Aim

The β-lactam penicillin is often used in the treatment of soft tissue infections and osteomyelitis caused by penicillin susceptible Staphylococcus aureus. Oral antibiotic treatment has been shown to be non-inferior to intravenous (IV) therapy when used during the first 6 weeks in complex orthopedic infections (OVIVA trial). However, the use of oral β-lactams in osteomyelitis treatment remains a topic of debate due to low and variable bioavailability. The aim was to assess the time for which the unbound penicillin concentration exceeded targeted minimum inhibitory concentrations (fT>MIC) in cancellous bone and subcutaneous tissue after IV (penicillin G) and oral (penicillin V) treatment in a porcine microdialysis model.

Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget.

In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears.

In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model.

Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits.

The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects.

Staphylococcus aureus is the most frequently isolated organism in periprosthetic joint infections. The mechanism by which synovial fluid (SF) kills bacteria has not yet been elucidated, and a better understanding of its antibacterial characteristics is needed. We sought to analyze the antimicrobial properties of exogenous copper in human SF against S. aureus.

SF samples were collected from patients undergoing total elective knee or hip arthroplasty. Different S. aureus strains previously found to be sensitive and resistant, UAMS-1 and USA300 WT, respectively, were used. We performed in-vitro growth and viability assays to determine the capability of S. aureus to survive in SF with the addition of 10µM of copper. We determined the minimum bactericidal concentration of copper (MBC-Cu) and evaluated the sensitivity to killing, comparing WT and CopAZB-deficient USA300 strains.

UAMS-1 evidenced a greater sensitivity to SF when compared to USA300 WT, at 12 (p=0.001) and 24 hours (p=0.027). UAMS-1 significantly died at 24 hours (p=0.017), and USA300 WT survived at 24 hours. UAMS-1 was more susceptible to the addition of copper at 4 (p=0.001), 12 (p=0.005) and 24-hours (p=0.006). We confirmed a high sensitivity to killing with the addition of exogenous copper on both strains at 4 (p=0.011), 12 (p=0.011), and 24 hours (p=0.011). Both WT and CopAZB-deficient USA300 strains significantly died in SF, evidencing a MBC-Cu of 50µM against USA300 WT (p=0.011).

SF has antimicrobial properties against S. aureus, and UAMS-1 was more sensitive than USA300 WT. The addition of 10µM of copper was highly toxic for both strains, confirming its bactericidal effect. We evidenced CopAZB-proteins involvement in copper effluxion by demonstrating the high sensitivity of the mutant strain to lower copper concentrations. Thus, we propose CopAZB-proteins as potential targets and the use of exogenous copper as possible treatment alternatives against S. aureus.

Over half of postpartum women experience pelvic ring or hip pain, with multiple anatomic locations involved. The sacroiliac joints, pubic symphysis, lumbar spine and pelvic girdle are all well documented pain generators. However, despite the prevalence of postpartum hip pain, there is a paucity of literature regarding underlying soft tissue intra-articular etiologies. The purpose of this systematic review is to document and assess the available evidence regarding underlying intra-articular soft tissue etiologies of peri- and postpartum hip pain.

Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until April 11, 2021. The inclusion criteria were English language studies, human studies, and those regarding symptomatic labral pathology in the peri- or postpartum period. Exclusion criteria were animal studies, commentaries, book chapters, review articles and technical studies. All titles, relevant abstracts and full-text articles were screened by two reviewers independently. Descriptive characteristics including the study design, sample size, sex ratio, mean age, clinical and radiographic findings, pathology, subsequent management and outcomes were documented. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument.

The initial search identified 2472 studies. A systemic screening and assessment of eligibility identified 5 articles that satisfied the inclusion criteria. Twenty-two females were included. Twenty patients presented with labral pathology that necessitated hip arthroscopy with labral debridement or repair with or without acetabuloplasty and/or femoroplasty. One patient presented with an incidental labral tear in the context of osteitis condensans illi. One patient presented with post-traumatic osteoarthritis necessitating a hip replacement. The mean MINORS score of these 5 non-comparative studies was 2.8 (range 0-7) demonstrating a very low quality of evidence.

The contribution of intra-articular soft tissue injury is a documented, albeit sparse, etiology contributing to peri- and postpartum hip pain. Further research to better delineate the prevalence, mechanism of injury, natural history and management options for women suffering from these pathologies at an already challenging time is necessary to advance the care of these patients.

Ligament reconstruction following multi-ligamentous knee injuries involves graft fixation in bone tunnels using interference screws (IS) or cortical suspensory systems. Risks of IS fixation include graft laceration, cortical fractures, prominent hardware, and inability to adjust tensioning once secured. Closed loop suspensory (CLS) fixation offers an alternative with fewer graft failures and improved graft-to-tunnel incorporation. However, graft tensioning cannot be modified to accommodate errors in tunnel length evaluation. Adjustable loop suspensory (ALS) devices (i.e., Smith & Nephew Ultrabutton) address these concerns and also offer the ability to sequentially tighten each graft, as needed. However, ALS devices may lead to increased graft displacement compared to CLS devices. Therefore, this study aims to report outcomes in a large clinical cohort of patients using both IS and CLS fixation.

A retrospective review of radiographic, clinical, and patient-reported outcomes following ligament reconstruction from a Level 1 trauma centre was completed. Eligible patients were identified via electronic medical records using ICD-10 codes. Inclusion criteria were patients 18 years or older undergoing ACL, PCL, MCL, and/or LCL reconstruction between January 2018 and 2020 using IS and/or CLS fixation, with a minimum of six-month post-operative follow-up. Exclusion criteria were follow-up less than six months, incomplete radiographic imaging, and age less than 18 years. Knee dislocations (KD) were classified using the Schenck Classification. The primary outcome measure was implant removal rate. Secondary outcomes were revision surgery rate, deep infection rate, radiographic fixation failure rate, radiographic malposition, Lysholm and Tegner scores, clinical graft failure, and radiographic graft failure. Radiographic malposition was defined as implants over 5 mm off bone or intraosseous deployment of the suspensory fixation device. Clinical graft failure was defined as a grade II or greater Lachman, posterior drawer, varus opening at 20° of knee flexion, and/or valgus opening at 20° of knee flexion. Radiographic failure was defined when over 5 mm, 3.2 mm, and/or 2.7 mm of side-to-side difference occurred using PCL gravity stress views, valgus stress views, and/or varus stress views, respectively. Descriptive statistics were used.

Sixty-three consecutive patients (mean age = 41 years, range = 19-58) were included. A total of 266 CLS fixation with Ultrabuttons and 135 IS were used. Mean follow-up duration was 383 days. Most injuries were KD type II and III. Graft revision surgery rate was 1.5%. Intraosseous deployment occurred in 6.2% and 17% had implants secured in soft tissue, rather than on bone. However, the implant removal rate was only 6.2%. Radiographic PCL gravity stress views demonstrated an average of 1.2 mm of side-to-side difference with 6.2% meeting criteria for radiographic failure. A single patient met radiographic failure criteria for collateral grafts. Mean Lysholm and Tegner scores were 87.3 and 4.4, respectively, with follow-up beyond one year.

Both IS and CLS fixation demonstrate an extremely low revision surgery rate, a high rate of implant retention, excellent radiographic stability, and satisfactory patient-reported outcome scores.

Incorrect implant deployment was seen in a total of 17% of patients, yet none required implant removal. A single patient required graft revision due to implant failure.

Aim

Local antibiotic treatment for bone and joint infections offers direct delivery of high concentrations of antibiotics with reduced systemic exposure and favourable safety profile. However, the possibility of prolonged release of antibiotics at sub-therapeutic levels creates concern about the possible development of antimicrobial resistance.

We investigated patients with recurrent bone and joint infection for evidence of antimicrobial resistance emerging from the use of local antibiotics.

Aim

One of the most severe complications of primary total knee arthroplasty (TKA) is periprosthetic joint infection (PJI). Nowadays, the use of antibiotic-loaded cement for prevention of infection is still controversial. The aim of the present study is to evaluate the use of an antibiotic-loaded cement to reduce the infection rate in primary total knee arthroplasty.

Abstract

Aim

The aim of this study is to evaluate if the gentamycin elution from bone cement is influenced by the timing of application of the antibiotic powder.

The trapeziometacarpal joint (TMCJ) is the most common hand joint affected by osteoarthritis (OA), and trapezium implant arthroplasty is a potential treatment for recalcitrant OA. This meta-analysis aimed to investigate the efficacy and safety of various trapezium implants as an interventional option for TMCJ OA. Web of Science, PubMed, Scopus, Google Scholar, and Cochrane library databases were searched for relevant studies up to May 2022. Preferred Reported Items for Systematic Review and Meta-Analysis guidelines were adhered to and registered on PROSPERO. The methodological quality was assessed by National Heart, Lung, and Blood Institute tools for observational studies and the Cochrane risk of bias tool. Subgroup analyses were performed on different replacement implants, the analysis was done via Open Meta-Analyst software and P values < 0.05 were considered statistically significant.

A total of 123 studies comprising 5752 patients were included. Total joint replacement (TJR) implants demonstrate greater significant improvements in visual analogue scale pain scores postoperatively. Interposition with partial trapezial resection implants was associated with the highest grip strength and highest reduction in the Disabilities of the Arm, Shoulder, and Hand score. Revision rates were highest in TJR (12.3%), and lowest in interposition with partial trapezial resection (6.2%).

Total joint replacement and interposition with partial trapezial resection implants improve pain, grip strength, and DASH scores more than other implant options. Future studies should focus on high-quality randomized clinical trials comparing different implants to accumulate higher quality evidence and more reliable conclusions.

Aim

Osteomyelitis (OM) is a debilitating infection of the bone that originates from hematogenous spreading of microbes or contamination after surgery/fracture. OM is mainly caused by the opportunistic bacterium Staphylococcus aureus (SA), which can evade the host immune response, acquire antibiotic resistance and chronically colonize the musculoskeletal tissue ^1,2, yet the underlying molecular and cellular processes are largely unclear. This study aimed to characterize the pathogenetic mechanisms of SA-OM with a focus on the long pentraxin 3 (PTX3), a soluble pattern recognition molecule and bone tissue component that is emerging as a new player in osteoimmunology ³ and a diagnostic marker of periprosthetic joint infections, a common form of OM⁴.

Current recommendations advocate for surgery within 48 hours from time of injury as a keystone in care for elderly patients with hip fractures. A spare population density within regional Australia provides physical challenges to meet time critical care parameters. This study aims to review the impact of delays to timely surgery for elderly hip fracture patients within a regional Australian population.

A retrospective, comparative analysis was undertaken of 140 consecutive hip fracture patients managed at a single rural referral hospital, from June 2020 until June 2021. Factors such as age, time to transfer, time to surgery, 30-day complication and 6-month complication rates were collected. Statistical analysis was performed where applicable.

Mean time to surgery was 33.9 hours. A greater proportion of patients whom directly presented underwent surgery within the recommended 48 hours (91.5% vs 75.3%). The statistically significant delay in time to surgery was found to be 6.4 hours. Lower 180-day morbidity and mortality rates were observed in patients undergoing surgery within 48 hours (13.8% vs 36%), This is in comparison to the overall mortality rate of 19.2%.

Delay to surgery for elderly hip fracture patients was associated with an increase 30-day and 180-day morbidity and mortality rate. A greater proportion of patients transferred from peripheral hospitals experienced a delay in surgery. Early transfer and prioritization of such patients is recommended to achieve comparative outcomes for rural and remote Australians.

Polyimide (MP-1, MMATech, Haifa, Israel), is a high performance aerospace thermoplastic used for its lubricity, stability, inertness and radiation resistance. A wear resistant thin robust bearing is needed for total hip arthroplasty (THR).

After independent laboratory testing, in 2006, the author used the material as a bearing in two Reflection (Smith and Nephew, USA) hip surgeries. The first, a revision for polyethylene wear, survives with no evidence of wear, noise, new osteolysis or complications related to the MP-1 bearing after 16 yrs. The second donated his asymptomatic MP-1 hip at 6.5yrs for post-mortem examination. There were no osteoclasts, cellular reaction bland in contrast to that of polyethylene.

In 2013 a clinical study with ethical committee approval was started using a Biolox Delta (Ceramtec, Germany) head against a polyimide liner in 97 patients. MMATech sold all liners, irradiated: steam 52:45. Sixteen were re-machined in New Zealand. Acetabular shells were Delta PF (LIMA, Italy). The liner locked by taper.

The cohort consisted of 46:51 M:F, and ages 43 to 85, mean 65. Ten received cemented stems. For contralateral surgery, a ceramic or polyethylene liner was used. Initial patients were lower demand, later, more active patients, mountain-biking and running.

All patients have on-going follow up, including MP-1 liner revision cases. There has been no measurable wear, or osteolysis around the acetabular components using weight-bearing radiographs. Squeaking within the first 6 weeks was noted in 39 number of cases and subtle increase in palpable friction, (passive rotation at 50 degrees flexion), but then disappeared. There were 6 revisions, four of which were related to cementless Stemsys implants (Evolutis, Italy) fixed distally with proximal linear lucencies in Gruen zones 1 and 7, and 2 and 6. No shells were revised and MP-1 liners were routinely changed to ceramic or polyethylene. The liners showed no head contact at the apex, with highly polished contact areas.

