Aims

Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems.

Purposes And Background. Having found a significant limitation of neural movement (66.6%) during SLR performed on the symptomatic side in patients with sub-acute lumbar intervertebral disc herniation (LIDH), we followed up on the same patients over 1.5 years to ascertain if changes in cord excursion accompany changes in clinical symptoms. Methods. 14 patients, who originally had sciatic symptoms due to subacute LIDH, were re-assessed both clinically and radiologically with a 1.5T magnetic resonance (MR) scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between maneuvers and with data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with decrease in low back pain and radicular symptoms. Results. Compared to previously presented baseline values, the data showed an extensive increase in neural sliding of 323.4% (2.52mm, p≤0.001) with the symptomatic SLR, 37.1% (0.82mm, p=0.0058) with asymptomatic SLR, and 48.2% (1.64mm, p≤0.001) with the bilateral SLR. Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson=−0.719, p≤0.001) and low back pain (Pearson=−0.693, p≤0.001). Multivariate regression models and backward variable selection method confirmed that improvement of neural sliding effects (p≤0.004) as the main variable being associated with improvement of self-reported clinical symptoms. Conclusion. To our knowledge, these are the first non-invasive data to objectively support the association between increase in magnitude of neural adaptive movement and decrease in clinical symptoms in in-vivo and structurally intact human subjects. No conflicts of interest. Sources of funding: This research was partly funded by Finnish National VTR Grant for Medical Research, grant number 128/2012

Osteoarthritis (OA) is the most common disorder of the Sternoclavicular Joint (SCJ). In our case-control study, we evaluated the relationship between clavicular length and OA at the SCJ. CT scans of adults presenting to the Emergency Department of our hospital were examined to look for OA, defined as the presence of osteophytes, subchondral cysts, or cortical sclerosis at the SCJ. Medial-most and lateral-most points of the clavicle were marked on the slices passing through the SC and AC joints respectively. Using x, y, and z-axis coordinates from the DICOM metadata, clavicular length was calculated as the distance between these two points with 3D geometry. Preliminary data of 334 SCJs from 167 patients (64% males, 36% females) with a mean age of 48.5 ± 20.5 years were analysed. Multivariate regression models revealed that age and clavicular length were independent risk factors for OA while gender did not reach statistical significance. A 1mm increase in length was associated with 9% and 7% reduction in the odds of developing OA on the left and the right respectively. Comparing the mean clavicular length using t-test showed a significantly shorter clavicle in the group with OA (145.8 vs 152.7, p=0.0001, left and 144.2 vs 150.3, p=0.0007, right). Our data suggest that the risk of developing OA at the SCJ is higher for shorter clavicles. This could be of clinical relevance in cases of clavicular fracture where clavicular shortening might lead to a higher risk of developing OA. Biomechanical studies are needed to find out the mechanism of this effect

Aims. The preventive effects of bisphosphonates on articular cartilage in non-arthritic joints are unclear. This study aimed to investigate the effects of oral bisphosphonates on the rate of joint space narrowing in the non-arthritic hip. Methods. We retrospectively reviewed standing whole-leg radiographs from patients who underwent knee arthroplasties from 2012 to 2020 at our institute. Patients with previous hip surgery, Kellgren–Lawrence grade ≥ II hip osteoarthritis, hip dysplasia, or rheumatoid arthritis were excluded. The rate of hip joint space narrowing was measured in 398 patients (796 hips), and the effects of the use of bisphosphonates were examined using the multivariate regression model and the propensity score matching (1:2) model. Results. A total of 45 of 398 (11.3%) eligible patients were taking an oral bisphosphonate at the time of knee surgery, with a mean age of 75.8 years (SD 6.2) in bisphosphonate users and 75.7 years (SD 6.8) in non-users. The mean joint space narrowing rate was 0.04 mm/year (SD 0.11) in bisphosphonate users and 0.12 mm/year (SD 0.25) in non-users (p < 0.001). In the multivariate model, age (standardized coefficient = 0.0867, p = 0.016) and the use of a bisphosphonate (standardized coefficient = −0.182, p < 0.001) were associated with the joint space narrowing rate. After successfully matching 43 bisphosphonate users and 86 non-users, the joint narrowing rate was smaller in bisphosphonate users (p < 0.001). Conclusion. The use of bisphosphonates is associated with decreased joint degeneration in non-arthritic hips after knee arthroplasty. Bisphosphonates slow joint degeneration, thus maintaining the thickness of joint cartilage in the normal joint or during the early phase of osteoarthritis. Cite this article: Bone Joint Res 2022;11(11):826–834

