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).

No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Leukocyte esterase (LE) is a synovial marker that has proven utility in the diagnosis of PJI. The purpose of this prospective study was to (1) identify the optimal cutoff for the use of LE in the diagnosis of PJI and (2) determine whether performance of the LE strip test varied by infecting organism. This prospective study enrolled 1,015 patients undergoing hip or knee revision arthroplasty at a single institution from 2009 to September 2021. PJI was defined using a modified version of 2018 International Consensus Meeting (ICM) criteria that excluded LE when calculating the ICM score. Receiver operating characteristic curves were used to assess the utility of the LE strip test in the diagnosis of PJI. 973 patients were included in the analyses. 246 (25.4%) were classified as ICM-positive and 727 (74.6%) were classified as ICM-negative. An LE cutoff of “1+” (AUC 0.819, sensitivity 73.2%, specificity 90.6%) had superior accuracy to an LE cutoff of “2+” (AUC 0.713, sensitivity 43.9%, specificity 98.8%) in the overall diagnosis of PJI (p<0.001). When stratifying by organism type, an LE cutoff of “1+” had the best diagnostic utility for PJI caused by methicillin resistant Staphylococcus aureus (AUC 0.888, sensitivity 87.0%, n=23) followed by Streptococcus spp. (AUC 0.882, sensitivity 85.7%, n=28), coagulase negative Staphylococci (AUC 0.836, sensitivity 76.6%, n=47), methicillin sensitive Staphylococcus aureus (AUC 0.806, sensitivity 70.6%, n=34), culture negative (AUC 0.793, sensitivity 67.9%, n=56), and gram negative rods (AUC 0.763, sensitivity 61.9%, n=21). To our knowledge, this is the largest study evaluating the utility of the LE strip test in the diagnosis of PJI. Based on our findings, it appears that a “1+” cutoff has higher diagnostic utility than a cutoff of “2+”

Periacetabular Osteotomy (PAO) has become the most important surgical procedure for patients with hip dysplasia, offering significant pain relief and improved joint function. This study focuses on recovery after PAO, specifically the return to sports (RTS) timeline, with the objective of identifying preoperative predictors to optimize patient outcomes. Our prospective, monocentric study from 2019 to 2023 included 698 hips from 606 patients undergoing PAO. Comprehensive preoperative data were collected, including demographic information, clinical assessments (Modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHot-12), Hip Disability and Osteoarthritis Outcome Score (HOOS), UCLA Activity Score) and psychological evaluations (Brief Symptom Inventory (BSI) and SF-36 Health Survey). Advanced logistic regression and machine learning techniques (R Core Team. (2016)) were employed to develop a predictive model. Multivariate regression analysis revealed that several preoperative factors significantly influenced the RTS timeline. These included gender, invasiveness of the surgical approach, preoperative UCLA Score, preoperative sports activity level, mHHS, and various HOOS subscales (Sport/Recreation, Symptoms, Pain) as well as psychological factors (BSI and SF-36). The subsequent model, using a decision tree approach, showed that the combination of a UCLA score greater than 3 (p<0.001), non-female gender (p=0.003), preoperative sports frequency not less than twice per week (p<0.001), participation in high-impact sports preoperatively (p=0.008), and a BSI anxiety score less than 2 (p<0.001) had the highest likelihood of early RTS with a probability of 71.4% at three months. Using a decision tree approach, this model provides a nuanced prediction of RTS after PAO, highlighting the synergy of physical, psychological, and lifestyle influences. By quantifying the impact of these variables, it provides clinicians with a valuable tool for predicting individual patient recovery trajectories, aiding in tailored rehabilitation planning and predicting postoperative satisfaction

Traditional mechanical debridement can only remove visibly infected tissue and is unable to completely clear all the biofilm that hides within muscle crevices and nerves. This study aims to determine the results of single-stage revision using noncontact low frequency ultrasonic debridement in treating chronic periprosthetic joint infections (PJI). A prospective study of consecutive patients requiring single-stage revision for chronic PJI was performed since August 2021. After mechanical debridement, an 8‑mm handheld non‑contact low‑frequency ultrasound probe was used for ultrasonic debridement at a frequency of (25±5) kHz and power of 90% for 5 minutes. Each ultrasound lasted 10 seconds with 3‑seconds intervals. The probe was repeatedly sonicated among all soft tissue and bsingle interface. The distal femoral canal and the posterior capsule of the knee were fully sonicated with a special right‑angle probe. Chemical debridement was then performed to irrigation the whole operative area. Recurrence of infection, culture results and number of colonies 24 hours after ultrasonic debridement were recorded. A total of 45 patients (25 hips and 20 knees) were included and 43 of them (95.6%) were free of infection at a mean follow-up time of 29 months (24 to 33). There were no intraoperative complications related to ultrasonic debridement (neurovascular and muscle injury, poor wound healing and fat liquefaction). The culture‑positive rate of wound liquid before ultrasonic debridement was 40.0% (18/45), which significantly increased to 75.6% (34/45) after ultrasonic debridement (P=0.001). The median number of colonies 24 hours after ultrasonic debridement was 2372 CFU/ml (310 to 4340 CFU/ml), which was significantly higher than that before debridement (307 CFU/ml; 10 to 980 CFU/ml) (P=0.000). Single-stage revision with non‑contact low‑frequency ultrasonic debridement can fully expose bacteria within biofilm, increase the efficacy of chemical debridement and lead to a favorable short‑term outcome without related complications

