Introduction. Osteoarthritis in the foot and ankle affects approximately 30,000 patients annually in the UK. Evidence has shown that excess weight exacerbates foot pain, with significant increases in joint forces. However, despite the current trend for Clinical Commissioning Groups to ration surgery for obese patients, studies have not yet determined the effect of weight loss in obese patients with foot and ankle arthritis. Aim. Pilot study to investigate the effect of simulated weight loss on pain scores in obese patients with symptomatic foot and ankle arthritis. Methods. Following ethical approval, a prospective study of 17 obese patients (mean BMI 39.2, range 31.2 – 50.3) with foot and ankle arthritis was undertaken (BOFAS funded). Under physiotherapist supervision, patients walked for one minute on an anti-gravity treadmill, which allowed simulated weight reduction. Following baseline assessment, reduced BMI was simulated, starting at 20, rising in increments of 5, until each patient's usual BMI was reached. Pain was assessed using a Visual Analogue Scale (VAS). Repeated measures ANOVA was used to assess for significant changes in pain, comparing baseline with each simulated BMI category (significance set at p< 0.05). Results. Simulated weight loss caused a significant reduction in pain (p=0.005, power 0.91). Mean VAS pain scores improved by 24% (p=0.003) and 17% (p=0.040) for BMI categories 20 and 25, compared with baseline. Pain scores were not significantly different comparing BMI categories of 25 and 20. Conclusion. Simulated weight loss to normal BMI significantly decreased pain in obese patients with foot and ankle arthritis. The use of the anti-gravity treadmill to demonstrate the feeling of normal BMI has also provided motivation to several patients to lose weight. The current study could be used to power future studies to investigate the effects of weight loss in foot and ankle patients

A retrospective follow-up study was done, assessing regional practices in acute cervical reduction in hospitals in the Western Cape. The constitutional court ruled on the urgency in managing cervical dislocations, and our task is to ensure that medical treatment is optimized to comply with best medical practice and the apex court. A questionnaire was distributed and completed by emergency departments at each hospital, the results retrieved, analysed, and compared to a similar survey done in 2016. Protocols for managing cervical spine dislocations had improved from 80% having no protocols to only over half of facilities (52,6%) not having protocols in place. Inadequate equipment availability remained a problem with only 50% of facilities having adequate equipment available in 2016 to 43,6% in 2023. 10,3% of participants did not know if there was equipment available. In terms of knowledge, there remained poor formal training with a drop from 93% participants identifying that the main indication to attempt emergency cervical reduction was acute cervical dislocation with worsening neurology, to only 46,2%. However, there was an increase in the number of participants who thought reduction was safe. The same percentage of participants from 2016 to 2023 would attempt emergency cervical reduction if given adequate training. Previously we found that most Western Cape hospitals had inadequate protocols, training, and equipment for cervical reductions. In 2023, more hospitals in the Province have protocols in place for cervical reductions and the same percentage of doctors would attempt emergency cervical reduction with adequate training. However, equipment and training for management of acute cervical dislocations has not improved. We conclude that most Western Cape Hospitals are unprepared to adequately manage acute cervical dislocations

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Purpose: To describe operative experience and reductions of pelvic ring fractures treated with a novel pelvic reduction frame. Method: All patients with displaced pelvic ring disruptions treated with the pelvic reduction frame were included. The series includes 35 patients, with 34 acute fractures and one malunion. Pre-operative and immediate post-operative radiographs were reviewed, and maximal displacement measured using two reproducible methods. Procedure and injury data were also recorded. Results: In our series of 35 patients, we had 19 vertical shear fractures and 16 compression injuries. Mean age was 33.5 + 2.4, and mean delay to surgery was 4.7 + 0.6 days. Mean operative time in isolated procedures was 103.4 + 6.5 minutes. All but one patient had iliosacral screws placed, 18 had anterior column screws, six had symphysis plates and 12 had anterior external fixators. Maximum horizontal or vertical displacement was improved from 30.8 + 2.7 mm to 7.1 + 0.7 mm. Diameter asymmetry as measured on the AP view was improved form 26.4 + 2.7 mm to 5.2 + 0.7 mm. Very good, good or fair reduction was obtained in all acute cases. There was no statistically significant impact of obesity, fracture type or delay to surgery on quality of reduction (p> 0.05). Conclusion: This novel pelvic reduction frame is a powerful tool in the effective reduction and fixation of displaced acute pelvic ring disruptions

