Aims. The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Methods. Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Results. Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as ‘black and minority ethnic’ (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. Conclusion. There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training. Cite this article: Bone Jt Open 2024;5(8):697–707

Aims

Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

The benefits of total hip arthroplasty (THA) may be significantly magnified in children, since the improvement in quality of life has a far greater exposure time and occurs during key developmental stages which may help to maximise lifetime achievement. The purpose of this study is to describe implant survival and patient reported outcomes (PROMS) in a cohort of children following THA. Retrospective cohort review of all patients treated with THA in a single centre. Routine data analysis did not require ethical approval. Survival was estimated using Kaplan-Meier and PROMs were recorded (EQ5D-S, Oxford hip score and modified Harris Hip Score) in a sub-group of patients. 66 hips in 47 patients with a median age of 16 years (range 10 to 19 years) underwent THA between 1971 and 2023. 57% (38/68) patients were female, the commonest indications were Mucopolysaccharidoses n = 15, Stills disease (n=15), and Avascular necrosis (n=12). 27 (41%) of constructs were cemented, 5 (8%) were hybrid, and 34 (51%) were cementless. 30 stems were custom made cementless stems. Median follow up was 3.8 years (range 0–34 years). Implant survival was 87% at 10 years, 61.6% at 20 years and 52.8% at 30 years. PROMS demonstrated mean preoperative OHS was 12, preoperative MHHS was 23 and EQ5Ds VAS of 38. PROMS improved steadily overtime with mean OHS of 43, MMHS of 75 and EQ5Ds VAS of 89 at one year. THA was associated with a very large change in patient reported hip function and quality of life. In this study, THA delivered a long-lasting solution to hip pain with survival similar to that seen in patients undergoing THA in the fourth and fifth decades of life. Socioeconomic benefits of THA need further investigation to establish treatment guidelines for children suffering with hip pain

Purpose and Background. Clinical practice guidelines (CPGs) recommend self-management for low back pain (LBP). Our recent narrative review on self-management needs revealed a consensus with respect to the critical components of self-management interventions. With mobile health advancements, apps offer innovative support for LBP management. This study aims to identify current apps for the self-management of LBP, assessing them for their quality, intervention content, theoretical approaches, and risk management approaches. Methods and Results. We identified 69 apps for LBP self-management from a systematic search in the UK iTunes and Google Play stores. The most recommended interventions are muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), and core stability exercises (n=32, 46.4%). The average MARS (SD) overall score for the included apps was 2.4 (0.44) out of a possible 5 points, with the engagement and information dimension scoring the lowest at 2.1. In terms of theoretical and risk management approaches, no apps offered a theoretical care model and all failed to specify the age group targeted; only one (1.4%) provided a tailored care approach; 18 (26.1%) included intervention progression; and 11 (15.9%) reported management safety checks. Conclusion. This study shows that app developers generally select interventions endorsed by CPGs. However, the application of a biopsychosocial care model is not being considered. Most of them are of low quality, lacking theoretical approaches to care and consideration of associated risks. It is essential to involve clinicians and patients in developing LBP self-management apps to improve the quality and related approach. Conflicts of interest. None. Sources of funding. No funding obtained. This study has been published in JMIR mHealth and uHealth

Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

Purpose and background. Although clinical guidelines recommend that low back pain (LBP) is best managed in primary or community care, in the UK and globally, LBP accounts for around 4% of emergency department (ED) attendances. Organising and delivering healthcare to be safe, effective, and acceptable requires hearing patients’ perspectives; this study therefore aimed to explore patients’ experiences of attending the ED for LBP. Methods and results. This was a multisite qualitative interview study with 47 adults (aged 23–79 years) who, in the past six weeks, had attended one of four UK NHS emergency departments for LBP (all types and durations). Purposive sampling was used to gain variation in the recruiting site, and LBP and demographic characteristics. Data were collected using individual, semi-structured, telephone interviews (median 45mins). Interviews were audio-recorded, transcribed verbatim, and analysed thematically. We identified significant variation in patients’ experiences of ED care for LBP, which we argue reflects contrasting cultures of ED care. We present three cultures, emergency screening only, ‘cynicism and neglect’, and ‘kindness’; these cultures differ in how they navigate the tension between the ED remit and patients’ perceived needs of care. We draw on Bourdieu's notions of field and habitus and professional identity theory to help explain these findings. Conclusion. Our findings suggest unwarranted variation in ED care for LBP. Implications include the need for urgent access to primary and community care and clarity about best practice managing LBP in the ED; best practice guidance and strategies to implement this should be informed by notions of culture and professional identity. No conflicts of interest.  . Sources of funding. Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Introduction. Most common osteoporotic fracture. 20-30% of patients with OVFs are presented to hospital while 2.2 million remain undiagnosed, as diagnosis is usually opportunistic. 66,000 OVFs occur annually in the UK with increase by 18,000 cases a year until 2025. 20% chance of another OVF in next 12 months and 3 times risk of hip fracture. Acute painful OVFs poorly tolerated by infirm elderly patients, leading to significant morbidity and 8 times increase in age-adjusted mortality. Materials and Methods. Classify fracture severity and patents with ovfs in 12-month period. To assess follow-up status and if kyphoplasty was offered within 6 weeks as per NICE guidelines. To introduce Royal Osteoporosis Society and GIRFT guidelines on management of symptomatic osteoporotic vertebral fractures. Results. Total no. of patients- 62. Initial pain assessment=40. Pain assessed at ≤6 weeks- 21. Duration from decision to operate to kyphoplasty 8.7 weeks. 11% had kyphoplasty of which 50% noted improvement in pain. 11 deaths. Nearly similar findings to NoSH study. Conclusion. To improve pain assessment on admission of patients with acute osteoporotic vertebral fractures. To follow GIRFT guidelines for early assessment and intervention in patients with acute osteoporotic vertebral fractures to improve pain, mobility and early discharge from hospital. Conflicts of interest. None. Sources of funding. None