To compare the incidence of Bone Cement Implantation Syndrome (BCIS), perioperative thromboembolic events and mortality in patients with a femoral neck fracture (FNF) treated with a hybrid total hip arthroplasty (THA) without intraoperative unfractioned heparin (UFH) (control) versus a group of patients who received intraoperative UFH before femoral cementation. We retrospectively reviewed 273 patients who underwent hybrid THA due to a FNF between 2015 and 2020. We compared a group of 139 patients without intraoperative administration of UFH (group A) with 134 patients who underwent THA with intraoperative administration of 10 UI/kg UFH (group B). UFH indication was dependent on surgeon´s preference. We assessed the advent of BCIS and 30-day thromboembolic events, as well as 90-day and 1-year mortality. BCIS was observed in 51 cases (18%), defined as Grade 1 (O2% < 94% or fall in systolic blood pressure of 20% to 40%) in 37 cases (13%) and Grade 2 (O2% < 88% or fall in systolic blood pressure of > 40%) in 14 cases (5%). Forty-seven BCIS (35%) were observed in the group that received UFH and 4 BCIS (3%) in the control group (p <0.001). Multivariate regression model showed that intraoperative UFH (OR=18, CI95% 6–52) and consumption of oral anticoagulants (OR=3.3, CI95% 1–10) had an increased risk of developing BCIS. Five patients developed a pulmonary embolism in the UFH group while 2 patients presented this complication in the non UFH group (p=0.231). Mortality was 1% for both groups at 90 days PO (p= 0.98), 2% at 1 year for group A and 3% for group B (p =0.38). BCIS in our series was 18%. We found a paradoxically 17-fold significant increase of BCIS with the use of UFH. Heparin did not prevent BCIS, thromboembolic events and mortality in this group of patients

Not all patients receive enhanced mobility and return to comfortable, independent living after Total Hip Arthroplasty (THA). It would be beneficial to both surgeons and patients to be able to predict short term outcomes for THA. The purpose of this study was to investigate factors affecting the short term outcome of primary THA and develop a multivariate regression model that can predict such outcomes. This was a prospective study of 101 patients, who underwent primary THA. All patients were followed for a minimum of 1 year. 12 independent variables, including age, gender, diagnosis, presence of preoperative comorbidities, BMI, preoperative WOMAC physical component (PC) score, type of anesthesia, type of fixation, surgical time, estimated blood loss, use of a postoperative drain, and length of stay were analyzed using correlation and multivariate regression analyses. Multivariate regression models were validated using an independent cohort. Correlation analyses showed three variables significantly influence short term THA outcome. These include preoperative WOMAC PC score (PC) (p< 0.01), gender (G) (p= 0.01) and the presence of preoperative comorbidities (CMB) (p= 0.02). By multivariate regression analysis, the following regression model was obtained: Outcome = PC*0.45 −G*9 + CMB*8 + 62. This model exhibited positive correlation (R2=.25) when compared to a separate cohort of 27 patients undergoing THA not included in the original equation derivation. Our multivariate regression analysis has yielded statistical, multivariate confirmation or non-confirmation of common, predictive THA factors that have previously been reported in the literature. This study provides a concrete, statistically significant measure indicating that preoperative WOMAC PC score, gender, and the presence of preoperative comorbidities are predictive factors for short term primary THA outcome. Finally, our multivariate regression equation can be used to predict the general short term patient outcome following primary THA

Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) is a validated patient reported outcome tool for paediatric foot and ankle conditions. It includes three domains with a maximum score of 100: physical, school and play, and emotional. The purpose of this cross-sectional study is to examine the differences between self-reported child and parent responses of different age groups, genders, and child-parent combinations. During a ten-month period, paediatric patients aged eight to 16 years and their parents completed the OxAFQ-C during routine clinic visits, providing a total 116 child-parent questionnaire dyads. Demographics and diagnostic information was obtained through medical record review. Parent and child responses in each domain were compared for concordance and for effect of demographic variables on the results. Means and standard deviations for parent and child questionnaires for each domain were reported and compared using a two-sample Wilcoxon rank-sum test. A multivariate regression model was used to assess the correlation between demographic characteristics with domain scores. Absolute agreement between patient and parent questionnaires was assessed using intra-class correlation coefficients (ICC) with a two-way random effects model. Seventy patients (60.3%) were female and 46 (39.7%) were male, the majority of parent respondents were mothers (85.3%), followed by fathers (11.2%). Mean patient age was 12.4 (± 2.2) years. Higher scores were reported by the child in every domain, though only the emotional domain score showed statistical significance (p = 0.024) between the parent scores. Male children scored significantly higher than females in school and play domain, (mean 82.38 vs 71.13, p = 0.037) and in the emotional domain (means 90.89 vs79.10, p = 0.002). Parents of males scored significantly higher than parents of females only in the emotional domain (means 86.95 vs 72.67, p = 0.001). Children younger than 13 years old scored significantly higher than older children in the emotional domain (p = 0.004). Child and parent responses for the OxAFQ-C are statistically concordant in the physical and school and play domains. Though children consistently scored themselves higher than their parents did in all domains, only differences in responses for the emotional domain were significant. The level of agreement between parent and child increases with in patients over 13 years of age. Both females and parents of females report lower scores than males and their male parents. Though the use of OxAFQ-C is supported and confirms parent perception of their child's foot and ankle condition is accurate, further research is needed to better understand gender and age differences on response concordance

Aims. The aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error. Methods. We retrospectively identified all proximal humeral fractures treated in our institution between October 2016 and October 2018 using the hospital information system. The patients’ medical and radiological data were collected, and we divided potential risk factors into two groups: preoperative factors and intraoperative factors. Preoperative factors included age, sex, height, weight, body mass index, proximal humeral bone mineral density, type of fracture, the condition of the medial hinge, and medial metaphyseal head extension. Intraoperative factors included the grade of surgeon, neck-shaft angle after reduction, humeral head height, restoration of medial support, and quality of reduction. Adjusted binary logistic regression and multivariate logistic regression models were used to identify pre- and intraoperative risk factors. Area under the curve (AUC) analysis was used to evaluate the discriminative ability of the multivariable model. Results. Data from 203 patients (63 males and 140 females) with a mean age of 62 years (22 to 89) were analyzed. In 49 fractures, the calcar screw was considered to be malpositioned; in 154 it was in the optimal position. The rate of malpositioning was therefore 24% (49/203). No preoperative risk factor was found for malpositioning of the calcar screws. Only the neck-shaft angle was found to be related to the risk of screw malpositioning in a multivariate model (with an AUC of 0.72). For the fractures in which the neck-shaft angle was reduced to between 130° and 150°, 91% (133/46) of calcar screws were in the optimal position. Conclusion. The neck-shaft angle is the key factor for the appropriate positioning of calcar screws when treating a proximal humeral fracture with a locking plate. We recommend reducing the angle to between 130° and 150°. Cite this article: Bone Joint J 2020;102-B(12):1629–1635

