The aim of this study was to measure the effect of hospital case volume on the survival of revision total hip arthroplasty (RTHA).

This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTHA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTHA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTHA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant.

From 1999 to 2019, 13,020 patients underwent RTHA surgery in Scotland (median age at RTHA 70 years (interquartile range (IQR) 62 to 77)). In all, 5,721 (43.9%) were female, and 1065 (8.2%) were treated for infection. 714 (5.5%) underwent a second revision procedure. Co-morbidity, younger age at index revision, and positive infection status were associated with need for re-revision (p<0.001). The ten-year survival estimate for RTHA was 93.3% (95% CI 92.8 to 93.8). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was not significantly associated with lower risk of re-revision (HR1, 95% CI 1.00 to 1.00, p 0.073)).

The majority of RTHA in Scotland survive up to ten years. Increasing yearly hospital case volume cases is not independently associated with a significant risk reduction of re-revision.

Technological advancements in orthopaedic surgery have mainly focused on increasing precision during the operation however, there have been few developments in post-operative physiotherapy. We have developed a computer vision program using machine learning that can virtually measure the range of movement of a joint to track progress after surgery. This data can be used by physiotherapists to change patients’ exercise regimes with more objectively and help patients visualise the progress that they have made. In this study, we tested our program's reliability and validity to find a benchmark for future use on patients.

We compared 150 shoulder joint angles, measured using a goniometer, and those calculated by our program called ArmTracking in a group of 10 participants (5 males and 5 females). Reliability was tested using adjusted R squared and validity was tested using 95% limits of agreement. Our clinically acceptable limit of agreement was ± 10° for ArmTracking to be used interchangeably with goniometry.

ArmTracking showed excellent overall reliability of 97.1% when all shoulder movements were combined but there were lower scores for some movements like shoulder extension at 75.8%. There was moderate validity shown when all shoulder movements were combined at 9.6° overestimation and 18.3° underestimation.

Computer vision programs have a great potential to be used in telerehabilitation to collect useful information as patients carry out prescribed exercises at home. However, they need to be trained well for precise joint detections to reduce the range of errors in readings.

To compare the long-term outcomes of fibular nailing and plate fixation for unstable ankle fractures in a cohort of patients under the age of 65 years.

Patients from a previously conducted randomized control trial comparing fibular nailing and plate fixation were contacted at a minimum of 10 years post intervention at a single study centre. Short term data were collected prospectively and long-term data were collected retrospectively using an electronic patient record software.

Ninety-nine patients from one trauma centre were included (48 fibular nails and 51 plate fixations). Groups were matched for gender (p = 0.579), age (p = 0.811), body mass index (BMI)(p = 0.925), smoking status (p = 0.209), alcohol status (p = 0.679) and injury type (p = 0.674). Radiographically at an average of 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p = 0.851). Both groups had 1 tibio-talar fusion (2% of both groups) secondary to osteoarthritis with no statistically significant difference in overall re-operation rate between groups identified (p = 0.518,). Forty-five percent (n=42) of patients had so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=19, plate fixation n=23). No significant difference was found between groups at 10 years for the Olerud and Molander Ankle Score (p = 0.990), the Manchester-Oxford Foot Questionnaire (p = 0.288), Euroqol-5D Index (p = 0.828) and Euroqol-5D Visual Analogue Score (p = 0.769).

The current study illustrates no difference between fibular nail fixation and plate fixation at a long-term follow up of 10 years in patients under 65 years old, although the study is currently under powered.

The Thompson hemiarthroplasty is a common treatment option for acute neck of femur fractures in the elderly population. Our department noted a significant number of patients returning with thigh pain, radiographic loosening and femoral osteolysis following cemented implantation of the titanium alloy version of the Thompson hemiarthroplasty. We are not aware of any previous reports documenting complications specific to the titanium Thompson implant and a retrospective cohort study was therefore initiated following clinical governance approval.

366 titanium alloy Thompson prostheses were implanted for hip fracture treatment between 2017 and 2020. As of February 2023, 6 of these have been revised at our hospital. 5 were revised for symptomatic femoral osteolysis and 1 presented with an acute periprosthetic fracture. All revised cases were determined to be aseptic. 32 living patients were excluded from recall on compassionate grounds due to permanent nursing home residence. 47 living patients were identified of which 33 attended for xray. 28 deceased and/or nursing home resident patients who had pelvis x-rays in the previous 12 months were also included in the analysis. Including the 6 index hips already revised, a total of 61 hip xrays were analysed, of which 19 hips (31.1%) showed radiographic evidence of femoral osteolysis or loosening.