Background. The usefulness of arthroscopic reduction for the intra-articular fracture of the distal radius has been reported, although it is technically difficult. Hypothesis. Our hypothesis is that the reduction using the external fixator is useful as equivalent to the arthroscopic reduction for the intra-articular fracture of the distal radius fracture in the fixation with the volar locking plate. Materials & Methods. The surgery was performed in both methods randomly for 40 patients; average age 64(24 to 92) years, 11 male, 29 female. Image evaluations were performed at 24 weeks after surgery. Ulnar variance, Radial inclination, Volar tilt in the X-ray image, and gap and step in the computed tomogram were evaluated. Clinical evaluation was performed at 6, 12, 24 weeks after surgery. Objective evaluations were ranges of motion and grip strength. Subjective evaluations were disabilities of the arm, shoulder, and hand (DASH). Results. The results of image and objective evaluation had no significant difference between the two groups. DASH in arthroscopic group was significantly inferior at 24 weeks because of minor complications. Discussion & Conclusion. The external fixator and the arthroscopy are equally valuable in reduction of articular surface

Abstract. Introduction. Multiple strategies, used either in isolation or combination, are available to reduce the need for post-operative blood transfusion in joint replacements. Amongst them, the use of tranexamic acid (TXA) has been rising and this study was conducted to compare the efficacy of topical and intravenous TXA in bilateral total knee replacement patients. Materials and methods. Randomised prospective study with 120 patients (male: female: 25:95) undergoing bilateral TKA. Patients were divided into two groups A and B after computer randomization, who received intravenous or topical (intra-articular) TXA respectively. Results. The average haemoglobin loss in intravenous group was 90.2379 g/L as compared to 39.137 g/L in topical group (p < 0.005). Moreover, there was reduction in blood loss in topical (330.1602 ml) as compared to intravenous group (764.9622 ml). The blood transfusion rate was more for the intravenous group (average 1.73 units) than for the topical group (average 0.75, unit). WOMAC score at 6 weeks in the intravenous group was 12.50, and in the topical group was 7.23 (p value < 0.001). Conclusion. Topical TXA is better than intravenous TXA for reduction of blood loss, which also reduces the need for blood transfusion in bilateral TKA patients

Introduction. Acquired chronic radial head (RH) dislocations present a significant surgical challenge. Co-existing deformity, length discrepancy and RH dysplasia, in multiply operated patients often preclude acute correction. This study reports the clinical and radiological outcomes in children, treated with circular frames for gradual RH reduction. Materials and Methods. Patient cohort from a prospective database was reviewed to identity all circular frames for RH dislocations between 2000–2021. Patient demographics, clinical range and radiographic parameters were recorded. Results. From a cohort of 127 UL frames, 30 chronic RH dislocations (14 anterior, 16 posterior) were identified. Mean age at surgery was 10yrs (5–17). Six pathologies were reported (14 post-traumatic, 11 HME, 2 Nail-Patella, 1 Olliers, OI, Rickets). 70% had a congruent RH reduction at final follow-up. Three cases re-dislocated and 6 had some mild persistent incongruency. Average follow up duration was 4.1yrs (9mnths-11.5yrs). Mean radiographic correction achieved in coronal plane 9. o. , sagittal plane 7. o. and carrying angle 12. o. Mean ulna length gained was 7mm and final ulnar variance was 7mm negative (congenital). All cases achieved bony union with 2 requiring bone grafting. Mean frame duration was 166 days. Mean final range of motion was 64. o. supination, 54 . o. pronation, 2. o. to 138. o. flexion. 5 complications and 7 further operations were reported. Conclusions. The majority of children having frame correction achieve complete correction or minor subluxation, which is well tolerated clinically. Frame assisted reduction is an effective tool for selective complex cases irrespective of the pathology driving the RH dislocation