There were no deep or superficial infections, but one traumatic anterior dislocation at 7 years associated with 5 mm subsidence of a non-collared stem.

The initial squeaking and increased friction was due to the engineering of the liner / shell composite as implanted, not allowing adequate clearance for fluid film lubrication and contributed to by shell distortion during impaction. The revised bearings were “equatorial” rather than polar, and with lack of wear or creep this never fully resolved. Where the clearance was better, function was normal. The “slow” utilization was due to my ongoing concern with clearances not being correct. The revision of 4 Stemsys stems, tribology issues may have contributed, but non “MP-1” / Stemsys combinations outside this study have shown the same response, thought to be due to de-bonding of the hydroxyapatite coating.

With correct engineering and clearances, a 3.6 mm thick MP-1 bearing, a surface Ra<0.5, steam sterilized, shows no appreciable wear, and with confidence, can be used as a high performance THR bearing.

Osteoarthritis (OA) is a disease of the synovial joint with synovial inflammation, capsular contracture, articular cartilage degradation, subchondral sclerosis and osteophyte formation contributing to pain and disability. Transcriptomic datasets have identified genetic loci in hip and knee OA demonstrating joint specificity. A limited number of studies have directly investigated transcriptional changes in shoulder OA. Further, gene expression patterns of periarticular tissues in OA have not been thoroughly investigated. This prospective case control series details transcriptomic expression of shoulder OA by analysing periarticular tissues in patients undergoing shoulder replacement for OA as correlated with a validated patient reported outcome measure of shoulder function, an increasing (clinically worsening) QuickDASH score. We then compared transcriptomic expression profiles in capsular tissue biopsies from the OA group (N=6) as compared to patients undergoing shoulder stabilisation for recurrent instability (the control group, N=26). Results indicated that top ranked genes associated with increasing QuickDASH score across all tissues involved inflammation and response to stress, namely interleukins, chemokines, complement components, nuclear response factors and immediate early response genes. Some of these genes were upregulated, and some downregulated, suggestive of a state of flux between inflammatory and anti-inflammatory signalling pathways. We have also described gene expression pathways in shoulder OA not previously identified in hip and knee OA, as well as novel genes involved in shoulder OA.

Aim

The use of medical devices has grown significantly over the last decades, and has become a major part of modern medicine and our daily life. Infection of implanted medical devices (biomaterials), like titanium orthopaedic implants, can have disastrous consequences, including removal of the device. For still not well understood reasons, the presence of a foreign body strongly increases susceptibility to infection. These so-called biomaterial-associated infections (BAI) are mainly caused by Staphylococcus aureus and Staphylococcus epidermidis. Formation of biofilms on the biomaterial surface is generally considered the main reason for these persistent infections, although bacteria may also enter the surrounding tissue and become internalized within host cells. To prevent biofilm formation using a non-antibiotic based strategy, we aimed to develop a novel permanently fixed antimicrobial coating for titanium devices based on stable immobilized quaternary ammonium compounds (QACs).

Ideberg-Goss type VI/AO F2(4) glenoid fossa fractures are a rare and complex injury. Although some advocate non-operative management, grossly displaced glenoid fossa fractures in the young patient may warrant fixation. Current approaches still describe difficulty with access of the entirety of the glenoid, particularly the postero-superior quadrant.

We present 2 cases of Ideberg-Goss type VI/AO F2(4) glenoid fossa fractures treated with fixation through a novel “Deltoid Takedown” approach, which allows safe access to the whole glenoid with satisfactory clinical results at 5 and 7 years respectively.

Introduction

Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures

Deep infection is a devastating complication of total knee arthroplasty (TKA). This study aimed to determine if there was a relationship between surgeon volume and the incidence of revision for infection after primary TKA.

Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1 September 1999 to 31 December 2020 for primary TKA for osteoarthritis that were revised for infection. Surgeon volume was defined by the number of primary TKA procedures performed by the surgeon in the year the primary TKA was performed and grouped as <25, 25-49, 50-74, 75-99, >100 primary TKA procedures per year. Kaplan Meir estimates for cumulative percent revision (CPR) and Cox Proportional Hazard Ratios were performed to compare rates of revision for infection by surgeon volume, with sub-analyses for patella and polyethylene use, age <65 years and male gender.

5295 of 602,919 primary TKA for osteoarthritis were revised for infection. High volume surgeons (>100 TKA/year) had a significantly lower rate of revision for infection with a CPR at 1 and 17 years of 0.4% (95% CI 0.3, 0.4) and 1.5% (95% CI 1.2, 2.0), respectively, compared with 0.6% (95% CI 0.5, 0.7) and 2.1% (95% CI 1.8, 2.3), respectively, for low volume surgeons (<25 TKR/year). Differences between the high-volume group and the remaining groups remained when sub-analysis for age, gender, ASA, BMI, patella resurfacing and the use of cross-linked polyethylene (XLPE).

High volume surgeons have lower rates of revision for infection in primary TKA.

We compared the rate of revision of two classes of primary anatomic shoulder arthroplasty, stemmed (aTSA) and stemless (sTSA) undertaken with cemented all polyethylene glenoid components.

A large national arthroplasty registry identified two cohort groups for comparison, aTSA and sTSA between 1^st January 2011 and 31^st December 2020. A sub-analysis from 1 January 2017 captured additional patient demographics. The cumulative percentage revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender.

Of the 7,533 aTSA procedures, the CPR at 8 years was 5.3% and for 2,567 sTSA procedures was 4.0%. There was no difference in the risk of revision between study groups (p=0.128).

There was an increased risk of revision for aTSA and sTSA undertaken with humeral head sizes <44mm (p=0.006 and p=0.002 respectively). Low mean surgeon volume (MSV) (<10 cases per annum) was a revision risk for aTSA (p=0.033) but not sTSA (p=0.926).

For primary diagnosis osteoarthritis since 2017, low MSV was associated with an increased revision risk for aTSA vs sTSA in the first year (p=0.048). Conversely, low MSV was associated with a decreased revision risk for sTSA in the first 6 months (p<0.001). Predominantly aTSA was revised for loosening (28.8%) and sTSA for instability/dislocation (40.6%).

Revision risk of aTSA and sTSA was associated with humeral head size and mean surgeon volume but not patient characteristics. Inexperienced shoulder arthroplasty surgeons experience lower early revision rates with sTSA in the setting of osteoarthritis. Revision of aTSA and sTSA occurred for differing reasons.

Background

The identification of novel biomarker which is highly specific and sensitive for periprosthetic joint (PJI) have the potential to improve diagnostic accuracy and ultimately improve patient outcomes. Thus, the aim of this systemic review is to identify and evaluate novel biomarkers for the preoperative diagnostics of PJI.

Introduction

Osteomyelitis is a challenge in diagnosis and treatment. 18F-FDG PET-CT provides a non-invasive tool for diagnosing and localizing osteomyelitis with a sensitivity reaching 94% and specificity reaching 100%. We aimed to assess the agreement in identifying the geographic area of infected bone and planned resection on plain X-ray versus 18F-FDG PET-CT.

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes.

Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection.

The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window.

Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure.

On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig).

This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry.

Classification systems for tibial plateau fractures suffer from poor interobserver agreement, and their value in preoperative assessment to guide surgical fixation strategies is limited. For tibial plateau fractures four major characteristics are identified: lateral split fragment, posteromedial fragment, anterior tubercle fragment, and central zone of comminution. These fracture characteristics support preoperative assessment of fractures and guide surgical decision-making as each specific component requires a respective fixation strategy. We aimed to evaluate the additional value of 3D-printed models for the identification of tibial plateau fracture characteristics in terms of the interobserver agreement on different fracture characteristics.

Preoperative images of 40 patients were randomly selected. Nine trauma surgeons, eight senior and eight junior registrars indicated the presence or absence of four fracture characteristics with and without 3D-printed models. The Fleiss kappa was used to determine interobserver agreement for fracture classification and for interpretation, the Landis and Koch criteria were used.

3D-printed models lead to a categorical improvement in interobserver agreement for three of four fracture characteristics: lateral split (Kconv = 0.445 versus K3Dprint = 0.620; P < 0.001), anterior tubercle fragment (Kconv = 0.288 versus K3Dprint = 0.449; P < 0.001) and zone of comminution (Kconv = 0.535 versus K3Dprint = 0.652; P < 0.001).

The overall interobserver agreement improved for three of four fracture characteristics after the addition of 3D printed models. For two fracture characteristics, lateral split and zone of comminution, a substantial interobserver agreement was achieved.

Fracture characteristics seem to be a more reliable way to assess tibial plateau fractures and one should consider including these in the preoperative assessment of tibial plateau fractures compared to the commonly used classification systems.

Aim

Prosthetic joint infection (PJI) represents the second most frequent complication of total joint arthroplasty (TJA) with up to 20% of low-grade PJI treated as aseptic failure. Sensitive diagnostic criteria have been provided by EBJIS. However, to date there is no single test to reliably diagnose all PJIs. Studies of Mazzucco et al. and Fu et al. suggest that synovial fluid (SF) viscosity could be considered as an important marker for PJI. The primary aim of our study was to determine if SF viscosity is a more reliable diagnostic criterion of PJI than the SF cell count with differential (CCD), and the combined diagnostic value of SF viscosity and CCD.

To identify the demographics, mechanisms of injury and treatment modalities of patients presenting at CHBAH with calcaneal fractures.

A retrospective study of all admitted patients with calcaneal fractures from 01 January 2018 to 31 December 2022. The data collected includes age, gender, side of injury, mechanism of injury, isolated injury versus polytrauma, open and close fractures, different treatment modalities and time to surgery. The descriptive data will be analysed, with results presented as frequency charts, histograms, and percentages.

A total of 98 patients showed a male predominance of 90.8% compared to 9.2% of females. The median age was 38 years, the commonest mechanism was from falls from height, accounting for 67.3% with gunshot injuries accounting for 5%. Bilateral fractures were observed in 5 patients, with similar total numbers between those isolated to the left (47) as compared to the injuries isolated to the right side (46). Calcaneus fractures associated with other injuries in polytrauma cases were observed in 17.4%, and open fractures were observed in 7 patients with 5 having occurred post gunshot injury.

A total of 48 patient required surgical treatment with the average time to surgery found to be 15 days. The surgical management varied, with open reduction and internal fixation with plate and screws in 68.7%, followed by 16.7% of patients who were treated with open reduction and internal screw fixation.

Calcaneal fractures occurred frequently amongst male patients secondary to fall from height. Half of the total patient number admitted had require a surgical intervention to treat the fracture, with open reduction and internal fixation with plate and screws being the frequent mode of fixation in this population group.

Gram-negative organisms are increasingly seen as causative pathogens in orthopaedic fracture surgery, which might necessitate a change in antibiotic prophylaxis protocols.

A single-centre retrospective review of antibiogram results from all patients treated for fracture-related infection (FRI) was conducted. Subgroup analysis was undertaken to identify any host, injury or treatment variables predisposed to Gram-negative infection.

The bacteriological results of 267 patients who underwent surgical treatment for FRI were analysed. Pathogens were isolated in 216 cases (81%), of which 118 (55%) were Gram-negative infections. Fractures involving the tibia and femur (p=0.007), the presence of soft tissue defect (p=0.003) and bone defects (p=0.001) were associated with an increased risk of developing a Gram- negative FRI.

Gram-negative fracture-related infections were associated with injuries experiencing bone loss and those requiring soft tissue reconstruction. It is, therefore, prudent to consider extended Gram-negative directed antimicrobial prophylaxis in these cases to prevent the development of fracture-related infection

Aim

Dalbavancin is a lipoglycopeptide with a half-life of 14 days (range 6.1 to 18.4), significantly longer than other antimicrobials, which avoids the need for daily antibiotic dosing. This multi-centre observational study aims to describe the use of dalbavancin to facilitate discharge in treating bone and joint infections.

Fracture related infection, in particular chronic osteomyelitis, requires complex management plans. Meta analyses and systematic reviews have not found a gold standard of treatment for this disease. In 2017 an alternative treatment protocol was undertaken in our institution; whereby staged surgery with the use of cheaply manufactured tailored antibiotic cement rods was used in the treatment of chronic osteomyelitis, secondary to traumatic long bone fractures. Short term outcomes for this protocol demonstrated a 75.7% microbiological resolution to a negative culture and a good clinical outcome of 84.2% overall was demonstrated in terms of sinus resolution, skin changes, pain and function. Our aim now was to assess the long term outcomes of this treatment strategy.

A cross-sectional study of patients who had previously undergone the set treatment protocol was performed. Patient satisfaction, effects on activities of daily living, return to work and clinical improvement at 5 years following the intervention were assessed using a patient questionnaire and the validated AAOS lower limb score.

The average AAOS lower limb score was 88 which was en par to other similar studies. 80% of patients had returned to some form of work. Ongoing mild pain was a persistent problem for 50% of the patients however 98% of the patients were overall satisfied with the treatment satisfaction at 5 years. Only 1 patient required further treatment. 8 patients could not be located for follow up.

Chronic osteomyelitis remains a complex disease to treat. This treatment protocol demonstrates favourable microbiological, serological and clinical short term outcomes and favourable patient satisfaction and functional long term outcomes at 5 years. Our study highlights antibiotic targeted cement rods as a feasible treatment option in managing chronic osteomyelitis.