We conclude that there is a concerning incidence of femoral osteolysis and implant loosening associated with the titanium Thompson implant. We have discontinued use of the implant and reported our experience to the MHRA. We encourage other Scottish Health-Boards who use this implant to consider enhanced follow-up.

To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU).

Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers.

In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3.

The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures.

Patellofemoral instability (PFI) is a common cause of knee pain and disability in the paediatric population. Patella alta, lateralised tibial tubercle, medial patellofemoral ligament (MPFL) deficiency, genu valgum and trochlear dysplasia are well known risk factors.

A prospective database was created including patients referred through our physiotherapy pathway following first-time patella dislocation. Patella alta and lateralisation of the tibial tuberosity was treated with a Fulkerson-type tibial tubercle osteotomy(TTO). Medial patellofemoral ligament was reconstructed using quads tendon autograft pull-down technique. A modified Sheffield protocol was used postoperatively allowing weightbearing in a hinged knee brace.

Forty patients were identified with 8 patients having bilateral presentations. Male to female ratio was 12:28 with an age range of 4–17 years. Eight patients had congenital PFI, five patients acquired PFI through traumatic patella dislocation and twenty-seven patients developed PFI from recurrent dislocations. Structural abnormalities were found in 38(95%) of patients. Patella alta (Caton-Deschamps index >1.2) was identified in 19(47%) patients, genu valgum in 12(30%) patients, increased tibial tubercle-trochlear groove distance(TT-TG>20mm) was present in 9(22.5%) patients and persistent femoral anteversion(> 20 deg) in 7(17%) patients.

Eight patients were treated with TTO and MPFL reconstruction, three patients with MPFL reconstruction alone and five patients had guided growth for genu valgum correction. Ten patients are awaiting surgery. No postoperative patients had recurrence of PFI at their latest follow up.

PFI is a common problem in the adolescent paediatric population with identifiable structural abnormalities. Correcting structural pathology with surgery leads to predictable and safe outcomes.

COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture.

This nationwide cohort study included all patients aged >50 years with a hip fracture between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to population-level records of COVID-19 vaccination and testing.

There were 13,345 patients with a median age of 82.0 years (IQR 74.0–88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34–0.48, p<0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12–3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk (OR 0.93, CI 0.53–1.60, p = 0.783).

Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents essential data for future outbreaks.

There is little published literature to support the claim that a successful total knee replacement (TKR) is predictive of future good outcomes on the contralateral side. The objective was to identify whether outcome from the first of staged TKRs could be used to predict the outcome of the contralateral TKR.

This was a retrospective cohort study of 1687 patients over a 25-year period undergoing staged bilateral TKRs in a UK arthroplasty centre. A control group of 1687 patients undergoing unilateral TKR with matched characteristics was identified. Primary outcomes were satisfaction and Knee Society Score (KSS) at one year.

Preoperative status was comparable for pain, ROM and KSS (mean 41, 45, 43±14). At one year follow up, dissatisfaction was similar for all groups (4% first of staged TKR, 4% second of staged TKR, 5% controls). If the first TKR had a good outcome, the relative risk of a contralateral bad outcome was 20% less than controls (95% CI 0.6–1.2). If the first TKR had a poor outcome, the risk of a second poor outcome was 4 times higher (95% CI 2.8–6.1), increasing from 6% to 27% (absolute risk).

Patients undergoing the second of staged TKRs with a previous good outcome are likely to do well in their second procedure (94 in 100 will go on to have a second good outcome). Of those with a previous poor outcome, 27 in 100 will have a second poor outcome. The trend was persistent despite correcting for gender, age, BMI, and diagnosis.

The aims were to assess whether vitamin D deficiency influenced mortality risk for patients presenting with a hip fracture.

A retrospective study was undertaken including all patients aged over 50 years that were admitted with a hip fracture to a single centre during a 24-month period. Serum vitamin D levels were assessed. Patient demographics and perioperative variables and mortality were collected. Cox regression analysis (adjusting for confounding) was utilised to determine the independent association between serum vitamin D level and patient mortality.

The cohort consisted of 2075 patients with a mean age of 80.7 years and 1471 (70.9%) were female. 1510 (72.8%) patients had a serum vitamin D level taken, of which 876 (58.0%) were deficient (<50nmol/l). The median follow up was 417 (IQR 242 to 651) days. During follow up there were 464 (30.7%) deaths. Survival at 1 year was significantly (p = 0.003) lower for patients who were vitamin D deficient (71.7%, 95% confidence intervals (CI) 68.6 to 74.9) compared to those who were not (79.0%, 95% CI 75.9 to 82.3). Vitamin D deficiency was also independently associated with an increased mortality risk at 2-years (HR 1.42, 95% CI 1.17 to 1.71, p = 0.03), but not at 1-year (p = 0.08).