ZrN-multilayer coating is clinically well established in total knee arthroplasty [1-3] and has demonstrated significant reduction in polyethylene wear and metal ion release [4,5]. The goal of our study was to analyze the biotribological behaviour of the ZrN-multilayer coating on a polished cobalt-chromium cemented hip stem. CoCr28Mo6 alloy hip stems with ZrN-multilayer coating (CoreHip®AS) were tested versus an un-coated version. In a worst-case-scenario the stems with ceramic heads have been tested in bovine serum in a severe cement interface debonding condition under a cyclic load of 3,875 N for 15 million cycles. After 1, 3, 5, 10 & 15 million cycles the surface texture was analysed by scanning-electron-microscopy (SEM) and energy-dispersive x-ray (EDX). Metal ion concentration of Co,Cr,Mo was measured by inductively coupled plasma mass spectroscopy (ICP-MS) after each test interval. Based on SEM/EDX analysis, it has been demonstrated that the ZrN-multilayer coating keeps his integrity over 15 million cycles of severe stem cemented interface debonding without any exposure of the CoCr28Mo6 substrate. The ZrN-multilayer coated polished cobalt-chromium cemented hip stem has shown a reduction of Co & Cr metal ion release by two orders of a magnitude, even under severe stem debonding and high interface micro-motion conditions. ZrN-multilayer coating on polished cobalt-chromium cemented hip stems might be a suitable option for further minimisation of Co & Cr metal ion release in total hip arthroplasty. Clinical evidence has to be proven during the next years

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters. Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups. Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001). Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature

Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced. A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case. Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures. 31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11. The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08). The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04). This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters. Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups. Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001). Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature

Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients. Trends were monitored using Shewhart control charts. 84,998 TJA over two-years were included. All groups showed a reduction in opioids prescribed. Importantly, no increased complications occurred concomitant to this reduction. No increases in ED visits or readmissions, and no decreases in KOOSJR/HOOSJR/PROMIS10 scores were noted in any of the groups. Using large data sets and registries can drive performance and improve quality. The MARCQI Postoperative opioid prescription recommendations and performance measures decreased total oral morphine equivalents prescribed over a large and diverse population by approximately 50% without decreasing PROs or increasing ED visits or hospital readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without an increase in complications across a large population

Ganz's studies made it possible to address joint deformities on both femoral and acetabular side brought by the Legg-Calvè-Perthes disease (LCPD). Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency along with periacetabular osteotomy (PAO). The purpose of this study is to show the clinical and morphologic outcomes of the technique, and an implemented planning approach. From 2015 to 2023, 13 FHROs were performed on 11 patients for LCPD, in two centers. 11 of 13 hips had an associated PAO. A specific CT and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiographic parameters (sphericity index, extrusion index, integrity of the Shenton's line, LCE angle, Tonnis angle, CCD angle) and clinical parameters (ROM, VAS, Merle d'Aubigné-Postel score, modified-HHS, EQ5D-5L). Early and late complications were reported. The mean follow-up was 40 months. The mean age at surgery was 11,4 years. No major complications were recorded. One patient required a total hip arthroplasty. Femoral Head Sphericity increased from 45% to 70% (p < 0,001); LCE angle from 18° to 42,8° (p < 0,001); extrusion Index from 36,6 to 8 (p < 0,001); Tonnis Angle from 14,4° to 6,2° (p = 0.1); CCD Angle from 131,7 to 136,5° (p < 0,023). The VAS score improved from 3,25 to 0,75,(p = 0.06); Merle d'Aubigné-Postel score from 14.75 to 16 (p = 0,1); Modified-HHS from 65,6 to 89,05 (p = 0,02). The EQ 5D 5L showed significant improvements. ROM increased especially in abduction and extra-rotation. FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical and morphologic outcomes in LCPD. The newly introduced simulation and planning algorithm may help to further refine the technique