Introduction

Adjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS).

Aim

The aim of this systematic review was to assess the existing published data on tuberculous arthritis involving native joints in adults aged 18 years and older. The specific research questions focused on the diagnosis and management of the disease.

Arthroscopic hip surgery is increasingly common in Australia. Hip arthroscopy is indicated for a range of diagnostic and therapeutic purposes, including labral tears, capsular laxity and femoral-acetabular impingement (FAI). Despite this, previous cohort studies aiming to characterise hip pathology seen on arthroscopic examination are mostly limited to patients with known diagnoses of FAI. Therefore, little is known of the native articular wear patterns encountered in other disease states. Therefore, we aimed to define common osteochondral wear patterns for a cohort of patients managed via hip arthroscopy.

We retrospectively analysed intraoperative data for 1127 patients managed via hip arthroscopy between 2008 and 2013, for either therapeutic or diagnostic purposes. Intraoperative data was categorized by location (A-E as defined by Fontana et al. 2016) and chondral damage (0-4 scale as defined by Beck et al. 2005) with respect to both acetabulum and femoral head.

Data for 1127 patients were included. Location of acetabular chondral pathology was variable with locations C₁ and D₁ representing the most common regions of damage. Labral tears predominated in locations C and D. Femoral chondral pathology was evenly distributed. The degree of femoral chondral injury was predominantly grade 1, whilst acetabular wear was evenly distributed.

Large proportions of wear were observed at the peripheral superior and anterior regions of the lunate surface of the acetabulum in keeping with prior works. However, we observed higher rates of central wear and lower rates of grade 4 acetabular damage extending into superior/posterior zones, in our cohort.

Our work characterises common articular wear patterns encountered at the time of hip arthroscopy. Further inquiry into the natural history of osteochondral lesions is needed to better understand and manage these conditions.

Introduction

The FitBone lengthening nail (Orthofix UK) is an intramedullary device licensed for the lengthening of long bones in adults in the UK. It contains a motor powered by electricity transmitted via an induction coil placed underneath the skin. It was developed in Germany two decades ago but uptake in the UK has only started more recently. The aim of this study was to review the first cohort of FitBone lengthening nails in a unit with significant experience of other lengthening nails (including PRECICE and Stryde).

The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures.

The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The nutritional status of children and fracture grade were identified and the two sets of data were compared against each other to try to identify a possible relation between fracture severity and malnutrition. Data was analysed in STATA and 5% level of significance was used to signify statistically significant associations.

150 patients were identified and included in the study. The majority of patients reviewed were in the normal nutritional range according to their z-scores. The severity of the fracture was not only associated with a poorer nutritional status however children with high and low z-scores (over weight as well as undernourished children) had the more severe fracture patterns, while children with normal z-scores had a fracture patterns of varying severity.

Children who were malnourished were more likely to sustain more severe fracture types. The results highlighted the need for all children to have a good nutritional status as this may play a role in preventing more complex fractures.

Introduction

A proportion of patients with hip and knee prosthetic joint infection (PJI) undergo multiple revisions with the aim of eradicating infection and improving quality of life. The aim of this study was to describe the microbiology cultured from multiply revised hip and knee replacement procedures to guide antimicrobial therapy at the time of surgery.

This study was performed at Assiut University, Assiut, Egypt.

Anterior distal femoral hemiepiphysiodesis (ADFH) using intra-articular plates for the correction of paediatric fixed knee flexion deformities (FKFD) has two main documented complications: postoperative knee pain and implant loosening. This study describes a biomechanical analysis and a preliminary report of a novel extra-articular technique for ADFH.

Sixteen femoral sawbones were osteotomized at the level of the distal femoral physis and fixed by rail frames to allow linear distraction simulating longitudinal growth. Each sawbone was tested twice: first using the conventional technique with medial and lateral parapatellar eight plates (group A) and then with the plates inserted in the proposed novel location at the most anterior part of the medial and lateral surfaces of the femoral condyles with screws in the coronal plane (group B). Gradual distraction was performed, and the resulting angular correction was measured. Strain gauges were attached to the plates, and the amount of strain (and equivalent stress) over the plates was recorded. This technique was then applied to 9 paediatric FKFDs of different aetiologies. The preoperative FKFD and the amount of subsequent angular correction were measured.

The amount of angular correction was higher in group B at 5, 10-, and 15-mm of distraction (p<0.001). The maximum and overall stresses measured throughout the distraction process were higher in group A (p<0.001). The mean FKFD improved from 24 ± 9° preoperatively to 9 ± 7° after 10 ± 3° months (p<0.001). The correction rate was 1.81 ± 0.65° per month.

During ADFH, the fixation of the eight plates in the coronal plane at the anterior part of the femoral condyles may produce greater correction and lower stresses over the implants as compared to the conventional technique. Preliminary results from our initial series seem to support the effectiveness of this technique with respect to the degree of angular correction achieved.

The aim of this study was to determine Anterior Cruciate Ligament (ACL) graft and contralateral ACL (CACL) survival in patients who have undergone ACL reconstruction (ACLR) with hamstring autograft following netball injuries, and determine factors associated with repeat ACL injury and return to netball.

From a prospectively collected database, a consecutive series of 332 female netballers who underwent primary ACLRs using hamstring autografts were identified. Subjects were surveyed at a minimum of five years following reconstruction, including details of further ACL injuries to either knee, return to netball or other sports and psychological readiness with the ACL-RSI score.

264 participants (80%) were reviewed at the mean follow up of 9 years (60-180 months). There were 12 ACL graft ruptures (5%) and 35 contralateral ACL ruptures (13%). ACL graft survival was 97% and 97%, 96% at 2, 5 and 7 years respectively. CACL survival was 99%, 94%, and 90% at 2, 5 and 7 years respectively. The 7-year ACL graft survival was 97% in those 25 or more and 93% in those under 25 years (p=0.126). The 7-year CACL survival was 93% in those 25 or more and 85% in those under 25 years (HR 2.6, 95%CI 1.3-5.0, p=0.007). A family history of ACL injury was reported by 32% of participants. A return to netball was reported by 61% of participants. The mean ACL-RSI score was 65 in those who returned to netball and 37 in those who did not (p=0.001).

ACLR with hamstring autografts is a reliable procedure for netballers with a survival rate of 96% at 7 years, allowing 63% of participants to return to netball. A successful return to sport was associated with greater psychological readiness. CACL injury occurred with more than double the frequency of ACL graft rupture and was increased by 2.6x in those <25 years.

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit.

A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed.

Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%).

Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition.

Aim

The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication.

Motorcycle accident-related traffic accidents contribute significantly to the burden of orthopaedic injuries seen in the South African Healthcare system. Subsequent to the Covid-19 pandemic, there has been an increase in the number of delivery drivers on the roads of South Africa. Many of these delivery drivers have no formal employment contracts. We aim to describe the demographics and injury patterns in motorcyclists involved in time dependent delivery work in South Africa; and to quantify the cost to the state of their orthopaedic surgeries.

We performed a consecutive case series study at all of the hospitals draining the study region over the period of one year. Epidemiological, clinical and cost to hospital data was collected from medical records, digital radiographs, theatre invoices and a dedicated patient questionnaire.

Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. A common belief of having ≥20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof.

We examined clinico-radiological outcomes in patients with intra-femoral tunnel graft lengths <20 and ≥20mm. Primary outcomes were knee scores at 1-year. Secondarily, graft revascularization was compared using magnetic resonance imaging (MRI). We hypothesized that outcomes would be independent of intra-femoral tunnel graft lengths.

This prospective, single-surgeon, cohort study was conducted at a tertiary care teaching centre between 2015–2018 after obtaining ethical clearances and consents. Eligible arthroscopic ACL reconstruction patients were sequentially divided into 2 groups based on the intra-femoral tunnel graft lengths (A: < 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those > 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively examined and scored (Lysholm and modified Cincinnati scores) at 3, 6 and 12 months. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using MRI. Statistical significance was set at p<0.05.

Age and sex-matched patients of both groups were followed to 1 year (1 dropout in each). Mean femoral and tibial tunnel diameters (P =0.225 and 0.595) were comparable. Groups A (<20mm) and B (≥20mm) had 27 and 25 patients respectively. At 3 months, 2 group A patients and 1 group B patient had grade 1 Lachman (increased at 12 months to 4 and 3 patients respectively). Pivot shift was negative in all patients. Lysholm scores at 3 and 6 months were comparable (P3= 0.195 and P6= 0.133). At 1 year both groups showed comparable Cincinnati scores. Mean ROM was satisfactory (≥130 degrees) in all but 2 patients of each group (125–130 degrees). MRI scans at 3 months and 1 year observed anatomical tunnels in all without any complications. Femoral tunnel signals in both groups showed a fall from 3–12 months indicating onset of maturation of graft at femoral tunnel.

Our hypothesis, clinical and radiological outcomes would be independent of intra-tunnel graft lengths on the femoral aspect, did therefore prove correct. Intra-femoral tunnel graft lengths of <20 mm did not compromise early clinical and functional outcomes of ACL reconstructions. There seems to be no minimum length of graft within the tunnel below which suboptimal results should be expected.

Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction.

Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis.

9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis.

Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction.

The optimal method of tibial fixation when using a hamstring tendon autograft in anterior cruciate ligament (ACL) reconstruction is unclear. This study aimed to compare the risk of revision ACL reconstruction between suspensory and interference devices on the tibial side.

Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. Only patients with a hamstring tendon autograft fixed with a suspensory device on the femoral side were included. The rate of revision ACL reconstruction was compared between suspensory and interference devices on the tibial side. Univariate Chi-Square test and multivariate Cox regression was performed to compute hazard ratios (HR) and 95% confidence intervals (CI) with adjustment for age, gender, time-to-surgery, activity at the time of injury, number of graft strands and graft diameter.

6145 cases were analyzed, of which 59.6% were fixed with a suspensory device on the tibial side (n = 3662), 17.6% fixed with an interference screw with a sheath (n = 1079) and 22.8% fixed with an interference screw without a sheath (n = 1404). When compared to suspensory devices (revision rate = 3.4%), a higher risk of revision was observed when using an interference screw with a sheath (revision rate = 6.2%, adjusted HR = 2.05, 95% CI 1.20 – 3.52, p = 0.009) and without a sheath (revision rate = 4.6%, adjusted HR = 1.81, 95% CI 1.02 – 3.23, p = 0.044). The number of graft strands and a graft diameter of ≥8 mm did not influence the risk of revision.

When reconstructing the ACL with a hamstring tendon autograft, the use of an interference screw, with or without a sheath, on the tibial side has a higher risk of revision when compared to a suspensory device.

Hip abductor tears(AT) have long been under-recognized, under-reported and under-treated. There is a paucity of data on the prevalence, morphology and associated factors. Patients with “rotator cuff tears of the hip” that are recognized and repaired during total hip arthroplasty(THA) report comparable outcomes to patients with intact abductor tendons at THA.

The study was a retrospective review of 997 primary THA done by a single surgeon from 2012–2022. Incidental findings of AT identified during the anterolateral approach to the hip were documented with patient name, gender, age and diagnosis. The extent and size of the tears of the Gluteus medius and Minimus were recorded. Xrays and MRI's were collected for the 140 patients who had AT and matched 1:1 with respect to age and gender against 140 patients that had documented good muscle quality and integrity. Radiographic measurements (Neck shaft angle, inter-teardrop distance, Pelvis width, trochanteric width and irregularities, bodyweight moment arm and abductor moment arm) were compared between the 2 groups in an effort to determine if any radiographic feature would predict AT.

The prevalence of AT were 14%. Females had statistically more tears than males(18vs10%), while patients over the age of 70y had statistically more tears overall(19,7vs10,4%), but also more Gluteus Medius tears specifically(13,9vs5,3%). Radiographic measurements did not statistically differ between the tear and control group, except for the presence of trochanteric irregularities. MRI's showed that 50% of AT were missed and subsequently identified during surgery.

Abductor tears are still underrecognized and undertreated during THA which can results in inferior outcomes. The surgeon should have an high index of suspicion in elderly females with trochanteric irregularities and although an MRI for every patient won't be feasible, one should always be prepared and equipped to repair the abductor tendons during THA.

Tendon injuries after distal radius fractures Introduction: Tendon injuries after distal radius fractures are a well-documented complication that can occur in fractures managed both operatively and non-operatively. The extensor tendons, in particular the extensor pollicis longus (EPL) tendon, can be damaged and present late after initial management in a cast, or by long prominent screws that penetrate the dorsal cortex and cause attrition. Similarly, a prominent or distally placed volar plate can damage the flexor pollicis longus tendon (FPL). The aim of our study was to evaluate the incidence of tendon injuries associated with distal radius fractures.

We conducted a single centre prospective observational study. Patients aged 18-99 who presented with a distal radius fracture between May 2018 to April 2020 were enrolled and followed-up for 24 months. Tendon injuries in the group were prospectively evaluated. Results: 199 patients with distal radius fractures were enrolled. 119 fractures (59.8%) had fixation and 80 (40.2%) were managed incast. In the non-operative group, 2 (2.5%) had EPL ruptures at approximately 4 weeks post injury. There were no extensor tendon ruptures in the operative group. In the operative group, there were 6 (5%) patients that required removal of metalware for FPL irritation. At the time of operation, there were no tendon ruptures noted. Within the operative group we evaluated plate prominence using a previously described classification (Soong et al.). 5 of the 6 patients (83%) with FPL irritation had Grade 3 prominence.