Patient controlled analgesia (PCA) is commonly used after TKR. Prolonged use of PCA may however have a negative impact on patients delaying their rehabilitation and therefore discharge. We aimed to evaluate the effect of the duration of PCA on the hospital length of stay (LOS) in patients who undergo TKR. We reviewed the casenotes of all patients who underwent a primary TKR in two South Australian teaching hospitals between 2006 and 2007. After excluding patients whose LOS was determined by placement issues and patients who developed intra-hospital post-operative complications, a number of 345 patients were included in this study. Data collected included: age, gender, ASA grade, regional blocks used, duration of postoperative PCA (< 24 hours, 24-48 hours, > 48 hours) and hospital LOS. Using SAS Version 9.2 statistical analysis software the data was analysed using univariate and multivariate Poisson regression models. Risk ratios, confidence intervals and P values were calculated. Univariate regression models showed that there was a significant difference in length of stay between the three PCA groups (p < 0.0001). Post hoc tests revealed that the length of stay was longer in the 24 to 48 hours and > 48 hours groups compared to the < 24 hours group (p < 0.0001). There was also a significant difference in hospital LOS between males and females (p = 0.0049) with females expected to stay on average 9.7% longer (risk ratio = 1.097, 95% CI 1.028, 1.169). Patients in the ASA categories (1 and 2) recorded shorter lengths of stay than patients in the ASA categories (3 and 4) (p < 0.0001). Also patients treated at one hospital had longer LOS than the patients treated at the other hospital (risk ratio = 1.122, p = 0.0001). There was no evidence for a relationship between the patients' ages, and use or type of regional block used and the hospital LOS. Results from the multivariate regression models showed that each of the four variables found to influence LOS significantly, did so independent of the other variables. Therefore, duration of PCA, gender, ASA and hospital were all independent predictors of hospital LOS after primary TKR. Longer administration of PCA, higher ASA grades and female gender are associated with longer hospital LOS after TKR. Reducing postoperative PCA, as well as improving ASA grading, could reduce LOS in these patients. A multimodal pain management strategy that shortens PCA use could reduce hospital LOS and costs after TKR

In-hospital length of stay (LOS) and discharge disposition following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, we wished to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge disposition following robotic-arm assisted (RO THA) versus conventional technique Total Hip Arthroplasty (CO THA). This large-scale, single institution study included patients of any age undergoing primary THA (N = 1,732) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for Post Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. The median LOS in the RO THA group was 54 hours (34, 78) versus 60 (51, 100) in the CO THA group, p<0.001. Discharge disposition was comparable between the two groups. In the multivariate model, age, need for PACU admission, ASA score > 2, female gender, general anaesthesia and utilisation of the conventional technique were significantly associated with LOS > 2 days. Our study showed that robotic-arm assistance was associated with a shorter LOS in patients undergoing primary THA and no difference in discharge destination. Our results suggest that robotic-arm assistance could be advantageous in partly addressing the upsurge of hip arthroplasty procedures and the concomitant health care burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies

With the coronavirus disease 2019 (COVID-19) pandemic, remote working has been ubiquitously implemented to reduce disease transmission via minimization of in-person interactions. Low back pain (LBP) is the first cause of disability worldwide and is frequently reported by workers with sedentary occupations. This cross-sectional study aimed to assess the role of remote working in a population of adults affected by LBP through an online questionnaire. We enrolled 136 teleworkers affected by LBP. A total of 101 responses were received and 93 suitable questionnaires were included in the final analysis. Demographic data, remote working features and tasks, and LBP burden were analysed. The psychological burden of remote working was evaluated with the World Health Organization Five Well-Being Index (WHO-5) and the Patient Health Questionnaire-2 (PHQ-2). LBP severity was evaluated using a visual analog scale (VAS). LBP-related disability was assessed using the Oswestry Disability Index (ODI). The effect of LBP on working capacity was examined with the Occupational Role Questionnaire (ORQ). Independent risk factors related to LBP worsening were identified using a multivariate logistic regression model. LBP severity was significantly higher compared to previous in-person working (p<0.0001) as well as average weekly work hours (p<0.001). Furthermore, the risk of LBP deterioration was associated with being divorced (OR: 4.28, 95% CI: 1.27-14.47; p=0.019) or living with others (OR: 0.24, 95% CI: 0.07-0.81; p=0.021), higher ill-being (OR: 0.91, 95% CI: 0.83-0.99; p=0.035) and depression scores (OR: 1.38, 95% CI: 1.00-1.91; p=0.048), as well as having reported unchanged (OR: 0.22, 95% CI: 0.08-0.65; p=0.006) or decreased job satisfaction (OR: 0.16, 95% CI: 0.05-0.54; p=0.003) and increased stress levels (OR: 3.00, 95% CI: 1.04-8.65; p=0.042). These findings highlight key factors to consider for improving remote workers’ physical and mental wellbeing and decrease their LBP burden