We undertook a retrospective audit to assess the effectiveness of use of Quixil in reducing the amount of blood transfusion requirements following revision THR. As Quixil was used from mid 2007 for revision THRs, we looked at blood transfusion requirements for 1 year before introduction of Quixil and compared it with requirements after introduction of Quixil for a similar period.

Method and Materials: 44 patients underwent revision THR by the senior author during the period from June 2007 – June 2008 (Quixil group) while 45 patients did not have Quixil during revision THR for the period May 2006 – May 2007 (Non-quixil group). In the quixil group, M: F = 18:26 and average age 75.3 (range: 63 – 88 yrs). In the non-quixil group, M: F = 17:28 and average age 71.3 (range: 47 – 85 yrs). The duration of surgery was similar in both groups. Blood loss during the operation was evaluated by measuring the volume in the suction apparatus and by estimating the amount of lost blood in the swabs at the end of the operation. Drains were not used in these procedures. All blood transfusions were recorded.

Results: The average blood loss was 1010 mls (range: 300 – 2200 mls) in the quixil group vs. 1021 mls (range: 500 – 2000 mls) in the non-quixil group. The use of cell saver and intra-operative blood transfusion were similar in both groups. The mean pre-op Hb in quixil vs. non-quixil group was 13.0 g/dl (range: 9.7– 16.2) vs. 12.4 g/dl (range: 8.8 – 16.2). The mean post-op Hb in quixil group vs. non-quixil group was 10.2 g/dl (range: 6.4 – 13.2) vs. 9.1 g/dl (range: 5.3 – 12.9)(a difference of 1.1 g/dl). There was a difference in the blood transfused post-operatively between the two groups – 21 vs. 29 patients. Total units of blood transfused in quixil vs. non-quixil group were 60 vs. 86 (a difference of 26 units stastically significant) and total units of intra-op blood transfused in quixil vs. non-quixil group were 16 vs. 23 (a difference of 7 units).

Limitations of the study: Retrospective study, Small numbers of patients

Conclusion: The use of fibrin tissue adhesive in revision total hip arthroplasty seems to be an effective and safe means with which to reduce blood loss and blood-transfusion requirements as well as prevent in the postoperative decrease in the level of hemoglobin.

Modular dual mobility (DM) articulations are increasingly utilized during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) abnormalities with serum metal ion levels in patients with DM articulations. All patients with an asymptomatic, primary THA and DM articulation with >2-year follow-up underwent MARS-MRI of the operative hip. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels. Forty-five patients (50 hips) with a modular DM articulation were included with average follow-up of 3.7±1.2 years. Two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels >3.0 μg/L. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/L. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels <1.0 μg/L, while one (2.6%) had a cobalt level of 1.4 μg/L. One patient (2.2%) had a chromium level >3.0 μg/L and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels >5.0 μg/L without associated MARS-MRI abnormalities. Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic dual mobility articulations occur infrequently (4.4%), but further assessment of these patients is necessary. Level of Evidence: Level IV