The incidence of both flexor and extensor tendon injury in our cohort was 4%, extensor tendon rupture was 1% and flexor tendon rupture was avoided by early metalware removal. This study demonstrates tendon injuries are not uncommon after distal radius fractures, and close examination and follow-up are necessary to prevent eventual rupture. Plate prominence at the time of fixation should be minimised to reduce the risk of rupture.

Aim

To compare outcomes of PJI in relation to treatment method versus classification using the JS-BACH system.

With an ageing population and an increasing number of primary arthroplasties performed, the revision burden is predicted to increase. The aims of this study were to 1. Determine the revision burden in an academic hospital over a 11-year period; 2. identify the direct hospital cost associated with the delivery of revision service and 3. ascertain factors associated with increased cost.

This is an IRB-approved, retrospective, single tertiary referral center, consecutive case series. Using the hospital data warehouse, all patients that underwent revision hip or knee arthroplasty surgery between 2008-2018 were identified. 1632 revisions were identified (1304 patients), consisting of 1061 hip and 571 knee revisions. The majority of revisions were performed for mechanical-related problems and aseptic loosening (n=903; 55.3%); followed by periprosthetic joint infection (n=553; 33.9%) and periprosthetic fractures (176; 10.8%). Cost and length of stay was determined for all patient. The direct in-hospital costs were converted to 2020 inflation-adjusted Canadian dollars. Several patients- (age; gender; HOMR- and ASA-scores; Hemoglobin level) and surgical- (indication for surgery; surgical site) factors were tested for possible associations.

The number of revisions increased by 210% in the study period (2008 vs. 2018: 83 vs. 174). Revision indications changed over study period; with prevalence of fracture increasing by 460% (5 in 2008 vs. 23 in 2018) with an accompanying reduction in mechanical-related reasons, whilst revisions for infection remained constant. The mean annual cost over the entire study period was 3.9 MMCAD (range:2.4–5.1 MMCAD). The cost raised 150% over the study period from 2.4 MMCAD in 2008 to 3.6 MMCAD. Revisions for fractured had the greatest length of stay, the highest mean age, HOMR-score, ASA and cost associated with treatment compared to other revision indications (p < 0 .001). Patient factors associated with cost and length of stay included ASA- and HOMR-scores, Charlson-Comorbidity score and age.

The revision burden increased 1.5-fold over the years and so has the direct cost of care delivery. The increased cost is primarily related to the prolonged hospital stay and increased surgical cost. For tertiary care units, these findings indicate a need to identify strategies on improving efficiencies whilst improving the quality of patient care (e.g. efficient ways of reducing acute hospital stay) and reducing the raise of the economic burden on a publicly funded health system.

Increased femoral head size reduces the rate of dislocation after total hip arthroplasty (THA). With the introduction of highly crosslinked polyethylene (HXLPE) liners in THA there has been a trend towards using larger size femoral heads in relatively smaller cup sizes, theoretically increasing the risk of liner fracture, wear, or aseptic loosening. Short to medium follow-up studies have not demonstrated a negative effect of using thinner HXLPE liners. However, there is concern that these thinner liners may prematurely fail in the long-term, especially in those with thinner liners. The aim of this study was to evaluate the long-term survival and revision rates of HXLPE liners in primary THA, as well as the effect of liner thickness on these outcomes. We hypothesized that there would be no significant differences between the different liner thicknesses.

We performed a retrospective database analysis from a single center of all primary total hip replacements using HXLPE liners from 2010 and earlier, including all femoral head sizes. All procedures were performed by fellowship trained arthroplasty surgeons. Patient characteristics, implant details including liner thickness, death, and revisions (all causes) were recorded. Patients were grouped for analysis for each millimeter of PE thickness (e.g. 4.0-4.9mm, 5.0-5.9mm). Kaplan-Meier survival estimates were estimated with all-cause and aseptic revisions as the endpoints.

A total of 2354 patients (2584 hips) were included (mean age 64.3 years, min-max 19-96). Mean BMI was 29.0 and 47.6% was female. Mean follow-up was 13.2 years (range 11.0-18.8). Liner thickness varied from 4.9 to 12.7 mm. Seven patients had a liner thickness <5.0mm and 859 had a liner thickness of <6.0mm. Head sizes were 28mm (n=85, 3.3%), 32mm (n=1214, 47.0%), 36mm (n=1176, 45.5%), and 40mm (n=109, 4.2%), and 98.4% were metal heads. There were 101 revisions, and in 78 of these cases the liner was revised. Reason for revision was instability/dislocation (n=34), pseudotumor/aseptic lymphocyte-dominant vasculitis associated lesion (n=18), fracture (n=17), early loosening (n=11), infection (n=7), aseptic loosening (n=4), and other (n=10). When grouped by liner thickness, there were no significant differences between the groups when looking at all-cause revision (p=0.112) or aseptic revision (p=0.116).

In our cohort, there were no significant differences in all-cause or aseptic revisions between any of the liner thickness groups at long-term follow-up. Our results indicate that using thinner HXPE liners to maximize femoral head size in THA does not lead to increased complications or liner failures at medium to long term follow-up. As such, orthopedic surgeons can consider the use of larger heads at the cost of liner thickness a safe practice to reduce the risk of dislocation after THA when using HXLPE liners.

Prior to the introduction of steroid management in Duchenne Muscular Dystrophy (DMD), the prevalence of scoliosis approached 100%, concomitant with progressive decreases in pulmonary function. As such, early scoliosis correction (at 20-25°) was advocated, prior to substantial pulmonary function decline. With improved pulmonary function and delayed curve progression with steroid treatment, the role of early surgery has been questioned. The purpose of this study was to compare the post-operative outcomes of early versus late scoliosis correction in DMD. We hypothesize that performing later surgery with larger curves would not lead to worse post-operative complications.

Retrospective cohort study. Patients with DMD who underwent posterior scoliosis correction, had pre-operative pulmonary function testing, and at least 1-year post-operative follow-up, were included; divided into 2 Groups by pre-operative curve angle – 1: ≤45°, 2: >45°. Primary outcome was post-operative complications by Clavien-Dindo (CD) grading. Secondary outcomes included: age at surgery, forced vital capacity (FVC), steroid utilization, fractional shortening (FS) by echocardiogram, surgery duration, blood transfusion requirements, ICU length of stay (LOS), days intubated post-operatively, hospital LOS, infection, curve correction. Two-tailed t-test and chi-square testing were used for analysis of patient factors and CD complication grade, respectively.

31 patients met the inclusion criteria, with a mean total follow-up of 8.3±3.2 years. Steroid treatment (prednisone, deflazacort) was utilized for 21 (67.7%) patients, for a mean duration of 8.2±4.0 years. Groups were comparable for steroid use, FVC, echo FS, and age at surgery (p>0.05). Primary curve angle was 31.7±10.4° and 58.3±11.1° for Groups 1 and 2, respectively (p 0.05). Surgery duration, ICU LOS, days intubated, hospital LOS, were also not different between Groups. For the entire cohort, however, the overall complication rate was higher for patients with steroid treatment [61.9% vs 10%, respectively (p=0.008)], the majority being CDII. Neither FVC nor echo FS were different between Groups at final follow-up (p=0.6; p=0.4, respectively).

Post-operative complication rates were not different for early and late scoliosis correction in DMD. In general, however, patients undergoing steroid treatment were at higher risk of blood transfusion and deep infection. Delaying scoliosis correction in DMD while PF is favourable is reasonable, but patients with prior steroid treatment should be counseled regarding the higher risk of complications.

Aim

To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery.

Abstract

Background

Fracture-related infection (FRI) is treated by adequate debridement, lavage, fracture stabilization (if indicated), adequate soft tissue coverage and systemic antimicrobial therapy. Additional administration of local antibiotics (LA), placed directly in the surgical field, is thought to be beneficial for successful eradication of infection.

Aim

Fungal periprosthetic joint infections are difficult to treat and often associated with a limited outcome for patients. Candida species account for approximately 90% of all fungal infections. In vivo biofilm models play major role to study biofilm development, morphology, and regulatory molecules for bacteria. However, in vivo modeling of biofilm-associated fungi models are very rare. Furthermore, due to ethical restrictions, mammalian models are replaced with other alternative models in basic research. Recently, we have developed insect infection model G. mellonella larvae to study implant associated biofilm infections with bacteria. This model organism was not used for fungi biofilm infection yet. Thus, we aimed to establish G. mellonella as in vivo model to study fungal implant infections using Candida albicans as model organism and to test anti-fungal medication.

Abstract

Aim

metagenomic next-generation sequencing (mNGS) has shown to be a useful method for pathogen detection in prosthetic joint infections (PJI). The technique promises to minimize the PJIs without the known causative agent. Our study aimed to compare diagnostic accuracies of cultures and mNGS.

Aim

Bone and joint infections (BJIs) are serious infections requiring early optimized antimicrobial therapy. BJIs can be polymicrobial or caused by fastidious bacteria, and the patient may have received antibiotics prior to sampling, which may decrease the sensitivity of culture-based diagnosis. Furthermore, culture-based diagnosis can take up to 14 days. Molecular approaches can be useful to overcome these concerns. The BioFire® system performs syndromic multiplex PCR in 1 hour, with only a few minutes of sample preparation. The BioFire® Joint Infection (JI) panel (BF-JI), recently FDA-cleared, detects both Gram-positive (n=15) and Gram-negative bacteria (n=14), Candida, and eight antibiotic resistance genes directly from synovial fluids. The aim of this study was to evaluate its performance in acute JIs in real-life conditions.

Abstract

Source of Study: London, United Kingdom

This intervention study was conducted to assess two developing protocols for quadriceps and hamstring rehabilitation: Blood Flow Restriction (BFR) and Neuromuscular Electrical Stimulation Training (NMES). BFR involves the application of an external compression cuff to the proximal thigh. In NMES training a portable electrical stimulation unit is connected to the limb via 4 electrodes. In both training modalities, following device application, a standardised set of exercises were performed by all participants. BFR and NMES have been developed to assist with rehabilitation following lower limb trauma and surgery. They offer an alternative for individuals who are unable to tolerate the high mechanical stresses associated with traditional rehabilitation programmes.

The use of BFR and NMES in this study was compared across a total of 20 participants. Following allocation into one of the training programmes, the individuals completed training programmes across a 4-week period. Post-intervention outcomes were assessed using Surface Electromyography (EMG) which recorded EMG amplitude values for the following muscles: Vastus Medialis, Vastus Lateralis, Rectus Femoris and Semitendinosus.

Increased Semitendinosus muscle activation was observed post intervention in both BFR and NMES training groups. Statistically significant differences between the two groups was not identified. Larger scale randomised-controlled trials are recommended to further assess for possible treatment effects in these promising training modalities.

Aim

The analysis of synovial fluid has proved to be of crucial importance in the diagnostic process of prosthetic joint infections (PJI), suggesting the presence of an infection before the microbiological culture results. In this context, several studies illustrated the efficacy of synovial calprotectin in supporting the diagnosis of PJI [1, 2]. However, several testing methods have been explored to detect synovial calprotectin levels, emphasizing the need to use a standardized, rapid and rapid test.

In this study, synovial calprotectin was analyzed by means of a commercial stool test [3] to explore whether the detected levels might predict PJIs and, therefore, being a promising tool for the fast and reliable diagnosis of this complication.

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery.

We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05.

Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique.

This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis.

Previously, we conducted a multi-center, double-blinded randomized controlled trial comparing arthroscopic Bankart repair with and without remplissage. The end point for the randomized controlled trial was two years post-operative, providing support for the benefits of remplissage in the short term in reducing recurrent instability. The aim of this study was to compare the medium term (3 to 9 years) outcomes of patients previously randomized to have undergone isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) for the management of recurrent anterior glenohumeral instability. The rate of recurrent instability and instances of re-operation were examined.

The original study was a double-blinded, randomized clinical trial with two 1:1 parallel groups with recruitment undertaken between 2011 and 2017. For this medium-term study, participants were reached for a telephone follow-up in 2020 and asked a series of standardized questions regarding ensuing instances of subluxation, dislocation or reoperation that had occurred on their shoulder for which they were randomized. Descriptive statistics were generated for all variables. “Failure” was defined as occurrence of a dislocation. “Recurrent instability” was defined as the participant reporting a dislocation or two or more occurences of subluxation greater than one year post-operative. All analyses were undertaken based on intention-to-treat whereby their data was analyzed based on the group to which they were originally allocated.

One-hundred and eight participants were randomized of which 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to final follow-up was 49.3 for the NO REMP group and 53.8 for the REMP group. The rates of re-dislocation or failure were 8% (4/52) in the REMP group at an average of 23.8 months post-operative versus 22% (11/50) in the NO REMP at an average of 16.5 months post-operative. The rates of recurrent instability were 10% (5/52) in the REMP group at an average of 24 months post-operative versus 30% (15/50) in the NO REMP group at an average of 19.5 months post-operative. Survival curves were significantly different favouring REMP in both scenarios.