A ceramic-on-ceramic hip resurfacing implant (cHRA) was developed and introduced in an MHRA-approved clinical investigation to provide a non metallic alternative hip resurfacing product. This study aimed to examine function and physical activity levels of patients with a cHRA implant using subjective and objective measures both before and 12 months following surgery in comparison with age and gender matched healthy controls.

Eighty-two unilateral cHRA patients consented to this study as part of a larger prospective, non-randomised, clinical investigation. In addition to their patient reported outcome measures (PROMs), self- reported measures of physical activity levels and gait analysis were undertaken both pre- operatively (1.5 weeks) and post operatively (52 weeks). This data was then compared to data from a group of 43 age gender and BMI matched group of healthy controls. Kinetics and kinematics were recorded using an instrumented treadmill and 3D Motion Capture. Statistical parametric mapping was used for analysis.

cHRA improved the median Harris Hip Score from 63 to 100, Oxford Hip score from 27 to 48 and the MET from 5.7 to 10.3. cHRA improved top walking speed (5.75km vs 7.27km/hr), achieved a more symmetrical ground reaction force profile, (Symmetry Index value: 10.6% vs 0.9%) and increased hip range of motion (ROM) (31.7° vs 45.9°). Postoperative data was not statistically distinguishable from the healthy controls in any domain.

This gait study sought to document the function of a novel ceramic hip resurfacing, using those features of gait commonly used to describe the shortcomings of hip arthroplasty. These features were captured before and 12 months following surgery. Preoperatively the gait patterns were typical for OA patients, while at 1 year postoperatively, this selected group of patients had gait patterns that were hard to distinguish from healthy controls despite an extended posterior approach. Applications for regulatory approval have been submitted.

We report the impact of implementing a new short-stay hip and knee arthroplasty pathway in a National Health Service (NHS) hospital. This was enacted due to existing concerns with a long length of stay (LOS) and reduced elective operating capacity each winter due to emergency bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimise readmission rates and generate financial savings, all combining to facilitate full elective activity during the winter. We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It includes rigorous preoperative optimisation, specific anaesthetic protocols and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, including the initial six months post implementation of the short-stay pathway. LOS data was collected for the full period and data was compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. There was an immediate and significant decrease in median LOS from 4 days pre-implementation to 1 day post-implementation. Patient satisfaction was high, and the 30-day readmission rate was unchanged (5.95%), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial cost savings due to reduced LOS and the elimination of routine post-operative blood tests, estimated at over £1.6m per year. Elective activity over winter was significantly higher (79%) than in the same time period in the previous year. An acute introduction of a carefully planned and coordinated short-stay hip and knee pathway is safe, cost-effective and popular with patients, but also contributes to increased efficiency in the delivery of elective healthcare in the context of increasing demand and financial constraints in the NHS

Background. It has become increasingly important to conduct studies assessing clinical outcomes, reoperation rates, and revision rates to better define the indications and efficacy of lumbar spinal procedures and its association with symptomatic adjacent segment degeneration (sASD). Adjacent segment degeneration (ASD) is defined as the radiographic change in the intervertebral discs adjacent to the surgically treated spinal level. SASD represents adjacent segment degeneration which causes pain or numbness due to post-operative spinal instability or nerve compression at the same level. The most common reason for early reoperation and late operation is sASD, therefore is in our best interest to understand the causes of ASD and make steps to limit the occurrence. Method. A comprehensive literature search was performed selecting Randomized controlled trials (RCTs) and retrospective or prospective studies published up to December 2023. Meta-analysis was performed on 38 studies that met the inclusion criteria and included data of clinical outcomes of patients who had degenerative disc disease, disc herniation, radiculopathy, and spondylolisthesis and underwent lumbar fusion or motion-preservation device surgery; and reported on the prevalence of ASD, sASD, reoperation rate, visual analogue score (VAS), and Oswestry disability index (ODI) improvement. Results. When compared to fusion surgery, a significant reduction of ASD, sASD and reoperation was observed in the cohort of patients that underwent motion-preserving surgery. Conclusion. Dynamic fusion constructs are treatment options that may help to prevent sASD. Conflicts of interest. This research was funded by Paradigm Spine. Sources of funding. Paradigm Spine