Background: context: In Adolescent Idiopathic Scoliosis (AIS), the correction of thoracic hypokyphosis with hooks instrumentation and also with pedicle screws system is moderate. Purpose: To compare radiographic results between two instrumentations with thoracic screws using two different. Methods: of reduction: cantilever reduction (CR group– MOSS-MIAMI system) versus simultaneous translation on two rods (ST group – PASSMED system). Study design: Retrospective comparative analysis of two consecutive cohorts of patients treated by the same surgeon at a single hospital. Patient sample: Forty-two adolescent idiopathic thoracic scoliosis (Lenke type 1, 2 and 3) underwent a posterior spinal fusion and instrumentation: 20 patients in CR group and 22 patients in the ST group. The minimum follow-up was two years (Mean follow-up: 71 months and 47 months). Outcomes measures: Thoracic sagittal kyphosis between T4 and T12 and Cobb angle measurements of major and minor curves evaluated preoperatively, postoperatively and the final visit, by an independent observer. Methods: In CR group, we have used polyaxial pedicle screws and one or two monoaxial thoracic hooks. In ST group, we have used polyaxial pedicle screws and poly-axial claws which provide same stability than screws. Three groups of preoperative kyphosis were generated: 11 patients with severe hypokyphosis (T4–T12 < 10°) (5 in CR group and 6 in ST group); 11 patients with mild hypokyphosis (between 10 and 20°) (respectively 4° vs 7°) and 20 with normokyphosis (> 20°) (respectively 11 vs 9). Results: At the final follow-up, for patients with a severe preoperative hypokyphosis, the mean gain was 14 degrees in the CR group (8° preop to 22° postop) and 25° in the ST group (6° preop to 31 postop) (p< 0.05). For patients xith mild hypokyphosis, te mean gains were respectively 7 degrees (16° preop to 23° postop) and 18° (16° preop to 34° postop) (p< 0.05). After surgery, 3 patients of CR group had hypokyphosis alors que all patients had normal kyphosis (> 20°) in the ST group. In the coronal plane, the mean correction of scoliosis are similar in the two groups (75% vs 69% p=NS). Discussion and Conclusion: In posterior instrumentation for AIS, simultaneous reduction on two rods provides a better correction of the thoracic kyphosis than the cantilever reduction in patient with preoperative hypokyphosis. This surgical technique seems to restore thoracic normal kyphosis

Executing an extended retinacular flap containing the blood supply for the femoral head, reduction osteotomy (FHO) can be performed, increasing the potential of correction of complex hip morphologies. The aim of this study was to analyse the safety of the procedure and report the clinical and radiographic results in skeletally mature patients with a minimum follow up of two years. Twelve symptomatic patients (12 hips) with a mean age of 17 years underwent FHO using surgical hip dislocation and an extended soft tissue flap. Radiographs and magnetic resonance imaging producing radial cuts (MRI) were obtained before surgery and radiographs after surgery to evaluate articular congruency, cartilage damage and morphologic parameters. Clinical functional evaluation was done using the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). After surgery, at the latest follow-up no symptomatic avascular necrosis was observed and all osteotomies healed without complications. Femoral head size index improved from 120 ± 10% to 100 ± 10% (p<0,05). Femoral head sphericity index improved from 71 ± 10% before surgery to 91 ± 7% after surgery (p<0,05). Femoral head extrusion index improved from 37 ± 17% to 5 ± 6% (p< 0,05). Twenty five percent of patients had an intact Shenton line before surgery. After surgery this percentage was 75% (p<0,05). The NAHS score improved from a mean of 41 ± 18 to 69 ± 9 points after surgery (p< 0,05). The HOS score improve from 56 ± 24 to 83 ± 17 points after surgery (p< 0,05) and the mHHS score improved from 46 ± 15 before surgery to 76 ± 13 points after surgery (p< 0,05). In this series, femoral head osteotomy could be considered as safe procedure with considerable potential to correct hip deformities and improve patients reported outcome measures (PROMS). Level of evidence - Level IV, therapeutic study. Keywords - Femoral head osteotomy, Perthes disease, acetabular dysplasia, coxa plana