A hot swollen joint is a commonly encountered condition in clinical practice. With a broad range of differentials, septic arthritis (SA) is perhaps one of the most concerning. Treated by culture-specific antibiotics and arthroscopic lavage, some patients require multiple washouts. We aimed to determine:. (1) What are the risk factors for development of SA?. (2) What are the risk factors for repeat washout in SA patients?. (3) What are the important clinical differences between a periprosthetic joint infection (PJI) and SA cohort?. All patients presenting to the emergency department, orthopaedic, and rheumatology clinics between January 2020 to January 2021 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma on the ipsilateral joint, with data missing from their medical records in any of the variables required for analysis, <24 months follow-up were excluded. Variables of interest in the three-month period preceding the diagnosis of SA were compared between SA and non-SA patients. Factors with a p-value of p<0.100 in univariate analysis were included in a stepwise multivariate logistic regression model. Similar analyses were performed to compare SA patients with multiple washouts with those needing one washout. Demographical and clinical data for PJI patients were collected to delineate important differences with SA cohort. 211 patients were included (SA:28;PJI:24;pseudogout:32;gout:26;others:101). Multivariate analysis showed rheumatoid arthritis (RA), skin infection, and liver disease were risk factors for SA. Amongst patients with septic arthritis, multivariate analysis showed that WBC levels above normal limits (3.6-10.5×109 cells/L) and RA were risk factors for multiple washouts. Between the SA and PJI cohorts, BMI (p=0.002) was significantly lower in the former, whilst WBC level (p=0.023) and CRP (p<0.0001) was significantly higher in the former. Early diagnosis of septic arthritis requires understanding the risk factors, namely RA, skin infection, and liver disease. Considering PJI and septic arthritis as the same entity can lead to wrong clinical judgement, and clinicians should be aware of important differences. We believe that the models in this study are of prognostic value to clinicians who are presented with the common presenting compliant of a hot swollen joint

Aims. Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. Methods. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. Results. A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Conclusion. Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail. Cite this article: Bone Jt Open 2024;5(6):457–463

Abstract. Introduction. Anterolateral procedures can reduce the risk of re-rupture after ACL reconstruction in high risk patients however, this effectiveness has never been evaluated in elite athletes. The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis in reducing revision rates in ACL reconstructions in elite athletes. Methodology. A consecutive cohort of elite athletes between 2005 and 2018 undergoing ACLR reconstruction with or without modified Lemaire lateral extra-articular tenodesis were analysed. A minimum of 2 years of follow-up was required. The association between the use of LET and ACL graft failure was evaluated with univariate and multivariate logistic regression models. Results. 455 elite athletes (83% male; 22.5±4.7 years) underwent primary ACL reconstruction with (n=117) or without (n=338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACL reconstruction reduced the risk of graft failure by 2.8 times with 16.5 athletes needing to be treated with LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (RR=0.325; p=.029) as compared to ACL reconstruction alone after controlling for age at ACL reconstruction and gender. Including graft type in the model did not significantly change the risk profile. Conclusion. The addition of LET in elite athletes undergoing primary ACL reconstruction reduced the risk of undergoing revision by 2.8 times