Background. Clinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants. Methods. Prospective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms. Results. Over 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4). Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing. Conclusion. Interim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment. Conflicts of interest. None. Sources of funding. This study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Purpose and Background. Guidelines recommend biopsychosocial care for chronic, complex musculoskeletal conditions, including non-specific low back pain. The aims were: 1/ to assess how patients with low back pain respond to osteopathic treatment, both before and after an osteopath has completed a Biopsychosocial Pain Management (BPM) course; and 2/ to assess if it is feasible and acceptable for osteopath participants to receive weekly SCED data and use it to guide patient management. Methods and Results. A multiple baseline single case experimental design trial (. clinicaltrials.gov. , on 18/10/2021, ID number NCT05120921) with 11 UK osteopaths was conducted. Patients were randomised to early, middle or late treatment start dates. Statistical analysis assessed the change between baseline, intervention and follow-up periods. Primary outcomes were the Numeric Pain Rating (NPR) and Patient Specific Function Scales (PSFS), measured during the baseline, the 6-week intervention, and during a 12-week follow-up period. At baseline, the osteopaths reported stronger biopsychosocial attitudes to pain, compared to biomedical beliefs (PABS: 34 behavioural scale; 29 biomedical scale). Overall, patient participants showed daily increases in symptoms during the pre-treatment phase (+0.24/day, p<0.001), and daily decreases during treatment (−2.94 over the treatment phase, p<0.001), which continued post-treatment (−3.36 over 12 weeks, p=0.04). Similar improvements were observed for function. Conclusion. Osteopathic care was shown to help patients with persistent low back pain. Patient recruitment was challenging because of the randomisation. With further development, the method shows feasibility as a means of enhancing research activity among practising clinicians. Previous presentations or publications of the work. The protocol was published (. https://doi.org/10.1016/j.ijosm.2023.100660. ) and presented at SBPR in 2022. The results were presented to an osteopathic conference in October 2023. Ethics approval was received from the University College of Osteopathy Research Ethics Committee. Conflicts of interests. Jerry Draper-Rodi receives fees from the sales of the e-learning course on the biopsychosocial management on the UCO CPD platform. Sources of funding. The research was funded by the Osteopathic Foundation

Aims. The aim of this study was to perform a systematic review and bias evaluation of the current literature to create an overview of risk factors for re-revision following revision total knee arthroplasty (rTKA). Methods. A systematic search of MEDLINE and Embase was completed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The studies were required to include a population of index rTKAs. Primary or secondary outcomes had to be re-revision. The association between preoperative factors and the effect on the risk for re-revision was also required to be reported by the studies. Results. The search yielded 4,847 studies, of which 15 were included. A majority of the studies were retrospective cohorts or registry studies. In total, 26 significant risk factors for re-revision were identified. Of these, the following risk factors were consistent across multiple studies: age at the time of index revision, male sex, index revision being partial revision, and index revision due to infection. Modifiable risk factors were opioid use, BMI > 40 kg/m. 2. , and anaemia. History of one-stage revision due to infection was associated with the highest risk of re-revision. Conclusion. Overall, 26 risk factors have been associated with an increased risk of re-revision following rTKA. However, various levels of methodological bias were found in the studies. Future studies should ensure valid comparisons by including patients with identical indications and using clear definitions for accurate assessments. Cite this article: Bone Jt Open 2024;5(8):644–651