Hip fracture patients with vitamin D deficiency had an increased mortality risk. This risk was independent of confounders at 2 years. The role of measuring vitamin D levels in these patients is unclear. Improved public health policy about vitamin D may be required to reduce deficiency in this patient population.

Stable Weber B fractures are typically treated non-operatively without complications but require close monitoring due to concerns over potential medial deltoid ligament injuries and the risk of delayed talar shift. Following recent evidence suggesting this is unlikely, a functional protocol with early weight bearing was introduced at Glasgow Royal Infirmary (GRI) following a pilot audit.

This study aims to evaluate the risk of delayed talar shift in isolated Weber B fractures managed with functional bracing and early weight-bearing, particularly if signs of medial ligament injury are present.

We conducted a retrospective review of 148 patients with isolated Weber B fractures without talar shift at presentation that were reviewed at the virtual fracture clinic at our institution between July 2019 and June 2020. The primary outcome was the incidence of delayed talar shift. Secondary outcomes were other complications and adherence to protocol.

48 patients had medial signs present and of these 1 (2%) showed possible talar shift on X-rays at 4 weeks, and was kept under review. This patient had a normal medial clear space at 3 months. No patients with medial signs not documented (n=19) or not present (n=81) had delayed talar shift. 10% of patients (n=15) had at least 1 complication: delayed union (n=2); non-union (n=3); ongoing pain (n=14).

Functional bracing with early weight-bearing is a safe, effective protocol for managing isolated Weber B fractures without initial talar shift. This study concludes that the risk of delayed talar shift is low in all patients, with or without medial signs.

Aims

To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Aims

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

Aims

The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Aims

The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Aims

To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial.

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Aims

The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

Aims

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

Aims

To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients.

Hip fracture patients are vulnerable to delirium. This study examined the associations between delirium and outcomes including mortality, length of stay, post-discharge care requirements, and readmission.

This cohort study collected validated healthcare data for all hip fracture patients aged ≥50 years that presented to a high-volume centre between March 2020-November 2021. Variables included: demographics, delirium status, COVID-19 status, treatment factors, and outcome measures. Wilcoxon rank sum or Chi-squared tests were used for baseline differences, Cox proportional hazard regression for mortality, logistic regression for post-discharge care requirements and readmission, and linear regression for length of stay. Analyses were adjusted for age, sex, deprivation, pre-fracture residence type and COVID-19.

There were 1822 patients (mean age 81 years; 72% female) of which 496/1822 (27.2%) had delirium (4AT score ≥4). Of 371/1822 (20.4%) patients that died within 180 days of admission, 177/371 (47.7%) had delirium during the acute stay. Delirium was associated with an increased 30- and 180-day mortality risk (adjusted HR 1.74 (95%CI 1.15-2.64; p=0.009 and 1.74 (1.36-2.22; p<0.001), respectively), ten day longer total inpatient stay [adj. B.coef 9.80 (standard error 2.26); p<0.001] and three-fold greater odds of higher care requirements on discharge [Odds Ratio 3.07 (95% Confidence Interval 2.27-4.15; p<0.001)].

More than a quarter of patients had delirium during the hip fracture stay, and this was independently associated with increased mortality, longer length of stay, and higher post-discharge care requirements. These findings are relevant for prognostication and service planning, and emphasise the importance of effective delirium screening and evidence-based interventions in this vulnerable population.

We aimed to determine the rate of and risk factors for post-traumatic osteoarthritis (PTOA) and total knee arthroplasty (TKA) requirement after operative management of tibial plateau fractures (TPF) in older adults.

We conducted a retrospective cohort study of 182 operatively managed TPFs in 180 patients ≥60 years old over a 12-year period with minimum follow up 1 year. Data including patient demographics, clinical frailty scores, mechanism of injury, management, reoperation and mortality were recorded. Radiographs were reviewed for: Schatzker classification; pre-existing knee osteoarthritis (KOA); severe joint depression >15mm; and development of PTOA. Kaplan Meier survival analysis was performed. Regression analysis was used to identify risk factors for radiographic indication for TKA and actual TKA.