Fracture related infections (FRI) are debilitating complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. This study aims to determine risk factors associated with FRI treatment failure, allowing clinicians to optimise them prior to treatment and identify patients at higher risk. A major trauma centre database was retrospectively reviewed over a six-year period. Of the 102 patients identified with a FRI (66 male, 36 female), 29.4% (n=30) had acute infections (onset <6 weeks post-injury), 34.3% (n=35) had an open fracture. Open fractures were classified using Gustilo-Anderson (GA) classification (type 2:n=6, type 3A:n=16, type 3B:n=10, type 3C:n=3). Patients with periprosthetic infections of the hip and knee joint, those without prior fracture fixation, soft tissue infections, diabetic foot ulcers, pressure sore infections, patients who died within one month of injury, <12 months follow-up were excluded. FRI treatment failure was defined as either infection recurrence, non-union, or amputation. Lifestyle, clinical, and intra-operative data were documented via retrospective review of medical records. Factors with a P-value of p<0.05 in univariate analysis were included in a stepwise multivariate logistic regression model. FRI treatment failure was encountered in 35.3% (n=36). The most common FRI site was the femoral shaft (16.7%; n=17), and 15.7% (n=16) presented with signs of systemic sepsis. 20.6% (n=21) had recurrent infection, 9.8% (n=10) had non-union, and 4.9% (n=5) required an amputation. The mean age at injury was 49.71 years old. Regarding cardiovascular risk factors, 37 patients were current smokers (36.3%), 31 patients were diabetics (30.4%), and 32 patients (31.4%) were obese (BMI≥30.0). Average follow-up time was 2.37 (range: 1.04-5.14) years. Risk factors for FRI treatment failure were BMI>30, GA type 3c, and implant retention. Given that FRI treatment in 35.3% (36/102) ended up in failure, clinicians need to take into account the predictive variables analysed in this study, and implement a multidisciplinary team approach to optimise these factors. This study could aid clinicians to redirect efforts to improve high risk patient management, and prompt future studies to trial adjuvant technologies for patients at higher risk of failure

Introduction. Antibiotic-impregnated bone cement (AIBC) has been used for decades to treat and prevent post-operative infections in joint arthroplasty. Local delivery of antibiotics may theoretically have a bactericidal effect, however evidence supporting this is controversial and literature suggests its prophylactic use in primary total knee arthroplasty (TKA) is seldom justified. With evolving standards of care, historical data is no longer relevant in addressing the efficacy of AIBC in the contemporary TKA. The purpose of this study was to evaluate outcomes following primary TKA using AIBC and regular non-AIBC by comparing rates of surgical site infection (SSI) and prosthetic joint infection (PJI). Methods. A retrospective review was conducted of all cemented primary TKA procedures from a large institutional database between January 1, 2015 and December 31st, 2016. This identified 6,073 cases, n=2,613 in which AIBC was used and n=3,460 cases using bone cement without antibiotics. Patients were stratified into low risk and high-risk groups based on age (>65 years), BMI (>40), and Charlson Comorbidity Index (CCI; >3). Medical records were reviewed for diagnoses of SSI (skin and superficial wound infections) and PJI (deep joint infections requiring surgery) over a 2-year postoperative period. Univariate analysis and multivariate regression models were used to ascertain the effects of cement type, patient factors (age, gender, BMI, CCI), operative time, and length of stay on infection rates. Additionally, mixed models (adjusted for gender, age, race, BMI, and CCI) were built to account for surgeon variability. Results. The use of AIBC and risk group distributions were equal across the study period and no collinearity was found between the study variables. The SSI rate was 3.0% and the PJI rate was 0.8% in the total study population. Univariate analysis showed there was no significant difference in SSI rates with AIBC compared to non-AIBC (3.3% vs. 2.8%, p=0.278) or in PJI rates (1.0% vs. 0.7%, p=0.203). Multivariate logistic regression analysis adjusted for patient factors, operative time, and length of stay showed no significant difference in SSI rates with a procedure using AIBC compared to non-AIBC (OR=0.90; 95% CI, 0.66–1.23; p=0.515) and no significant difference in PJI rates (OR=1.01; 95% CI, 0.55–1.84; p=0.984). Mixed models also showed no difference in PJI rates with AIBC use after adjusting for surgeon variability as well as patient factors (gender, race, age, BMI, and CCI). Discussion. Prophylactic use of AIBC in primary TKA is not without consequence when considering the significant increase in cost and its potential side effects, namely organism specific antibiotic resistance and mechanical loosening. This study shows that even when adjusted for patient factors, procedure-related factors, and length of stay, there is no clinically significant decrease in infection rates with the use of AIBC in primary TKAs