Purpose and background. Low back pain burdens individuals, society and services, including Emergency Departments (ED), straining services and prolonging wait times. Despite reported personal influences on deciding to attend ED, the role of third-party advice remains underexplored. Sparse guidance for clinicians and service-users highlights the need for effective back pain management strategies, to alleviate system pressure and optimise patient outcomes. This study explored how advice influences the decision to attend the ED for back pain. Methods and Results. From a subtle realist stance, the design was a secondary analysis of qualitative data, where 47 patients (26M:21F, aged 23–79 years) with back pain were purposively sampled from four EDs (2 Northern and 2 Southern) in England between August and December 2021. Eight patients had previously visited ED for this episode of back pain. As this was during the pandemic, semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed using a reflective thematic analysis. Three themes were identified as crucial in making the decision to attend ED: The Healthcare professional; Trusted others; and the Individual. Healthcare professionals often dictated decisions, leaving participants feeling powerless. Trusted others provided varying support levels, often acting as allies. Individuals grappled with anxieties around their condition and treatment expectations. Conclusion. This study highlights the need for clinicians to provide clarity and guidance to individuals and their Trusted others, seeking advice regarding escalation to visit the ED with back pain. There was evidence that worrying about pain was a significant motivator for attending ED, resulting in malalignment with current practice guidelines. No conflicts of interest.  . Sources of funding. Funding for primary data: Health Education England & National Institute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

The August 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Comparing augmented and nonaugmented locking-plate fixation for proximal humeral fractures in the elderly; Elevated five-year mortality following shoulder arthroplasty for fracture; Total intravenous anaesthesia with propofol reduces discharge times compared with inhaled general anaesthesia in shoulder arthroscopy: a randomized controlled trial; The influence of obesity on outcomes following arthroscopic rotator cuff repair; Humeral component version has no effect on outcomes following reverse total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial; What is a meaningful improvement after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex?; The safety of corticosteroid injection prior to shoulder arthroplasty: a systematic review; Mortality and subsequent fractures of patients with olecranon fractures compared to other upper limb osteoporotic fractures.

The August 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Antibiotic prophylaxis and infection rates in paediatric supracondylar humerus fractures; Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK; Health-related quality of life in idiopathic toe walkers: a multicentre prospective cross-sectional study; Children with spinal dysraphism: a systematic review of reported outcomes; No delay in age of crawling, standing, or walking with Pavlik harness treatment: a prospective cohort study; No value found with routine early postoperative radiographs after implant removal in paediatric patients; What do we know about the natural history of spastic hip dysplasia and pain in total-involvement cerebral palsy?; Evaluating the efficacy and safety of preoperative gallows traction for hip open reduction in infants

The August 2024 Trauma Roundup³⁶⁰ looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.

The August 2024 Wrist & Hand Roundup³⁶⁰ looks at: Methotrexate shows potential in reducing pain for hand osteoarthritis with synovitis; Circumferential casting versus plaster splinting in adult distal radius fractures: the CAST study findings; Surgery shows superior long-term success for Dupuytren contracture compared to needle fasciotomy and collagenase injection; Evolving trends in surgical management of wrist arthritis: a decade-long national analysis; Mid-term outcomes of three commonly used surgical reconstructions for scapholunate instability; SLAC and SNAC: what is the evidence for treatment?; Steroids for trapeziometacarpal osteoarthritis?; When is it safe to return to driving after distal radius fracture fixation? A prospective study.

The August 2024 Knee Roundup³⁶⁰ looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford.

Aims

The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery.

Aims. Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient’s functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA. Methods. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Eligible studies of THA patients that conducted at least one type of objective functional assessment both pre- and postoperatively were identified through Embase, Medline/PubMed, and Cochrane Central database-searching from inception to 15 September 2023. The assessments included were subgrouped for analysis: gait analysis, motion analysis, wearables, and strength tests. Results. A total of 130 studies using 15 distinct objective functional assessment methods (FAMs) were identified. The most frequently used method was instrumented gait/motion analysis, followed by the Timed-Up-and-Go test (TUG), 6 minute walk test, timed stair climbing test, and various strength tests. These assessments were characterized by their diagnostic precision and applicability to daily activities. Wearables were frequently used, offering cost-effectiveness and remote monitoring benefits. However, their accuracy and potential discomfort for patients must be considered. Conclusion. The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. Gait analysis and the TUG, along with advancing wearable sensor technology, have the potential to enhance patient care, surgical planning, and rehabilitation. Cite this article: Bone Joint J 2024;106-B(8):764–774

Aims

The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.