Forty-seven percent were Schatzker II fractures. Radiographic KOA was present at fracture in 32.6%. Fracture fixation was performed in 95.6% cases and acute TKA in 4.4%. Thirteen patients underwent late TKA (7.5%). At five-years, 11.8% (6.0-16.7 95% CI) had required TKA and 20.9% (14.4-27.4 95% CI) had a radiographic indication for TKA. Severe joint depression and pre-existing KOA were associated with worse survival for endpoints radiographic indication for TKA and actual TKA. Severe joint depression (HR 2.49(1.35-4.61 95% CI), p=0.004), pre-existing KOA (HR 2.23(1.17-4.23), p=0.015) and inflammatory arthropathy (HR 2.4(1.04-5.53), p=0.039) were independently associated with radiographic indication for TKA.

In conclusion, severe joint depression and pre-existing arthritis are independent risk factors for both severe PTOA and TKA after TPFs in older adults. These features should be considered as an indication for primary management with acute TKA.

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period.

Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year.

388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276).

Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856).

Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures.

The suprascapular nerve is an ideal target for nerve blockade to alleviate shoulder pain given its widespread innervation to the shoulder girdle. Many techniques have been described. To widen the availability of this treatment we investigate whether an anatomical landmark technique can be easily learned by novice injectors to provide efficacious blockade.

Five injectors were recruited with varying experience; from the novice medical student to an orthopaedic consultant. Five torsos (10 shoulders) were used. A single page of written instruction and illustration of the Dangoisse landmark technique was provided prior to injection of a Thiel embalmed cadaver bilaterally. A pre-mixed injectate with blue dye was used. Cadavers were dissected and the presence or absence of dye staining reported by 3 observers and a consensus agreement reached.

Dissection demonstrated diffuse staining in the suprascapular fossa. 90% of shoulders were found to have adequate staining of the suprascapular nerve directly, or its distal branches, in a manner which would provide adequate anaesthesia. The inter-observer agreement was good (k = 0.73) for staining at the supraspinous fossa and excellent (k=0.87) for staining distally. The technique was easily performed by novice injectors with a 100% success rate.

We demonstrate that this technique is reproducible by a range of clinicians to effectively provide anaesthesia of the SScN. The main risks are ineffective block (10% in this series) and of intravascular injection. Within a resource strained healthcare environment greater uptake of this technique is likely to be of benefit to a wider array of patients.

Hip fractures are a major cause of morbidity and mortality, and malnutrition is a critical determinant of these outcomes. This systematic review and meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with hip fracture. An electronic systematic literature search was conducted in August 2022 using four databases. Randomized trials documenting ONS in older patients with hip fracture (aged 50+) were included. Two reviewers evaluated study eligibility, data extraction and assessed study quality.

There were 812 studies identified of which 18 studies involving 1,512 patients met the inclusion criteria. The overall meta-analysis demonstrates that ONS was associated with a significant risk reduction in infective complications (odds ratio (OR) 0.54, 95%CI 0.38, 0.76), pressure ulcers (OR 0.54, 95%CI 0.33, 0.88), total complications rate (OR 0.57, 95%CI 0.42, 0.79). Length of hospital stay (LOS) was also significantly reduced (weighted mean difference (WMD) −2.01, 95%CI −3.52, −0.5), particularly in the rehabilitation LOS (WMD −4.17, 95%CI −7.08, −1.26). There was a tendency towards lower risk in mortality (OR 0.93, 95%CI 0.62, 1.4) and readmission (OR 0.52, 95%CI 0.16, 1.73), though statistical significance was not achieved. The overall compliance to ONS ranged from 64.1% to 100%, but no factors influencing compliance were identified.

This systematic review was the first to quantitatively demonstrate that ONS reduces half the risk of infective complications, pressure ulcers, total complication rate and reduces LOS. ONS should be a regular and integrated part of medical practice, especially given that the compliance to ONS is acceptable.

The aims of this study in relation to distal radius fractures were to determine (1) the floor and ceiling effects for the QuickDASH and PRWE, (2) the floor and ceiling effects when defined to be within the minimal clinically important difference (MCID) of the minimal or maximal scores, (3) the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and (4) patent factors associated with a floor or ceiling effect.

A retrospective cohort study of patients sustaining a distal radius fracture during a single year was undertaken. Outcome measures included the QuickDASH, PRWE, EQ-5D-3L and normal wrist score.

There were 526 patients with a mean age of 65yrs and 77% were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs. A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the MCID of the best score, the effect increased to 62.8% for the QuickDASH and 60% for PRWE. Patients that achieved the best functional outcome according to the QuickDASH and PRWE felt their wrist was only 91% and 92% normal, respectively. Sex (p=0.000), age (p=0.000), dominant wrist injury (p=0.006 for QuickDASH and p=0.038 for PRWE), fracture type (p=0.015), and a better health-related quality of life (p=0.000) were independently associated with achieving a ceiling score.