Introduction. Hip and knee replacements are being performed at increasing rates and currently account for one of the largest procedure expenditures in the Medicare budget. Outcomes of total knee replacement (TKR) depend on surgeon, patient and implant factors. The impact that the specific implants might have on patient-reported outcomes is unknown. The primary purpose of this study was to evaluate the patient-reported functional outcomes and satisfaction after primary total knee arthroplasty in patients with osteoarthritis who underwent TKR using five different brands of posterior-stabilized implants. Specifically, the aim was to evaluate for any difference in patient-reported outcomes based on implant brand used. The hypothesis was that there would be no difference in functional outcome that could be attributed to the implant used in primary TKR. Methods. Using our institution's total joint arthroplasty registry, we identified 4,135 patients who underwent total knee replacement (TKR) using one of the five most common implant brands used at our institution. These included Biomet Vanguard (N=211 patients), Depuy/Johnson&Johnson Sigma (N=221), Exactech OptetrakLogic (N=1,507), Smith & Nephew Genesis II (N=1,414), and Zimmer NexGen (N=779). Only posterior-stabilized primary TKRs in patients with osteoarthritis were included. Patients were evaluated preoperatively using the Knee Osteoarthritis Outcomes Score (KOOS), Lower Extremity Activity Scale (LEAS), and Short Form-12 (SF-12). Demographics including age, body mass index (BMI), Charleston Comorbidity Index (CCI), ASA physical status classification, sex, and smoking status were collected. Postoperatively, 2-year KOOS, LEAS, SF-12, and satisfaction scores were compared between implant groups. Results. At 2-year follow-up, patient-reported outcome scores were available for a total of 4,069 patients. In multiple regression analysis which separately compared each implant group to the aggregate of all others, after accounting for age, BMI, CCI, ASA status, and sex, there were no clinically significant differences in KOOS score changes from baseline to 2-year follow-up between any of the implants. In 2-year satisfaction, >80% of patients in each implant group were satisfied in all domains measured. In the multivariate regression model, patients in the NexGen group had the highest likelihood of being satisfied (OR 1.63, p=0.006) and OptetrakLogic patients had the lowest likelihood of being satisfied (OR 0.60, P<0.001) although these differences were below the minimal clinically important thresholds. Conclusion. TKR provides patient satisfaction and improvement in function regardless of implant type. While some implant systems had higher outcome scores than others, these differences were all below clinically significant thresholds. Whether these differences are a function of surgeon expertise or implant design is unknown. Future research should focus on identifying specific design elements that contribute to improved patient outcomes. Healthcare administrators may find the similarities in clinical outcomes to be a useful consideration when negotiating implant purchasing contracts