Arthroscopic Bankart repair combined with remplissage is an effective procedure in the treatment of patients with an engaging Hill-Sachs lesion and minimal glenoid bone loss (<15%). Patients can expect favourable rates of recurrent instability when compared with isolated Bankart repair at medium term follw-up.

Olecranon fractures are common injuries representing roughly 5% of pediatric elbow fractures. The traditional surgical management is open reduction and internal fixation with a tension band technique where the pins are buried under the skin and tamped into the triceps. We have used a modification of this technique, where the pins have been left out of the skin to be removed in clinic. The purpose of the current study is to compare the outcomes of surgically treated olecranon fractures using a tension-band technique with buried k-wires (PINS IN) versus percutaneous k-wires (PINS OUT).

We performed a retrospective chart review on all pediatric patients (18 years of age or less) with olecranon fractures that were surgically treated at a pediatric academic center between 2015 to present. Fractures were identified using ICD-10 codes and manually identified for those with an isolated olecranon fracture. Patients were excluded if they had polytrauma, metabolic bone disease, were treated non-op or if a non-tension band technique was used (ex: plate/screws). Patients were then divided into 2 groups, olecranon fractures using a tension-band technique with buried k-wires (PINS IN) and with percutaneous k-wires (PINS OUT). In the PINS OUT group, the k-wires were removed in clinic at the surgeon's discretion once adequate fracture healing was identified. The 2 groups were then compared for demographics, time to mobilization, fracture healing, complications and return to OR.

A total of 35 patients met inclusion criteria. There were 28 patients in the PINS IN group with an average age of 12.8 years, of which 82% male and 43% fractured their right olecranon. There were 7 patients in the PINS OUT group with an average age of 12.6 years, of which 57% were male and 43% fractured their right olecranon. All patients in both groups were treated with open reduction internal fixation with a tension band-technique. In the PINS IN group, 64% were treated with 2.0 k-wires and various materials for the tension band (82% suture, 18% cerclage wire). In the PINS OUT group, 71% were treated with 2.0 k-wires and all were treated with sutures for the tension band. The PINS IN group were faster to mobilize (3.4 weeks (range 2-5 weeks) vs 5 weeks (range 4-7 weeks) p=0.01) but had a significantly higher complications rate compared to the PINS OUT group (6 vs 0, p =0.0001) and a significantly higher return to OR (71% vs 0%, p=0.0001), mainly for hardware irritation or limited range of motion. All fractures healed in both groups within 7 weeks.

Pediatric olecranon fractures treated with a suture tension-band technique and k-wires left percutaneously is a safe and alternative technique compared to the traditional buried k-wires technique. The PINS OUT technique, although needing longer immobilization, could lead to less complications and decreased return to the OR due to irritation and limited ROM.

Adverse spinopelvic characteristics (ASC) have been associated with increased dislocation risk following primary total hip arthroplasty (THA). A stiff lumbar spine, a large posterior standing tilt when standing and severe sagittal spinal deformity have been identified as key risk factors for instability. It has been reported that the rate of dislocation in patients with such ASC may be increased and some authors have recommended the use of dual mobility bearings or robotics to reduce instability to within acceptable rates (<2%).

The aims of the prospective study were to 1: Describe the true incidence of ASC in patients presenting for a THA 2. Assess whether such characteristics are associated with greater symptoms pre-THA due to the concomitant dual pathology of hip and spine and 3. Describe the early term dislocation rate with the use of ≤36mm bearings.

This is an IRB-approved, two-center, multi-surgeon, prospective, consecutive, cohort study of 220 patients undergoing THA through anterolateral- (n=103; 46.8%), direct anterior- (n=104; 27.3%) or posterior- approaches (n=13; 5.9%). The mean age was 63.8±12.0 years (range: 27.7-89.0 years) and the mean BMI 28.0±5.0 kg/m² (range: 19.4-44.4 kg/m²). There were 44 males (47.8%) and 48 females (52.2%). The mean follow-up was 1.6±0.5 years. Overall, 54% of femoral heads was 32 mm, and 46% was 36mm.

All participants underwent lateral spinopelvic radiographs in the standing and deep-flexed seated positions were taken to determine lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA) and pelvic incidence (PI) in both positions. Spinal stiffness was defined as lumbar flexion <20° when transitioning between the standing and deep-seated position; adverse standing PT was defined as >19° and adverse sagittal lumbar balance was defined as mismatch between standing PI and LL >10°.

Pre-operative patient reported outcomes was measured using the Oxford Hip Score (OHS) and EuroQol Five-Dimension questionnaire (EQ-5D). Dislocation rates were prospectively recorded. Non-parametric tests were used, significance was set at p<0.05.

The prevalence of PI-LL mismatch was 22.1% (43/195) and 30.4% had increased standing PT (59/194). The prevalence of lumbar stiffness was 3.5% (5/142) and these patients had all three adverse spinopelvic characteristics (5/142; 3.5%).

There was no significant difference in the pre-operative OHS between patients with (20.7±7.6) and patients without adverse spinopelvic characteristics (21.6±8.7; p=0.721), nor was there for pre-operative EQ5D (0.651±0.081 vs. 0.563±0.190; p=0.295).

Two patients sustained a dislocation (0.9%): One in the lateral (no ASC) and one in the posterior approaches, who also exhibited ASC pre-operatively.

Sagittal lumbar imbalance, increased standing spinal tilt and spinal stiffness are not uncommon among patients undergoing THA. The presence of such characteristics is not associated with inferior pre-operative PROMs. However, when all characteristics are present, the risk of instability is increased. Patients with ASC treated with posterior approach THA may benefit from the use of advanced technology due to a high risk of dislocation. The use of such technology with the anterior or lateral approach to improve instability is to date unjustified as the rate of instability is low even amongst patients with ASCs.

The routine use of intraoperative vancomycin powder to prevent postoperative wound infections has not been borne out in the literature in the pediatric spine population. The goal of this study is to determine the impact of vancomycin powder on postoperative wound infection rates and determine its potential impact on microbiology.

A retrospective analysis of the Harms Study Group database of 1269 adolescent idiopathic scoliosis patients was performed. Patients that underwent a posterior fusion from 2004-2018 were analyzed. A comparative analysis of postoperative infection rates was done between patients that received vancomycin powder to those who did not. Statistical significance was determined using Chi-squared test. Additionally, the microbiology of infected patients was examined.

In total, 765 patients in the vancomycin group (VG) were compared to 504 patients in the non-vancomycin group (NVG). NVG had a significantly higher rate of deep wound infection (p<0.0001) and associated reoperation rate compared to VG (p<0.0001). Both groups were compared for age, gender, race, weight, surgical time, blood loss, number of levels instrumented, and preop curve magnitude. There were significant differences between the groups for race (p<0.0001); surgical time (p=0.0033), and blood loss (p=0.0021). In terms of microbiology, VG grew p.acnes (n=2), and serratia (n=1), whereas NVG grew p.acnes (n=1) and gram positive bacilli (n=1). The remaining cultures were negative.

The use of intraoperative vancomycin powder in adolescent idiopathic scoliosis appears to contribute significantly to deep wound infection prevention and reduction of associated reoperations. Based on this study's limited culture data, Vancomycin does not seem to alter the microbiology of deep wound infections.

Abstract

Acute Compartment Syndrome (ACS) is an orthopaedic emergency that can develop after a wide array of etiologies. In this pilot study the MY01 device was used to assess its ease of use and its ability to continuously reflect the intracompartmental pressure (ICP) and transmit this data to a mobile device in real time. This preliminary data is from the lead site which is presently expanding data collection to five other sites as part of a multi-center study.

Patients with long bone trauma of the lower or upper extremity posing a possibility of developing compartment syndrome were enrolled in the study. Informed consent was obtained from the patients. A Health Canada licensed continuous compartmental pressure monitor (MY01) was used to measure ICP. The device was inserted in the compartment that was deemed most likely to develop ACS and ICP was continuously measured for up to 18 hours. Fractures were classified according to the AO/OTA classification. Patient clinical signs and pain levels were recorded by healthcare staff during routine in-patient monitoring and were compared to the ICP from the device. Important treatment information was pulled from the patient's chart to help correlate all of the patient's data and symptoms.

The study period was conducted from November 2020 through December 2021. Twenty-six patients were enrolled. There were 17 males, and nine females. The mean age was 38 years (range, 17–76). Seventeen patients received the device post-operatively and nine received it pre-operatively. Preliminary results show that post-operative ICPs tend to be significantly higher than pre-operative ICPs but tend to trend downwards very quickly. The trend in this measurement appears to be more significant than absolute numbers which is a real change from the previous literature. One patient pre-operatively illustrated a steep trend upwards with minimal clinical symptoms but required compartment release at the time of surgery that exhibited no muscle necrosis. The trend in this patient was very steep and, as predicted, predated the clinical findings of compartment syndrome. This trend allows an early warning signal of the absolute pressure, to come, in the compartment that is being assessed by the device.

Preliminary results suggest that this device is reliable and relatively easy to use within our institutions. In addition it suggests that intracompartmental pressures can be higher immediately post-op but lower rapidly when the patient does not develop ACS. These results are in line with current literature of the difference between pre and post-operative baselines and thresholds of ICP, but are much more striking, as continuous measurements have not been part of the data set in most of past studies.

Further elucidation of the pressure thresholds and profiles are currently being studied in the ongoing larger multicenter study and will add to our understanding of the critical values. This data, plus the added value of continuous trends in the pressure, upwards or downwards, will aid in preventing muscle necrosis during our management of these difficult long bone fractures.

A huge commitment is required from patients and families who undergo a limb reconstruction procedure using the hexapod frame. This includes turning the struts on the frame, pin site care and intensive rehabilitation. Montpetit et al (2009) discovered that function, participation, engagement in regular activities of daily living is severely impacted during the hexapod lengthening period. Due to the long duration and burden for families, it is imperative that healthcare professionals understand the impact that the hexapod frame has on functional abilities and health related quality of life (HRQL).

This project involved a retrospective review of prospectively collected data on function and HRQL during two periods of time: (1) when the hexapod frame is applied on the child's lower extremity and (2) when the lengthening phase is completed, and the hexapod frame is removed. Data from 38 children (mean age: 12 years SD 3.8) who completed lower extremity reconstruction using the hexapod frame and completed either or both the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL) and Pediatric Outcomes data Collection Instrument (PODCI) was included. Analysis included, standardized response means, the non-parametric Wilcoxon test and effect size calculation.

A Wilcoxon signed rank test for those children who completed pre and post frame PODCI’;s revealed those scores were significantly greater once the hexapod frame was removed (Md=85.10, n=10) compared to during (Md=66.50, n=10) with a large effect size, r= 1.45. Similar, the PedsQL scores improved post frame removal (Md= 66.30, n=10) compared to during treatment (Md = 53.34, n=10), with a medium size effect, r= 0.62. All subtests improved once the frame was removed.

This study provides essential insights into the burden of the hexapod frame for children and provides valuable information for all allied healthcare professionals targeted interventions for health domains. This study shows that children's function improves once the hexapod frame is removed. However, this study highlights the importance for all healthcare professional to address health domains for the duration of the hexapod procedure where the child scored lower e.g. sports and physical function, pain and comfort, happiness from the PODCI. The PedsQL identified lower mean scores in physical and emotional function.

Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. To be a valid predictor of disease and management, radiographic evaluation should include frontal and lateral views of the spine and a complete view of the pelvis, leading to accurate Cobb angle measurements and Risser staging. The study objectives were to determine 1) the adequacy of index images to inform treatment decisions at initial consultation by generating a score and 2) the utility of index radiology reports for appropriate triage decisions, by comparing reports to corresponding images.

We conducted a retrospective chart and radiographic review including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1-April 30, 2021. A score was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity (view of full spine, coronal=two, lateral=one, pelvis=one, ribcage=one). Index images were considered inadequate if repeat imaging was necessary. Comparisons were made between index radiology report, associated imaging, and new imaging if obtained at initial consultation. Major discrepancies were defined by inter-reader difference >15°, discordant Risser staging, or inaccuracies that led to inappropriate triage decisions. Location of index imaging, hospital versus community-based private clinic, was evaluated as a risk factor for inadequate or discrepant imaging.

There were 94 patients reviewed with 79% (n=74) requiring repeat imaging at initial consultation, of which 74% (n=55) were due to insufficient quality and/or visualization of the sagittal profile, pelvis or ribcage. Of index images available for review at initial consult (n=80), 41.2% scored five out of five and 32.5% scored two or below. New imaging showed that 50.0% of those patients had not been triaged appropriately, compared to 18.2% of patients with a full score. Comparing index radiology reports to initial visit evaluation with <60 days between imaging (n=49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients, with 18.4% (95% CI 10.0, 31.4) categorized as major discrepancies. Risser stage was reported in only 14% of index radiology reports. In 13.8% (n=13) of the total cohort, surgical or brace treatment was recommended when not predicted based on index radiology report. Repeat radiograph (p=0.001, OR=8.38) and discrepancies (p=0.02, OR=7.96) were increased when index imaging was obtained at community-based private clinic compared to at a hospital. Re-evaluation of available index imaging demonstrated that 24.6% (95% CI 15.2, 37.1) of Cobb angles were mis-reported by six to 21 degrees.

Most pre-referral paediatric spine radiographs are inadequate for idiopathic scoliosis evaluation. Standardization of spine imaging and reporting should improve measurement accuracy, facilitate triage and decrease unnecessary radiation exposure.