The August 2024 Children’s orthopaedics Roundup. 360. 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 Wrist & Hand Roundup. 360. 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 Research Roundup³⁶⁰ looks at: Effect of vitamin D deficiency on periprosthetic joint infection and complications after primary total joint replacement; Postoperative angiotensin receptor blocker use associated with decreased rates of manipulation under anaesthesia in patients undergoing total knee arthroplasty; Central sensitization: the missing link between psychological distress and poor outcome following primary total knee arthroplasty; Thromboprophylaxis for the trauma and orthopaedic surgeon; Life expectancy after treatment of metastatic bone disease: an international trend analysis.

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

Aims. Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI. Methods. A prospective longitudinal study was conducted at a level 1 trauma centre from January 2020 to December 2022. In total, 56 patients treated for FRI were enrolled. The ICD-10 symptom rating (ISR) and an expectation questionnaire were assessed at five timepoints: preoperatively, one month postoperatively, and at three, six, and 12 months. Results. Recurrent FRI cases consistently exceeded the symptom burden threshold (0.60) in ISR scores at all assessment points. The difference between preoperative-assessed total ISR scores and the 12-month follow-up was not significant in either group, with 0.04 for primary FRI (p = 0.807) and 0.01 for recurrent FRI (p = 0.768). While primary FRI patients showed decreased depression scores post surgery, recurrent FRI cases experienced an increase, reaching a peak at 12 months (1.92 vs 0.94; p < 0.001). Anxiety scores rose for both groups after surgery, notably higher in recurrent FRI cases (1.39 vs 1.02; p < 0.001). Moreover, patients with primary FRI reported lower expectations of returning to normal health at three (1.99 vs 1.11; p < 0.001) and 12 months (2.01 vs 1.33; p = 0.006). Conclusion. The findings demonstrate the significant psychological burden experienced by individuals undergoing treatment for FRI, which is more severe in recurrent FRI. Understanding the psychological dimensions of recurrent FRIs is crucial for comprehensive patient care, and underscores the importance of integrating psychological support into the treatment paradigm for such cases. Cite this article: Bone Jt Open 2024;5(7):621–627

Aims

Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice.

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures

Femoral shaft fractures are fairly common injuries in paediatric age group. The treatment protocols are clear in patients of age less than 4 years and greater than 6 years. The real dilemma lies in the age group of 4–6 years. The aim of this study is to find whether a conservative line should be followed, or a more aggressive surgical intervention can provide significantly better results in these injuries.

This study was conducted in a tertiary care hospital in Bhubaneswar, India from January 2020 to March 2021. A total of 40 patients with femur shaft fractures were included and randomly divided in two treatment groups. Group A were treated with a TENS nail while group B were treated with skin traction followed by spica cast. They were regularly followed up with clinical and radiological examination to look out for signs of healing and any complications. TENS was removed at 4–9 months’ time in all Group A patients.

Group A patients had a statistically significant less hospital stay, immobilisation period, time to full weight bearing and radiological union. Rotational malunions were significantly lower in Group A (p-value 0.0379) while there was no statistically significant difference in angular malunion in coronal and sagittal plane at final follow up. Complications unique to group A were skin necrosis and infection.

We conclude that TENS is better modality for treatment of shaft of femur fractures in patients of 4–6 years age as they significantly reduce the hospital stay, immobilization period and rotational malalignment.

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Aims. Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. Methods. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36). Results. There were no differences between the two treatment groups with regard to mean change in haemoglobin concentration (p = 0.477), length of stay (LOS, p = 0.172), mean polyethylene thickness (p = 0.065), or postoperative complication rates (p = 0.295). At the most recent follow-up, the primary robotic arm-assisted TKA group had a statistically significantly improved OKS compared with the revision UKA to TKA group (44.6 (SD 2.7) vs 42.3 (SD 2.5); p = 0.004) but there was no difference in the overall ROM (p = 0.056) or FJS between the two treatment groups (86.1 (SD 9.6) vs 84.1 (4.9); p = 0.439). Conclusion. Robotic arm-assisted revision of UKA to TKA was associated with comparable intraoperative blood loss, early postoperative rehabilitation, functional outcomes, and complications to primary robotic TKA at short-term follow-up. Robotic arm-assisted surgery offers a safe and reproducible technique for revising failed UKA to TKA. Cite this article: Bone Joint J 2024;106-B(7):680–687

Aims

This study aims to identify the top unanswered research priorities in the field of knee surgery using consensus-based methodology.

Aims. To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods. A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1). Results. We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion. A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments. Cite this article: Bone Jt Open 2024;5(6):524–531

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).