Introduction. Total Hip Replacement (THR) is an effective treatment for end stage degenerative disease of the hip and offers patients the prospect of long term pain relief, improved joint function and quality of life. Enhanced Recovery Programmes (ERP) aim to standardise routine perioperative care, reduce hospital length of stay (LOS) and promote rapid recovery after elective surgery. The aim of this study was to determine whether the implementation of an ERP could successfully reduce the length of hospital stay associated with primary THR and whether this could be achieved without compromising the expected functional outcome or risking an increased dislocation rate. Patients/Materials & Methods. Prospectively collected data on 1161 patients (611 managed with traditional rehabilitation and 550 with ERP) undergoing primary unilateral THR between 2005 and 2013 was retrospectively reviewed. Univariable statistical analysis was undertaken to identify factors that appeared to predict length of stay and a multiple linear regression model was then constructed to determine the significance and strength of effect of the individual predictors. Results. Median LOS was 5 days for those managed in the traditional method and 3 days for those managed with ERP (p<0.001). Multivariate regression models demonstrate that this effect on LOS is independent of and stronger than other factors affecting LOS and we did not observe increased rates of dislocation (1.03% versus 0.73%, p=0.75) or mortality (1.5% versus 0.6%, p=0.14) at one year postoperative in patients managed with ERP. Both groups demonstrated significant improvement in mean Harris Hip Score (+42.8 versus +41.5) at twelve to eighteen months postoperative and there was no significant difference in the magnitude of improvement between groups (p=0.09). Discussion. This is the first study to demonstrate the independent effect of ERP on LOS through multiple regression analysis and to directly compare functional outcomes of patients managed with ERP with the accepted gold standard (traditional rehabilitation) and these findings will be of use to surgeons counselling patients peiroperatively and healthcare planners. Conclusion. Implementation of ERP can reduce the hospital LOS for primary THR without adverse effects on dislocation rates and functional outcomes at 12 to 18 months postoperative

Our study is still in progress. The results mentioned in the abstract are preliminary results. The final results will be provided at the time of presentation. Over the past decade, the widespread availability of high-resolution ultrasonography coupled with advances in regional anaesthesia have popularised peripheral nerve blocks for anterior cruciate ligament reconstructions (ACLRs). The aim of this study is to investigate whether the femoral nerve block (FNB) administered at the time of ACLR has any long-term impact on the quadriceps strength as compared to patients who did not receive a FNB. This is a retrospective study. Four hundred charts of patients who underwent ACLR at our institution and had subsequent Biodex testing (an isokinetic rehabilitation test that provides objective information about muscle strength deficits and imbalances of the operated leg compared to the non-operated leg) from 2004 to 2015 were reviewed. Patients who had prior ipsilateral knee surgery, multi-ligament knee injury or at extreme ages were excluded from the study. The following baseline patient characteristics was recorded for each reviewed chart: age, sex, medical comorbidities, the date of the injury, date of the surgery, surgery technical notes and associated procedures, the surgeon, the hospital were the patient was operated, the Biodex test date and the Biodex test results. Data extraction assessed any association between the ACLR patients' who received FNB with the results of the Biodex test after completing the rehabilitation protocol. Descriptive statistics were used to compare the type of anaesthesia, mode of pain control and the results of the Biodex tests between patients grouped by the mode of anaesthesia used at the time of surgery (FNB versus no FNB). A multivariate regression model then compared quadriceps strength (inferred by Biodex test results) between groups while controlling for baseline differences between groups. Fifty five percent of the ACLR patients received FNB compared to 45% that did not receive FNB over the last 11 years of performing ACLRs (2004–2015) at our institute. Fifty percent of the patients that received FNB failed to achieve more than or equal to 80% quadriceps strength (compared to the contralateral non-operated leg) at 6 months on Biodex test. On the other hand, only 20% of the non-FNB group failed to achieve more than or equal to 80% quadriceps strength. This study lead us to think that ACLR patients that received FNB are significantly weaker in quadriceps strength at 6 months post ACLR in comparison to non-FNB ACLR patients. This finding subsequently might affect the time needed to return to sports and might indicate a considerable clinical consequence of the FNB on ACL-reconstruction patients