Aim

Previous publications have suggested that the incidence of revisions due to infection after THA is increasing. We performed updated time-trend analyses of risk and timing of revision due to infection after primary THAs in the Nordic countries during the period 2004–2018.

Aim

Aim was to compare revision rates when using single versus dual antibiotic loaded cement (ABLC) in hip fracture arthroplasty and aseptic revision hip or knee arthroplasty using data from the Dutch national joint registry (LROI).

To compare preoperative and postoperative Health Related Quality of Life (HRQoL) scores in operated Adolescent Idiopathic Scoliosis (AIS) patients with and without concomitant isthmic spondylolisthesis.

A retrospective study of a prospective cohort of 464 individuals undergoing AIS surgery between 2008 and 2018 was performed. All patients undergoing surgery for AIS with a minimum 2-year follow-up were included. We excluded patients with prior or concomitant surgery for spondylolisthesis. HRQoL scores were measured using the SRS-22 questionnaire. Comparisons were performed between AIS patients with vs. without concomitant spondylolisthesis treated non-surgically.

AIS surgery was performed for 36 patients (15.2 ±2.5 y.o) with concomitant isthmic spondylolisthesis, and 428 patients (15.5 ±2.4 y.o) without concomitant spondylolisthesis. The two groups were similar in terms of age, sex, preoperative and postoperative Cobb angles. Preoperative and postoperative HRQoL scores were similar between the two groups. HRQoL improved significantly for all domains in both groups, except for pain in patients with spondylolisthesis. There was no need for surgical treatment of the spondylolisthesis and no slip progression during the follow-up duration after AIS surgery.

Patients undergoing surgical treatment of AIS with non-surgical management of a concomitant isthmic spondylolisthesis can expect improvement in HRQoL scores, similar to that observed in patients without concomitant spondylolisthesis.

Abstract

Aim

Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2).

Abstract

The Cierny and Mader classification assists with decision-making in the management of osteomyelitis by strafying the host status and the pathoanatomy of disease. However the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies.

A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed.

Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08– 8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistical significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months))

This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis.

However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time.

Specific and rapid detection methods for spinal tuberculosis, with sufficient sensitivity in HIV-1 co-infected individuals, are needed, to ensure early initiation of appropriate treatment to prevent physical disability and neurological fallout. In addition, understanding the systemic and local pathophysiology of spinal tuberculosis, and its interaction with HIV-1 infection, is crucial to guide future therapeutic interventions.

We prospectively enrolled adult patients presenting with signs and symptoms of suspected spinal tuberculosis, at Groote Schuur Hospital, between November 2020 and December 2021. TB diagnostic testing was performed on open and CT-guided spinal biopsies using Xpert MTB/RIF Ultra compared to gold standards TB culture and histology. A highly sensitive droplet digital PCR assay for detecting and quantifying Mycobacterium tuberculosis complex (MTBC) and HIV-1 DNA was tested. Plasma inflammatory proteins were measured to assess systemic inflammation.

Xpert Ultra had a high sensitivity of 94.7% and specificity of 100% for STB against TB culture and histology in both open and CT-guided biopsy samples. The ddPCR assay confirmed TB detection in 94% of patients with positive Xpert Ultra results. Four patients with negative TB diagnostic results had MTBC DNA detected by ddPCR. HIV-1 DNA was detected in the spinal tissues from all HIV-1-infected patients. MTBC DNA levels were significantly higher in HIV-1-co-infected spinal tissue samples (p< 0.01). We identified four biomarkers significantly associated with higher bacterial burden at the disease site (p< 0.01).

Xpert Ultra and MTBC ddPCR improve the detection of STB. DdPCR can be utilized as an additional, highly sensitive tool for detecting and quantifying Mtb, in pathological samples that may be paucibacillary. These findings provide novel diagnostic and pathophysiologic insight into STB, in the context of HIV-1 infection, and provide rationale to include these tests in hospital and research settings for patients from communities burdened by TB and HIV-1.

Aim

Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life, and high healthcare costs. In 2009 a nationwide, multidisciplinary infection control program was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%.

The primary aim was to investigate whether the PRISS project reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis.

Paediatric bone and joint infections remain common in low- and middle-income countries (LMICs). We aimed to determine the complication rate and incidence of disseminated infection in paediatric bone and joint infections in an LMIC setting. Secondly, we aimed to elucidate factors associated with complications and disseminated disease.

We retrospectively reviewed our database for children that presented with bone and joint infections between September 2015 and March 2019. Data were extracted to identify factors that were associated with development of complications and disseminated infection.

We analysed 49 children. The median age at presentation was 6 years (range 1 month to 12 years). Locally advanced disease was present in 13 children (27%). The remaining 36 children were evenly divided (18/49 each, 37%) between isolated AHOM and SA, respectively. Disseminated disease was present in 16 children (33%) and was associated with locally advanced disease, an increase in number of surgeries and an increased length of stay. Twenty-six complications were documented in 22 (45%) children. Chronic osteomyelitis developed in 15/49 (31%) cases, growth arrest in 5/49 (10%), and pathological fracture, DVT and septic shock in 2/49 (4%) each. Complicated disease was associated with locally advanced disease, a higher number of surgeries, disseminated disease and an increased length of stay. Sixty five percent of cases cultured Staphylococcus aureus, while 25% (12/49) were culture negative. The median time from admission to surgery was one day, and the median time from onset of symptoms to surgery was seven days.

We found a high complication rate. One third of patients had locally advanced disease, and this was associated with the development of complications and disseminated disease. Further studies are needed to be able to predict which children will have poor outcomes.

Dual plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation, as these are common reasons for revision surgery. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating to traditional small-fragment clavicle plates for biomechanical non-inferiority and to determine if an optimal plate configuration could be identified, using a cadaveric model.

Twenty-four cadaveric clavicles were randomized to one of six groups (n=4 per group), stratified by CT-based bone mineral content (BMC). The six different plating configurations compared were: pre-contoured superior or anterior fixation using a single 3.5-mm LC-DC plate, and four different dual-plating constructs utilizing 2.4-mm and 2.7-mm reconstruction or LC-DC plates. The clavicles were plated and then osteotomized to create an inferior butterfly fracture, which was then fixed with a single interfragmentary screw (OTA 15.2B). Axial, torsional, and bending (anterior and superior surface loading) stiffness were determined for each construct through non-destructive cyclic testing, using an MTS 858 Bionix materials testing system. This was followed by a load-to-failure test in three-point superior-surface bending. Kruskal-Wallace H and Mann-Whitney U were used to test for statistical significance.

There were no significant differences in BMC (median 7.9 g, range 4.2-13.8 g) for the six groups (p=1.000). For axial stiffness, the two dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either reconstruction or LC-DC) were significantly stiffer than the other four constructs (p=0.021). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared to the 3.5-mm superior plate (p=0.043). In addition, a 3.5-mm plate placed anterior was a stiffer construct than a superior 3.5-mm plate (p=0.043). No significant differences were found in torsional stiffness or load-to-failure between the different constructs.

Dual plating using mini-fragment plates is biomechanically superior for fixation of midshaft clavicle fractures when compared to a single superior 3.5-mm plate and has similar biomechanical properties to a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual plating constructs were compared to each other. However, placing a 2.4-mm plate superiorly in combination with a 2.7-mm plate anteriorly might be the optimal construct, given the biomechanical superiority over the 3.5-mm plate placed superior.

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury.

We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded.

The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41.

Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this.

Meniscal tears are the most common knee injuries, occurring in acute ruptures or in chronic degenerative conditions. Meniscectomy and meniscal repair are two surgical treatment options. Meniscectomy is easier, faster, and the patient can return to their normal activities earlier. However, this procedure has long-term consequences in the development of degenerative changes in the knee, potentially leading to knee replacement. On the other hand, meniscal repair can offer prolonged benefits to the patients, but it is difficult to perform and requires longer rehabilitation.

Sutures are used for meniscal repairs, but they have limitations. They induce tissue damage when passing through the meniscus. Furthermore, under dynamic loading of the knee, they can cause tissue shearing and potentially lead to meniscal repair failure.

Our team has developed a new technology of resistant adhesive hydrogels to coat the suture used to repair meniscal tissue.

The objective of this study is to biomechanically compare two suture types on bovine menisci specimens: 1) pristine sutures and 2) gel adhesive puncture sealing (GAPS) sutures, on a repaired radial tear under cyclic tensile testing.

Five bovine knees were dissected to retrieve the menisci. On the 10 menisci, a complete radial tear was performed. They were separated in two groups and repaired using either pristine (2-0 Vicryl) or GAPS (2-0 Vicryl coated with adhesive hydrogels) with a single stitch and five knots.

The repaired menisci were clamped on an Instron machine. The specimens were cyclically preconditioned between one and 10 newtons for 10 cycles and then cyclically loaded for 500 cycles between five and 25 newtons at a frequency of 0.16 Hz. The gap formed between the edges of the tear after 500 cycles was then measured using an electronic measurement device. The suture loop before and after testing was also measured to ensure that there was no suture elongation or loosening of the knot.

The groups were compared statistically using Mann-Whitney tests for nonparametric data. The level of significance was set to 0.05.

The mean gap formation of the pristine sutures was 5.61 mm (SD = 2.097) after 500 cycles of tensile testing and 2.38 mm (SD = 0.176) for the GAPS sutures. Comparing both groups, the gap formed with the coated sutures was significantly smaller (p = 0.009) than with pristine sutures. The length of the loop was equal before and after loading. Further investigation of tissue damage indicated that the gap was formed by suture filament cutting into the meniscal tissue.

The long-term objective of this research is to design a meniscal repair toolbox from which the surgeon can adapt his procedure for each meniscal tear. This preliminary experimentation on bovine menisci is promising because the new GAPS sutures seem to keep the edges of the meniscal tear together better than pristine sutures, with hopes of a clinical correlation with enhanced meniscal healing.

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids.

EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies.

Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively.

Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients.

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice.

A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (12 weeks - 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up.

A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m2), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05).

We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction.

Novel immersive virtual reality (IVR) technologies are revolutionizing medical education. Virtual anatomy education using head-mounted displays allows users to interact with virtual anatomical objects, move within the virtual rooms, and interact with other virtual users. While IVR has been shown to be more effective than textbook learning and 3D computer models presented in 2D screens, the effectiveness of IVR compared to cadaveric models in anatomy education is currently unknown. In this study, we aim to compare the effectiveness of IVR with direct cadaveric bone models in teaching upper and lower limb anatomy for first-year medical students.

A randomized, double-blind crossover non-inferiority trial was conducted. Participants were first-year medical students from a single University. Exclusion criteria included students who undertook prior undergraduate or graduate degrees in anatomy. In the first stage of the study, students were randomized in a 1:1 ratio to IVR or cadaveric bone groups studying upper limb skeletal anatomy. All students were then crossed over and used cadaveric bone or IVR to study lower limb skeletal anatomy. All students in both groups completed a pre-and post-intervention knowledge test. The educational content was based on the University of Toronto Medical Anatomy Curriculum. The Oculus Quest 2 Headsets (Meta Technologies) and PrecisionOS Anatomy application (PrecisionOS Technology) were utilized for the virtual reality component. The primary endpoint of the study was student performance on the pre-and post-intervention knowledge tests. We hypothesized that student performance in the IVR groups would be comparable to the cadaveric bone group.

50 first-year medical students met inclusion criteria and were computer randomized (1:1 ratio) to IVR and cadaveric bone group for upper limb skeletal anatomy education. Forty-six students attended the study, 21 completed the upper limb modules, and 19 completed the lower limb modules. Among all students, average score on the pre-intervention knowledge test was 14.6% (Standard Deviation (SD)=18.2%) and 25.0% (SD=17%) for upper and lower limbs, respectively. Percentage increase in students’ scores between pre-and post-intervention knowledge test, in the upper limb for IVR, was 15 % and 16.7% for cadaveric bones (p = 0. 2861), and for the lower limb score increase was 22.6% in the IVR and 22.5% in the cadaveric bone group (p = 0.9356).

In this non-inferiority crossover randomized controlled trial, we found no significant difference between student performance in knowledge tests after using IVR or cadaveric bones. Immersive virtual reality and cadaveric bones were equally effective in skeletal anatomy education. Going forward, with advances in VR technologies and anatomy applications, we can expect to see further improvements in the effectiveness of these technologies in anatomy and surgical education. These findings have implications for medical schools having challenges in acquiring cadavers and cadaveric parts.

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

The reconstruction of peri-acetabular defects after severe bone loss or pelvic resection for tumor is among the most challenging surgical intervention. The Lumic® prosthesis (Implantcast, Buxtehude, Germany) was first introduced in 2008 in an effort to reduce the mechanical complications encountered with the classic peri-acetabular reconstruction techniques and to improve functional outcomes. Few have evaluated the results associated with the use of this recent implant.

A retrospective study from five Orthopedic Oncology Canadian centers was conducted. Every patient in whom a Lumic® endoprosthesis was used for reconstruction after peri-acetabular resection or severe bone loss with a minimal follow-up of three months was included. The charts were reviewed and data concerning patients’ demographics, peri-operative characteristics and post-operative complications was collected. Surgical and functional outcomes were also assessed.