The QuickDASH and PRWE demonstrated ceiling effects following a distal radius fracture. Patients achieving ceiling scores did not consider their wrist to be ‘normal’ for them.

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture.

A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period.

The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction.

Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures.

Sub-acromial decompression surgery (SAD) has been widely used to treat shoulder impingement. Its validity has been questioned in multi-centric clinical trials and dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients.

All patients with SAD dissatisfaction in the local Upper Limb database between 2015-19 (n=74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), QuickDASH score, EQ-5D-3L (TTO+VAS) at weeks 26 and 52 post-operatively. Patients' clinical history, radiographs, consultation and operative notes were reviewed.

28% of patients were dissatisfied with surgery. Mean age =52.3±13.4 years with equal gender distribution. 87% were operated arthroscopically. 67% were in physically demanding occupations. There was a significant increase in OSS and QuickDASH at weeks 26 and 52 post-operatively (p<0.05), similar improvement was not noted in VAS pain score. Pain followed by stiffness were the main contributors of dissatisfaction. Multiple implicating factors were noted, the most common being acromio-clavicular joint arthritis (25.7%), suggesting concomitant pathologies as an additional cause for patient dissatisfaction.

This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction and a predilection for those involved in physically demanding occupations. We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to improve outcomes in selected patients needing SAD following failure of conservative management.

To our knowledge, we are the only centre in the UK where Achilles tenotomies (TA) for CTEV Ponseti correction are performed in outpatient clinic under local anaesthetic by an Advanced Physiotherapy Practitioner (APP) in orthopaedics. This study aims to present the outcomes and safety of this practice.

Retrospective analysis of cases of idiopathic CTEV undergoing Ponseti correction January 2020 to October 2022. Demographic data: Pirani score and number of casts before boots and bar. Patients were divided into five groups: Group 1: TA performed by an Orthopaedic consultant under general anaesthetic (GA) in theatre. Group 2: TA performed by an Orthopaedic consultant under local anaesthetic (LA) in theatre. Group 3: TA performed by APP under GA in theatre. Group 4: TA performed by APP under LA in theatre. Group 5: TA performed by an APP under LA in outpatient clinic. Complications recorded: revision TA, infection, neurovascular injury or need for re-casting. Mean follow up 18 months.

45 feet included. Mean Pirani score 5.5, age started casting 33 days and total number of casts 6. No significant difference in demographic details between groups. 6, 4, 20, 5 and 10 tenotomies were performed in groups 1, 2, 3, 4, and 5 respectively. Complications were 1 revision tenotomy from group 2, one from group 4 and 1 renewal of cast from 3.

This study demonstrates that TAs performed in outpatient clinic under LA by an APP is safe and feasible. No increase in complications were observed compared to TAs performed by orthopaedic consultants.

Multiligament knee injuries (MLKI) are associated with significant morbidity and healthcare requirements. The primary aim of this study is to report the patient reported outcomes measures (PROMs) after reconstructive surgery.

Patients undergoing surgery for MLKI between 2014 and 2018 in the single large-volume trauma centre were included. Electronic patient records were reviewed for demographic data, details of surgery and complications. PROMs collected were EQ-5D-5L, Lysholm Knee Score (LKS), UCLA Activity and Sport and patient satisfaction.

Thirty-five patients were included. Mean age was 31 years (range 16-66), and 71% were male. The most common mechanism of injury was sports-related (71%). Obesity was present in eight (23%) patients. No vascular injuries were recorded and four patients sustained nerve injuries. PROMs were available for 18 patients (51%) with a median follow up of 4.5 years. Median EQ-5D-5L was 0.78 (IQR 0.14). Median LKS was 84.5 (IQR 21) and there was no correlation with time to surgery (p=0.43). Grade of MLKI did not impact LKS (p=0.09). Fifteen patients (83%) saw a reduction in their activity level. All patients were satisfied with their surgical treatment. Recurrent instability was noted in four patients (11%). Three patients (8%) required further surgery (one revision reconstruction, one meniscectomy, one conversion to a hinged knee replacement.

This study demonstrates two groups of patients who sustain MLKI: the sporting population and obese patients. Health related quality of life, functional outcomes and satisfaction are high after surgery. Time to surgery did not impact on functional outcomes.

Midfoot arthrodesis is the conventional surgical intervention for midfoot arthritis. Arthrodesis aims to stabilise, realign and fuse the affected joints, providing patients with improved pain and function. Current research neglects the measurement of patient reported outcomes.