Flexible fixation techniques combined with anatomic (open) syndesmosis reduction have demonstrated improved functional outcomes and rates of malreduction. Suture-button devices allow physiologic motion of the syndesmosis without need for implant removal, which may lower the risk of recurrent syndesmotic diastasis. There is limited longer-term assessment of the maintenance of reduction between static and flexible syndesmotic fixation using bilateral ankle CT evaluation. This is an a priori planned subgroup analysis of a multi-centre, randomized clinical trial comparing static syndesmosis fixation (two 3.5 mm screws) with flexible fixation (single knotless Tightrope) for patients with AO- OTA 44-C injuries. Patients who completed bilateral ankle CT scans at 3- and 12-month follow-up were included. The primary outcome measure was syndesmotic malreduction based on bilateral ankle CT scans, using the uninjured, contralateral ankle as a control. Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance were calculated to measure syndesmosis reduction. Secondary outcomes included re-operation, adverse events and functional outcomes including the EQ5D, Olerud-Molander Ankle Score (OM), Foot and Ankle Disability Index (FADI), and Work Productivity Activity Impairment Questionnaire (WPAI). Paired samples t-tests were used to compare injured to control ankles (R, v 3.5.1). 42 patients (24 Group S, 18 Group T) were included. ASD for Group T was 5.22mm (95%CI 4.69–5.77) at 3 months compared to 4.26mm (95%CI 3.82–4.71; p=0.007) in controls and 5.38mm (95%CI 4.72–6.04) at 12 months compared to 4.44mm (95%CI 3.73–5.16; p=0.048) in controls. ASD for Group S was 4.63mm (95%CI 4.17– 5.10) at 3 months compared to 4.67mm (95%CI 4.24–5.10; p=0.61) in controls, but significantly increased to 5.73mm (95%CI 4.81–6.66) at 12 months compared to 4.65mm (95%CI 4.15–5.15; p=0.04) in controls. MSD results were similar; Group T had a larger MSD than control ankles at 3 months (p=0.03) and 12 months (p=0.01), while the MSD in Group S was not different at 3 months (p=0.80) but increased at 12 months (p=<0.01). 88% (21/24) of Group S had broken or removed screws by 12 months. Unplanned re-operation was 15% in Group S and 4% in Group T (p=0.02), with an overall re-operation rate of 30% in Group S. There was no significant difference between treatment groups for EQ-5D, OM, FADI or WPAI at 3- or 12-month follow-up. Tightrope fixation resulted in greater diastasis of the ASD and MSD compared to contralateral, uninjured ankles at 3- and 12-months post-fixation. Group S initially had syndesmotic reduction similar to control ankles, but between 3- and 12-months post-fixation, there was significantly increased syndesmosis diastasis compared to controls. The majority of Group S (88%) had either broken screws or scheduled screw removal, which may explain the increased tibio-fibular diastasis seen at 12-months

Glenohumeral dislocation is complicated with a greater tuberosity fracture in 16% of cases. Debate regarding the safety of closed reduction in the emergency department exists, with concerns over fracture propagation during the reduction manoeuvre. The study aim was to report the results of closed reduction, identify complications and define outcome for these injuries. 188 consecutive glenohumeral dislocations with a tuberosity fracture were identified from a prospective database from 2014–2017. 182 had an attempted closed reduction under appropriate sedation using standard techniques, five were manipulated in theatre due to contra-indications to sedation. Clinical, radiographic and patient reported outcomes, in the form of the QuickDASH and Oxford Shoulder Score (OSS), were collected. A closed reduction in the emergency department was successful in 162 (86%) patients. Two iatrogenic fractures of the proximal humerus occurred, one in the emergency department and one in theatre, representing a 1% risk. 35 (19%) of patients presented with a nerve lesion due to dislocation. Surgery was performed in 19 (10%) cases for persistent or early displacement (< 2 weeks) of the greater tuberosity fragment. Surgery resulted in QuickDASH and OSS scores comparable to those patients in whom the tuberosity healed spontaneously in an anatomical position (p=0.13). 18 patients developed adhesive capsulitis (10%). Glenohumeral dislocation with greater tuberosity fracture can be safely treated by closed reduction within the emergency department with a low risk of humeral neck fracture. Persistent or early displacement of the tuberosity fragment will occur in 10% of cases and is an indication for surgery