Sixteen patients, 11 males and five females, were included and were followed for 28 months [3 – 60]. Mean age was 55 [17–86], and mean BMI reached 28 [19.6 – 44]. Twelve patients (75%) had a Lumic® after a resection of a primary sarcoma, two following pelvic metastasis, one for a benign tumor and one after a comminuted acetabular fracture with bone loss. Twelve patients (75%) had their surgery performed in one stage whereas four had a planned two-stage procedure. Mean surgical time was 555 minutes [173-1230] and blood loss averaged 2100 mL [500-5000]. MSTS score mean was 60.3 preoperatively [37.1 – 97] and 54.3 postoperatively [17.1-88.6]. Five patients (31.3%) had a cemented Lumic® stem. All patients got the dual mobility bearing, and 10 patients (62.5%) had the largest acetabular cup implanted (60 mm). In seven of these 10 patients the silver coated implant was used to minimize risk of infection. Five patients (31.3%) underwent capsular reconstruction using a synthetic fabric aiming to reduce the dislocation risk. Five patients had per-operative complications (31.3%), four were minor and one was serious (comminuted iliac bone fracture requiring internal fixation). Four patients dislocated within a month post-operatively and one additional patient sustained a dislocation one year post-operatively. Eight patients (50%) had a post-operative surgical site infection. All four patients who had a two-stage surgery had an infection. Ten patients (62.5%) needed a reoperation (two for fabric insertion, five for wash-outs, and three for implant exchange/removal). One patient (6.3%) had a septic loosening three years after surgery. At the time of data collection, 13 patients (81.3%) were alive with nine free of disease. Silver coating was not found to reduce infection risk (p=0.2) and capsuloplasty did not prevent dislocation (p=1).

These results are comparable to the sparse data published. Lumic® endoprosthesis is therefore shown to provide good functional outcomes and low rates of loosening on short to medium term follow-up. Infection and dislocation are common complications but we were unable to show benefits of capsuloplasty and of the use of silver coated implants. Larger series and longer follow-ups are needed.

Despite advances in treating acute spinal cord injury (SCI), measures to mitigate permanent neurological deficits in affected patients are limited. Augmentation of mean arterial blood pressure (MAP) to promote blood flow and oxygen delivery to the injured cord is one of the only currently available treatment options to potentially improve neurological outcomes after acute spinal cord injury (SCI). However, to optimize such hemodynamic management, clinicians require a method to measure and monitor the physiological effects of these MAP alterations within the injured cord in real-time. To address this unmet clinical need, we developed a series of miniaturized optical sensors and a monitoring system based on multi-wavelength near-infrared spectroscopy (MW-NIRS) technique for direct transdural measurement and continuous monitoring of spinal cord hemodynamics and oxygenation in real-time. We conducted a feasibility study in a porcine model of acute SCI. We also completed two separate animal studies to examine the function of the sensor and validity of collected data in an acute experiment and a seven-day post-injury survival experiment.

In our first animal experiment, nine Yorkshire pigs underwent a weight-drop T10 vertebral level contusion-compression injury and received episodes of ventilatory hypoxia and alterations in MAP. Spinal cord hemodynamics and oxygenation were monitored throughout by a transdural NIRS sensor prototype, as well as an invasive intraparenchymal (IP) sensor as a comparison. In a second experiment, we studied six Yucatan miniature pigs that underwent a T10 injury. Spinal cord oxygenation and hemodynamics parameters were continuously monitored by an improved NIRS sensor over a long period. Episodes of MAP alteration and hypoxia were performed acutely after injury and at two- and seven-days post-injury to simulate the types of hemodynamic changes patients experience after an acute SCI. All NIRS data were collected in real-time, recorded and analyzed in comparison with IP measures.

Noninvasive NIRS parameters of tissue oxygenation were highly correlated with invasive IP measures of tissue oxygenation in both studies. In particular, during periods of hypoxia and MAP alterations, changes of NIRS-derived spinal cord tissue oxygenation percentage were significant and corresponded well with the changes in spinal cord oxygen partial pressures measured by the IP sensors (p < 0.05).

Our studies indicate that a novel optical biosensor developed by our team can monitor real-time changes in spinal cord hemodynamics and oxygenation over the first seven days post-injury and can detect local tissue changes that are reflective of systemic hemodynamic changes. Our implantable spinal cord NIRS sensor is intended to help clinicians by providing real-time information about the effects of hemodynamic management on the injured spinal cord. Hence, our novel NIRS system has the near-term potential to impact clinical care and improve neurologic outcomes in acute SCI. To translate our studies from bench to bedside, we have developed an advanced clinical NIRS sensor that is ready to be implanted in the first cohort of acute SCI patients in 2022.

Aim

S. aureus and S. epidermidis remain the leading biofilm-forming agents causing orthopedic implant-associated infections (OIAI), but other coagulase-negative Staphylococcus (CoNS) with clinical importance is emerging. Besides, few studies have assessed specific genomic traits associated with patient outcome. This is a preliminary descriptive study of phenotypic and genomic features identified in clinical isolates of S. aureus and CoNS isolates recovered from OIAIs patients that progressed to treatment failure.

Shoulder arthroplasty humeral stem design has evolved to accommodate patient anatomy characteristics. As a result, stems are available in numerous shapes, coatings, lengths, sizes, and vary by fixation method. This abundance of stem options creates a surgical paradox of choice. Metrics describing stem stability, including a stem's resistance to subsidence and micromotion, are important factors that should influence stem selection, but have yet to be assessed in response to the diametral (i.e., thickness) sizing of short stem humeral implants.

Eight paired cadaveric humeri (age = 75±15 years) were reconstructed with surgeon selected ‘standard’ sized short-stemmed humeral implants, as well as 2mm ‘oversized’ implants. Stem sizing conditions were randomized to left and right humeral pairs. Following implantation, an anteroposterior radiograph was taken of each stem and the metaphyseal and diaphyseal fill ratios were quantified. Each humerus was then potted in polymethyl methacrylate bone cement and subjected to 2000 cycles of 90º forward flexion loading. At regular intervals during loading, stem subsidence and micromotion were assessed using a validated system of two optical markers attached to the stem and humeral pot (accuracy of <15µm).

The metaphyseal fill ratio did not differ significantly between the oversized and standard stems (0.50±0.06 vs 0.50±0.10; P = 0.997, Power = 0.05); however, the diaphyseal fill ratio did (0.52±0.06 vs 0.45±0.07; P < 0.001, Power = 1.0). Neither fill ratio correlated significantly with stem subsidence or micromotion. Stem subsidence and micromotion were found to plateau following 400 cycles of loading. Oversizing stem thickness prevented implant head-back contact in all but one specimen with the least dense metaphyseal bone, while standard sizing only yielded incomplete head-back contact in the two subjects with the densest bone. Oversized stems subsided significantly less than their standard counterparts (standard: 1.4±0.6mm, oversized: 0.5±0.5mm; P = 0.018, Power = 0.748;), and resulted in slightly more micromotion (standard: 169±59µm, oversized: 187±52µm, P = 0.506, Power = 0.094,).

Short stem diametral sizing (i.e., thickness) has an impact on stem subsidence and micromotion following humeral arthroplasty. In both cases, the resulting three-dimensional stem micromotion exceeded, the 150µm limit suggested for bone ingrowth, although that limit was derived from a uniaxial assessment. Though not statistically significant, the increased stem micromotion associated with stem oversizing may in-part be attributed to over-compacting the cancellous bed during broaching, which creates a denser, potentially smoother, interface, though this influence requires further assessment. The findings of the present investigation highlight the importance of proper short stem diametral sizing, as even a relatively small, 2mm, increase can negatively impact the subsidence and micromotion of the stem-bone construct. Future work should focus on developing tools and methods to support surgeons in what is currently a subjective process of stem selection.

Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation.

After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples t-tests and Chi-square tests were used to compare the characteristics of patients who had preoperative bloodwork versus those who did not. The cost of preoperative blood work was estimated.

During these two years, 627 patients met inclusion criteria, and 27% (n=168) of these patients had bloodwork completed pre-operatively, while only 34% (n=57) of these had one or more abnormal laboratory parameters. These abnormalities were minor and did not alter clinical management or result in repeated bloodwork peri-operatively. Patients who had bloodwork were significantly older (40.2 years) compared with patients without preoperative blood work (37.8 years; p=0.03), but there was no difference in sex between those who had bloodwork (53.4% male) and those who did not (51.4% male; p=0.63). The most common blood test ordered was a complete blood count, and the most commonly abnormal result was a mildly elevated white blood cell count (19%; n= 29). The most common patients to receive bloodwork were those with ankle (34%) and distal radius (34%) fractures. The bloodwork was primarily ordered by clinical associates (26%; n=46) and emergency department physicians (22%; n=38). Without considering lab personnel, consumables, and analysis time, the cost of this bloodwork was approximately $7685, an average of $45 per patient.

Pre-operative bloodwork in young, healthy, asymptomatic patients requiring outpatient surgery for minor orthopaedic trauma had no clinical significance and did not change patient management. Rigorous prospective research is warranted to establish national guidelines for appropriate pre-operative bloodwork ordering to minimize unnecessary and costly investigations.

Aim

Osteomyelitis is a difficult-to-treat disease with high chronification rates. The surgical amputation of the afflicted limb sometimes remains as the patients’ last resort. Several studies suggest an increase in mitochondrial fission as a possible contributor to the accumulation of intracellular reactive oxygen species and thereby to cell death of infectious bone cells. The aim of this study is to analyze the ultrastructural impact of bacterial infection and its accompanying microenvironmental tissue hypoxia on osteocytic and osteoblastic mitochondria.

Increased collection of patient-reported outcome measures (PROM) in registries enables international comparison of patient-centered outcomes after knee and hip replacement. We aimed to investigate 1) variations in PROM improvement, 2) the possible confounding factor of BMI, and 3) differences in comorbidity distributions between registries.

Registries affiliated with the International Society of Arthroplasty Registries (ISAR) or OECD membership countries were invited to report aggregate EQ-5D, OKS, OHS, HOOS-PS and KOOS-PS values. Eligible patients underwent primary total, unilateral knee or hip replacement for osteoarthritis within three years and had completed PROMs preoperatively and either 6 or 12 months postoperatively, excluding patients with subsequent revisions. For each PROM cohort, Chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (male/female, age 20-64/65-74/>75, high or low preoperative PROM scores). Comorbidity distributions were reported for available comorbidity indexes.

Thirteen registries from 9 countries contributed data, n~130000 knee (range 140 to 79848) and n~113000 hip (range 137 to 85281). Mean EQ-5D index values (10 registries) ranged from 0.53 to 0.71 (knee) and 0.50 to 0.70 (hips) preoperatively and 0.78 to 0.85 (knee) and 0.83 to 0.87 (hip) postoperatively. Mean OKS (6 registries) ranged from 19.3 to 23.6 preoperatively and 36.2 to 41.2 postoperatively. Mean OHS (7 registries) ranged from 18.0 to 23.2 preoperatively and 39.8 to 44.2 postoperatively. Four registries reported KOOS-PS and three reported HOOS-PS. Proportions of patients with BMI >30 ranged from 35 to 62% (10 knee registries) and 16 to 43% (11 hip registries). For both knee and hip registries, distributions of patients across six BMI categories differed significantly among registries (p30 were for patients in the youngest age groups (20 to 64 and 65 to 74 years) with the lowest baseline scores. Additionally, females with lowest preoperative PROM scores had highest BMI. These findings were echoed for the OHS and OKS cohorts. Proportions of patients with ASA scores ≥3 ranged from 7 to 42% (9 knee registries) and 6 to 35% (8 hip registries).

PROM-score improvement varies between international registries, which may be partially explained by differences in age, sex and preoperative scores. BMI and comorbidity may be relevant to adjust for.

Direct oral anticoagulant (DOAC) use is becoming more widespread in the geriatric population. Depending on the type of DOAC, several days are required for its anticoagulant effects to resorb, which may lead to surgical delays. This can have an important impact on hip fracture patients who require surgery. The goal of the current study is to compare surgical delays, mortality and complications for hip fracture patients who were on a DOAC to those who were not.

A retrospective cohort study was conducted at a university hospital in Sherbrooke. All hip fracture patients between 2012 and 2018 who were on a DOAC prior to their surgery were included. These patients were matched with similar patients who were not on an anticoagulant (non-DOAC) for age, sex, type of fracture and date of operation. Demographic and clinical data were collected for all patients. Surgical delay was defined as time of admission to time of surgery. Mortality and complications up to one year postoperative were also noted.

Each cohort comprised of 74 patients. There were no statistically signification differences in Charleson Comorbidty Index and American Society of Anesthesiologists scores between cohorts. Surgical delay was significantly longer for DOAC patients (36.3±22.2 hours vs. 18.6±18.9 hours, p < 0 .001). Mortality (6.1%) and overall complication (33.8%) rates were similar between the two cohorts. However, there were more surgical reinterventions in DOAC patients than non-DOAC ones (16.2% vs. 0.0%, p < 0 .001). Among DOAC patients, mortality was greater for those operated after 48 hours (23.1% vs. 3.3%, p < 0 .05) and complications were more frequent for those operated after 24 hours (52.0% vs. 37.5%, p < 0 .05).