This study aimed to investigate objective, and patient reported outcomes of midfoot arthrodesis. The secondary aim was to identify variables predicting the development of non-union.

An automated search of online patient records identified 108 eligible patients (117 feet). The rates of union, re-operations, and complications were calculated using radiographs and medical records. Logistic regression was used to model variables influencing the odds of non-union. All living patients were posted a Manchester Oxford Foot Questionnaire (MOx-FQ), a patient reported outcome assessment. Pre-operative MOx-FQ results were available in a minority of cases. Students t-test was used to compare pre- and post-operative MOx-FQ scores.

The rate of union achieved was 74%. The rate of re-operations was 35%. The rate of complications was 14%. Bone grafts and staple fixation independently impacted the odds of non-union. Bone grafts decreased the odds of non-union, whilst staple fixation increased the odds. This finding agrees with the opinion of other researchers.

We recommend the use of bone grafts, and the avoidance of fixation with staples. Previous attempts have been made to assess patient outcomes. However, this study is the first to use the MOx-FQ, a validated questionnaire. Therefore, this study establishes a baseline for improvements in patient reported outcomes.

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance.

Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores.

A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37)

Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year.

The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures.

COVID 19 led to massive disruption of elective services across Scotland. This study was designed to assess the impact on elective service that the COVID-19 pandemic had, to what extent services have been restarted and the associated risks are in doing so.

This is a retrospective observational study. The primary outcomes are the number of operations completed, 30-day mortality, 30-day complication rates and nosocomial infection with COVID-19 compared to previous years. Data was collected from 4 regions across Scotland from 27th March 2020 - 26th March 2021. This was compared to the same time period the previous year.

3431 elective operations were completed in the year post-pandemic compared with 12255, demonstrating a reduction of 72%. Both groups had comparable demographics. Major joint arthroplasty saw a 72% reduction, with TKR seeing a reduction of 82%. Each of the 4 health boards were affected in a similar fashion. Nosocomial COVID-19 infection was 0.4% in the post covid group. 30 day mortality was the same at 0.1%. Total complications rose from 5.7% to 10.1% post covid.

This study shows that there has been a substantial reduction in elective activity across Scotland that is disproportionate to the level of COVID-19. The risk of developing COVID-19 from elective surgery is low at 0.4%, however all complications saw a significant rise. This is likely multifactorial. This study will inform decision makers in future pandemics, that it is safe to continue elective orthopaedic surgery and of the potential impact of cessation of services.

Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection.

Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio.

Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection.

In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings.

Revision Total Knee Arthroplasty (rTKA) is predicted to increase by more than 600% between 2005 and 2030. The survivorship of primary TKA has been extensively investigated, however more granular information on the risks of rTKA is needed. The aim of the study was to investigate the incidence of re-revision TKA, with explanatory variables of time from primary to revision, and indication (aseptic vs septic). Secondary aim was to investigate mortality.

This is an analysis of the Scottish Arthroplasty Project data set, a national audit prospectively recording data on all joint replacements performed in Scotland. The period from 2000 to 2019 was studied.

4723 patients underwent revision TKA. The relationship between time from primary to revision TKA and 2nd revision was significant (p<0.001), with increasing time lowering probability of re-revision (OR 0.99 95% CI 0.987 to 0.993). There was no significant association in time to first revision on time from 1st revision to re-revision (p>0.05). Overall mortality for all patients was 32% at 10 years (95% CI 31-34), Time from primary TKA to revision TKA had a significant effect on mortality: p=0.004 OR 1.03 (1.01-1.05). Septic revisions had a reduced mortality compared to aseptic, OR 0.95 (0.71-1.25) however this was not significant (p=0.69).

This is the first study to demonstrate time from primary TKA to revision TKA having a significant effect on probability of re-revision TKA. Furthermore the study suggests mortality is increased with increasing time from primary procedure to revision, however decreased if the indication is septic rather than aseptic.

The aim of the study was to report the survival of open reduction and internal fixation (ORIF) of Vancouver B fractures associated with the Exeter Stem (ES) at a minimum of 5 years.

This retrospective cohort study assessed 129 consecutive patients with Vancouver B type fractures treated with ORIF from 2008-2016 at a minimum of 5 years. Patient records were examined, and the following recorded: details of primary prosthesis, details of injury, Vancouver classification, details of operative management, complications, and requirement for reoperation. Data was analysed using SPSS. Survival analysis was undertaken using the endpoint ‘reoperation for any reason’.

