholders. Results. The Wales Lower Limb Trauma Recovery scale was identified, demonstrating validation evidence in the target population. In addition, ten candidate OMIs met the shortlisting criteria. Six patients, eight healthcare professionals, and 11 research methodologists attended the consensus meeting. Consensus was achieved for the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS) to measure ‘Quality of life’ and ‘Walking, gait and mobility’ in future research trials, audit, and clinical assessment, respectively. No instrument met consensus criteria to measure ‘Being able to return to life roles’ and ‘Pain or discomfort’. However, the EQ-5D-5L was found to demonstrate good face validity and could also be used pragmatically to measure these two outcomes, accepting limitations in sensitivity. Conclusion. This study recommends the LEFS and EQ-5D-5L to measure the core outcome set for adult open lower limb fracture. Cite this article: Bone Joint Res 2023;12(6):352–361