Direct oral anticoagulant (DOAC) use in hip fracture patients is associated with longer surgical delays. Longer delays to surgery are associated with higher mortality and complication rates in hip fracture patients taking a DOAC. Hip fracture patients should have their surgery performed as soon as medically possible, regardless of anticoagulant use.

It has been established that a dedicated orthopaedic trauma room (DOTR) provides significant clinical and organizational benefits to the management of trauma patients. After-hours care is associated with surgeon fatigue, a high risk of patient complications, and increased costs related to staffing. However, hesitation due to concerns of the associated opportunity cost at the hospital leadership level is a major barrier to wide-spread adoption. The primary aim of this study is to determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency. Secondly, we sought to evaluate the associated financial impact of the DOTR, with respect to both after-hours care costs as well as the opportunity cost of displaced elective cases.

This was a retrospective cost-analysis study performed at a single academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a four-year period from 2016-2019 were included. Patient data acquired for two-years prior and two-years after the implementation of a DOTR were compared, adjusting for the number of cases performed. Surgical duration and number of day-time and after-hours cases was recorded pre- and post-implementation. Cost savings of performing trauma cases during daytime and the opportunity cost of displacing elective cases by performing cases during the day was calculated. A sensitivity analysis accounting for varying overtime costs and hospital elective case profit was also performed.

1960 orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR. After accounting for the total number of each procedure performed, the mean weighted reduction was 31.4% and the mean time saved was 29.6 minutes per surgery. The number of daytime surgical hours increased 21%, while nighttime hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2,476.

Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Through the regular scheduling of a DOTR at a single hospital in Canada, the number of surgeries occurring during daytime hours increased while the number of after-hours cases decreased. The same surgeries were also completed nearly one-third faster (30 minutes per case) on average. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Notably, the savings partially stem from decreased OR time as well as decreased nurse overtime. Widespread implementation can improve patient care while still remaining financially favourable.

The number of women entering medical school has been steadily increasing over the past two decades; however, the number of women pursuing careers in orthopaedic surgery has not increased at the same rate. One of the suggested reasons for this discrepancy is the perceived incompatibility of having a family while upholding the demands of a surgical career in orthopaedics. A growing body of scientific literature has also outlined the increased rate of infertility and pregnancy complications in women surgeons. The extent to which these factors play a role in the recruitment and retention of women in orthopaedic surgery is unknown. Understanding pregnancy and parenthood in orthopaedic surgery is a critical first step in addressing this issue.

A scoping review was conducted to identify literature pertaining to the perceptions and experiences of pregnancy and/or parenthood of women in orthopaedic surgery. Embase, MEDLINE and PsychINFO were searched on June 7th, 2021 with Boolean operators to combine the following terms: orthop?e*, pregnancy, maternity, motherhood, parenthood, parental, and parenting. Studies pertaining to orthopaedic surgery residents, fellows and staff were included. The Arksey and O'Malley framework for scoping studies was followed. Descriptive statistics were used to quantify the included studies while thematic analysis as described by Braun and Clarke was used to analyze the qualitative data.

A total of 17 studies from 2006 to 2021 met inclusion criteria. Over half of the available research was conducted within the last two years (n=9, 53%). The majority of studies were conducted in the United States (n=15, 88%) and the United Kingdom (n=2, 12%). The most commonly used study design was survey-based research (n=13, 76%), followed by review studies (n=3, 18%), and case series (n=1, 6%). Thematic analysis revealed five key themes contributing to the women's experiences of pregnancy and/or parenthood in orthopaedics: (1) women are subtly or blatantly discouraged from becoming pregnant by their colleagues and superiors, (2) women delay childbearing to preserve their professional reputation, (3) there are higher rates of infertility and preterm labor in orthopaedic surgeons than in the general population, (4) the orthopaedic work environment can be hazardous and challenging for the pregnant woman, but accommodations are possible to mitigate risks, and (5) overall, there is limited support for pregnant and/or parenting women in orthopaedics throughout their career.

The first woman to be board-certified in orthopaedic surgery in the United States was Ruth Jackson in 1937. Eighty-four years later, orthopaedic surgery has the lowest number of women of the surgical specialties. The barriers related to pregnancy and/or parenthood during a woman's career in orthopaedics may be one cause. This study identified five themes related to pregnancy and parenthood that warrant further investigation. Qualitative research approaches can be used to elucidate the details of women's experiences and to provide suggestions for structural changes in the orthopaedic work environment.

Abstract

To describe the longitudinal trends in patients with obesity and Metabolic Syndrome (MetS) undergoing TKA and the associated impact on complications and lengths of hospital stay.

We identified patients who underwent primary TKA between 2006 – 2017 within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We recorded patient demographics, length of stay (LOS), and 30-day major and minor complications. We labelled those with an obese Body Mass Index (BMI ≥ 30), hypertension, and diabetes as having MetS. We evaluated mean BMI, LOS, and 30-day complication rates in all patients, obese patients, and those with MetS from 2006-2017. We used multivariable regression to evaluate the trends in BMI, complications, and LOS over time in all patients and those with MetS, and the effect of BMI and MetS on complication rates and LOS, stratified by year.

270,846 patients underwent primary TKA at hospitals participating in the NSQIP database. 63.71% of patients were obese (n = 172,333), 15.21% were morbidly obese (n = 41,130), and 12.37% met criteria for MetS (n = 33,470). Mean BMI in TKA patients increased at a rate of 0.03 per year (0.02-0.05; p < 0 .0001). Despite this, the rate of adverse events in obese patients decreased: major complications by an odds ratio (OR) of 0.94 (0.93-0.96; p < 0 .0001) and minor complications by 0.94 (0.93-0.95; p < 0 .001). LOS also decreased over time at an average rate of −0.058 days per year (-0.059 to −0.057; p < 0 .0001). The proportion of patients with MetS did not increase, however similar improvements in major complications (OR 0.94 [0.91-0.97] p < 0 .0001), minor complications (OR 0.97 [0.94-1.00]; p < 0 .0330), and LOS (mean −0.055 [-0.056 to −0.054] p < 0 .0001) were found. In morbidly obese patients (BMI ≥ 40), there was a decreased proportion per year (OR 0.989 [0.98-0.994] p < 0 .0001). Factors specifically associated with major complications in obese patients included COPD (OR 1.75 [1.55-2.00] p < 0.0001) and diabetes (OR 1.10 [1.02-1.1] p = 0.017). Hypertension (OR 1.12 [1.03-1.21] p = 0.0079) was associated with minor complications. Similarly, in patients with MetS, major complications were associated with COPD (OR 1.72 [1.35-2.18] p < 0.0001). Neuraxial anesthesia was associated with a lower risk for major complications in the obese cohort (OR 0.87 [0.81-0.92] p < 0.0001). BMI ≥ 40 was associated with a greater risk for minor complications (OR 1.37 [1.26-1.50] p < 0.0001), major complications (1.11 [1.02-1.21] p = 0.015), and increased LOS (+0.08 days [0.07-0.09] p < 0.0001).

Mean BMI in patients undergoing primary TKA increased from 2006 - 2017. MetS comorbidities such as diabetes and hypertension elevated the risk for complications in obese patients. COPD contributed to higher rates of major complications. The obesity-specific risk reduction with spinal anesthesia suggests an improved post-anesthetic clinical course in obese patients with pre-existing pulmonary pathology. Encouragingly, the overall rates of complications and LOS in patients with obesity and MetS exhibited a longitudinal decline. This finding may be related to the decreased proportion of patients with BMI ≥ 40 treated over the same period, possibly the result of quality improvement initiatives aimed at delaying high-risk surgery in morbidly obese patients until healthy weight loss is achieved. These findings may also reflect increased awareness and improved management of these patients and their elevated risk profiles.

Abstract

The Accolade®TMZF is a taper-wedge cementless metaphyseal coated femoral stem widely utilized from 2002-2012. In recent years, there have been reports of early catastrophic failure of this implant. Establishing a deeper understanding of the rate and causes of revision in patients who developed aseptic failure in stems with documented concerns about high failure rates is critical. Understanding any potential patient or implant factors which are risk factors for failure is important to inform both clinicians and patients. We propose a study to establish the long-term survival of this stem and analyze patients who underwent aseptic revision to understand the causes and risk factors for failure.

A retrospective review was undertaken of all patients who received a primary total hip arthroplasty with an Accolade® TMZF stem at a high-volume arthroplasty center. The causes and timing of revision surgery were documented and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to minimize loss to follow-up. Survivorship analysis was performed with use of the Kaplan-Meier curves to determine the overall and aseptic survival rates at final follow-up. Patient and implant factors commonly associated with aseptic failure were extracted and Cox proportional hazards model was used.

A consecutive series of 2609 unilateral primary THA patients implanted with an Accolade®TMZF femoral hip stem were included. Mean time from primary surgery was 12.4 years (range 22 days to 19.5 years). Cumulative survival was 96.1% ± 0.2 at final follow-up. One hundred and seven patients underwent revision surgery with aseptic loosening of the femoral component was the most common cause of aseptic failure in this cohort (33/2609, 1.3%). Younger age and larger femoral head offset were independent risk factors for aseptic failure.

To our knowledge, this is the largest series representing the longest follow-up of this taper-wedge cementless femoral implant. Despite early concerns, the Accolade® TMZF stem has excellent survivorship in this cohort. Trunnionosis as a recognized cause for revision surgery was rare. Younger age and larger femoral head offset were independent risk factors for aseptic failure.

This study aimed to identify factors associated with increased rates of blood transfusion in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF).

A retrospective case-control study was performed for AIS patients treated at a large children's hospital between August 2018 and December 2020. All patients with a diagnosis of AIS were evaluated. Data on patient demographics, AIS, and transfusion parameters were collected. Univariate regression and multivariate logistic modeling were utilized to assess risk factors associated with requiring transfusion. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Surgeries were done by three surgeons and thirty anesthesiologists. To quantify the influence of anesthesia practice preferences a categorical variable was defined as “higher-transfusion practice preference”, for the provider with the highest rate of transfusion.

A total of 157 AIS patients were included, of whom 56 were transfused RBC units (cases), and 101 did not receive any RBC transfusion (controls). On univariate analysis, the following variables were significantly correlated with receiving RBC transfusion: “higher-transfusion practice preference,” “administration of crystalloids,” “receiving fresh frozen plasma (FFP),” “receiving platelets,” “pre-operative hemoglobin,” “cell saver volume,” and “surgical time.” On multiple regression modeling, “pre-operative hemoglobin less than 120 g/L” (OR 14.05, 95% CI: 1.951 to 135.7) and “higher-transfusion practice preference” (OR 11.84, 95% CI: 2.505 to 63.65) were found to be meaningfully and significantly predictive of RBC transfusion.

In this cohort, we identified pre-operative hemoglobin of 120 g/L as a critical threshold for requiring transfusion. In addition, we identified significant contribution from anesthesia transfusion practice preferences. Our multivariate model indicated that these two factors are the major significant contributors to allogenic blood transfusion. Although further studies are required to better understand factors contributing to transfusion in AIS patients, we suggest standardized, peri-operative evidence-based strategies to potentially help reduce variations due to individual provider preferences.

Aim

Prompt and sufficient broad spectrum empirical antibiotic treatment is key to prevent infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off minimal inhibitory concentrations (T>MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC-targets were applied: 1 and 4 µg/mL for vancomycin and 0.125 and 2 µg/mL for meropenem.

Single level discectomy (SLD) is one of the most commonly performed spinal surgery procedures. Two key drivers of their cost-of-care are duration of surgery (DOS) and postoperative length of stay (LOS). Therefore, the ability to preoperatively predict SLD DOS and LOS has substantial implications for both hospital and healthcare system finances, scheduling and resource allocation. As such, the goal of this study was to predict DOS and LOS for SLD using machine learning models (MLMs) constructed on preoperative factors using a large North American database.

The American College of Surgeons (ACS) National Surgical and Quality Improvement (NSQIP) database was queried for SLD procedures from 2014-2019. The dataset was split in a 60/20/20 ratio of training/validation/testing based on year. Various MLMs (traditional regression models, tree-based models, and multilayer perceptron neural networks) were used and evaluated according to 1) mean squared error (MSE), 2) buffer accuracy (the number of times the predicted target was within a predesignated buffer), and 3) classification accuracy (the number of times the correct class was predicted by the models). To ensure real world applicability, the results of the models were compared to a mean regressor model.

A total of 11,525 patients were included in this study. During validation, the neural network model (NNM) had the best MSEs for DOS (0.99) and LOS (0.67). During testing, the NNM had the best MSEs for DOS (0.89) and LOS (0.65). The NNM yielded the best 30-minute buffer accuracy for DOS (70.9%) and ≤120 min, >120 min classification accuracy (86.8%). The NNM had the best 1-day buffer accuracy for LOS (84.5%) and ≤2 days, >2 days classification accuracy (94.6%). All models were more accurate than the mean regressors for both DOS and LOS predictions.

We successfully demonstrated that MLMs can be used to accurately predict the DOS and LOS of SLD based on preoperative factors. This big-data application has significant practical implications with respect to surgical scheduling and inpatient bedflow, as well as major implications for both private and publicly funded healthcare systems. Incorporating this artificial intelligence technique in real-time hospital operations would be enhanced by including institution-specific operational factors such as surgical team and operating room workflow.