Mean age at fracture was 78.2 (SD10.6, 46-96) and 54 (43%) were female. Vancouver subclassifications were: 24% B1, 70.5% B2 and 5.5% B3. For all Vancouver B fractures, Kaplan Meier analysis demonstrated a 5 year survival free from reoperation of 88.8% (82.0-94.7 95%CI). Fourteen patients required reoperation, most commonly within the first year for non-union and plate fracture (5.4%). Five-year survival for any reoperation differed significantly according to fracture type (p=0.016) and was worst in B1s: B1 76.6% (61.3-91.9); B2 92.6% 986.9-98.3); and 100% of B3. Univariate analysis identified B1 type (p=0.008) and a transverse fracture pattern (p=0.003) to be significantly associated with the need for reoperation.

Adopting a strategy of fixation of all Vancouver B fractures involving the ES where the fracture was anatomically reducible and the bone cement interface was well-fixed was associated with a 5 year survival, free from reoperation of 88.8%.

The UK falls behind other European countries in the early detection of Developmental Dysplasia of the hip (DDH) and there remains controversy surrounding screening strategies for early detection. Clinical detection of DDH is challenging and recognised to be dependent on examiner experience. No studies exist assessing the number of personnel currently involved in such assessments.

Our objective was to study the current screening procedure by studying a cohort of new-born babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual.

This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020. Record of each initial baby check was obtained from Maternity or Neonatal Badger. Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records.

1037 babies were examined by 65 individual examiners representing 9 different healthcare professional groups. The range of examinations conducted per examiner was 1- 97 with a mean of 15.9 examinations per person. 49% individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. Of the 5 babies (0.48%) treated for DDH, one was picked up on neonatal assessment.

In a system where so many examiners are involved in neonatal hip assessment the experience is limited for most examiners. It is unsurprising that high current rates of late presentation of DDH are observed locally, which are in accordance with published national experience.

We aim to determine the differences in lower limb joint kinematics during the golf swing of patients who had undergone Total Knee Arthroplasty (TKA) and a control group of native knee golfers.

A case-control study was undertaken with ten golfers who had undergone TKA (cruciate retaining single radius implant) and five age and matched golfers with native knees. Each golfer performed five swings with a driver whilst being recorded at 200Hz by a ten-camera motion capture system. Knee and hip three-dimensional joint angles (JA) and joint angular velocities (JAV) were calculated and statistically compared between the groups at six swing events.

The only significant differences in knee joint kinematics between TKA and control groups was a lower external rotation JA in the left knee during the backswing (p=0.010). There was no significant difference in knee JAV between the groups. Both hips demonstrated significantly (p=0.023 for left and p=0.037 for right) lower flexion in the TKA group during the takeaway swing event, and there was lower internal rotation in the backswing and greater external rotation in the downswing of the right hip. There was also slower left hip extension JAV in the downswing.

Normal knee kinematics were observed during the golf swing following TKA, with the exception of reduced external rotation in the left knee during the back swing and the right during the down swing. The differences demonstrated in the hip motion indicate that they may make compensatory movements to adjust to the reduced external rotation demonstrated in the knee.

The hip fracture burden on health and social care services in Scotland is anticipated to increase significantly, primarily driven by an ageing population. This study forecasts future hip fracture incidence and the annual number of hip fractures in Scotland until 2029.

The monthly number of patients with hip fracture aged ≥ 50 admitted to a Scottish hospital between 01/01/2017 and 31/12/2021 was identified through data collected by the Scottish Hip Fracture Audit. This data was analysed using Exponential Smoothing and Auto Regressive Integrated Moving Average forecast modelling to project future hip fracture incidence and the annual number of hip fractures until 2029. Adjustments for population change were accounted for by integrating population projections published by National Records of Scotland.

Between 2017 and 2021 the annual number of hip fractures in Scotland increased from 6675 to 7797, with a respective increase in hip fracture incidence from 313 to 350 per 100,000. By 2029, the averaged projected annual number of hip fractures is 10311, with an incidence rate of 463 per 100,000. The largest percentage increase in hip fracture occurs in the 70-79 age group (57%), with comparable increases in both sexes (30%). Based upon these projections, overall length of stay following hip fracture will increase from 142713 bed days per annum in 2021, to 203412 by 2029, incurring an additional cost of over £25 million.

Forecast modelling demonstrates that the annual number of hip fractures in Scotland will rise substantially by 2029, with considerable implications for health and social care services.

Accurate evaluation of lower limb coronal alignment is essential for effective pre-operative planning of knee arthroplasty. Weightbearing hip-knee-ankle (HKA) radiographs are considered the gold standard. Mako SmartRobotics uses CT-based navigation to provide intra-operative data on lower limb coronal alignment during robotic assisted knee arthroplasty. This study aimed to compare the correlation between the two methods in assessing coronal plane alignment.

Patients undergoing Mako partial (PKA) or total knee arthroplasty (TKA) were identified from our hospital database. The hospital PACS system was used to measure pre-operative coronal plane alignment on HKA radiographs. This data was correlated to the intraoperative deformity assessment during Mako PKA and TKA surgery.

443 consecutive Mako knee arthroplasties were performed between November 2019 and December 2021. Weightbearing HKA radiographs were done in 56% of cases. Data for intraoperative coronal plane alignment was available for 414 patients. 378 knees were aligned in varus, and 36 in valgus. Mean varus deformity was 7.46° (SD 3.89) on HKA vs 7.13° (SD 3.56) on Mako intraoperative assessment, with a moderate correlation (R= 0.50, p<0.0001). Intraoperative varus deformity of 0-4° correlated to HKA measured varus (within 3°) in 60% of cases, compared to 28% for 5-9°, 17% for 10-14°, and in no cases with >15° deformity. Mean valgus deformity was 6.44° (SD 4.68) on HKA vs 4.75° (SD 3.79) for Mako, with poor correlation (R=0.18, p=0.38).

In this series, the correlation between weightbearing HKA radiographs and intraoperative alignment assessment using Mako SmartRobotics appears to be poor, with greater deformities having poorer correlation.

The COVID-19 pandemic presented a significant impact on orthopaedic surgical operating. This multi-centre study aimed to ascertain what factors contributed to delays to theatre in patients with shoulder and elbow trauma.

A retrospective cohort study of 621 upper limb (shoulder and elbow) trauma patients between 16/03/2020 and 16/09/2021 (18-months) was extracted from trauma lists in NHS Tayside, Highland and Grampian and Picture Archiving and Communication Systems (PACS).

Median patient age =51 years (range 2-98), 298 (48%) were male and 323 (52%) female. The commonest operation was olecranon open reduction internal fixation (ORIF) 106/621 cases (17.1%), followed by distal humerus ORIF − 63/621 (10.1%). Median time to surgery was 2 days (range 0-263). 281/621 (45.2%) of patients underwent surgical intervention within 0-1 days and 555/621 patients (89.9%) had an operation within 14 days of sustaining their injury. 66/621 (10.6%) patients waited >14 days for surgery. There were 325/621 (52.3%) patients with documented evidence of delay to surgery; of these 55.6% (181/325) were due to amendable causes. 66/325 (20.3%) of these patients suffered complications; the most common being post-operative stiffness in 48.6% of cases (n=32/66).

To our knowledge, this is the first study to specifically explore effect of COVID-19 pandemic on upper limb trauma patients. We suggest delays to theatre may have contributed to higher rates of post-operative stiffness and require more physiotherapy during the rehabilitation phase. In future pandemic planning, we propose dedicated upper-limb trauma lists to prevent delays to theatre and optimise patients’ post-operative outcomes.

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the cost-effectiveness of using a Radiographic Union Score for HUmeral fractures (RUSHU)<8 to facilitate selective fixation for patients at risk of nonunion.

From 2008-2017, 215 patients (mean age 57yrs [17–81], 61% female) with a non-operatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n=165/215) after non-operative management, with 23% (n=50/215) uniting after nonunion surgery. The EuroQol Five-Dimension (EQ-5D) Health Index was obtained via postal survey. An incremental cost-effectiveness ratio (ICER) <£20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective.

At a mean of 5.4yrs (1.2–11.0), the mean EQ-5D was 0.736. Multiple regression demonstrated that uniting after nonunion surgery was independently associated with an inferior EQ-5D (beta=0.103, p=0.032). Routine fixation for all patients to reduce the nonunion rate would be associated with increased treatment costs (£1,542/patient) but confer a potential EQ-5D benefit of 0.120/patient. The ICER of routine fixation was £12,850/QALY gained. Selective fixation, based upon a RUSHU<8 at 6wks post-injury, would be associated with reduced treatment costs (£415/patient) and confer a potential EQ-5D benefit of 0.335 per ‘at-risk patient’.

Routine fixation for patients with humeral shaft fractures, to reduce the nonunion rate observed after non-operative management, appears to be cost-effective at 5yrs post-injury. Selective fixation for patients at risk of nonunion based upon the RUSHU may confer greater cost-effectiveness, given the potential savings and improvement in EQ-5D.