Orthopaedic surgeons prescribe more opioids than any other surgical speciality. Opioids remain the analgesic of choice following arthroscopic knee and shoulder surgery. There is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients’ pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. The objective of the current randomized controlled trial (RCT) was to evaluate the efficacy of a multi-modal, opioid-sparing approach to postoperative pain management in patients undergoing arthroscopic shoulder and knee surgery.

The NO PAin trial is a pragmatic, definitive RCT (NCT04566250) enrolling 200 adult patients undergoing outpatient shoulder or knee arthroscopy. Patients are randomly assigned in a 1:1 ratio to an opioid-sparing group or standard of care. The opioid-sparing group receives a three-pronged prescription package consisting of 1) a non-opioid prescription: naproxen, acetaminophen and pantoprazole, 2) a limited opioid “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group is the current standard of care as per the treating surgeon, which consists of an opioid analgesic. The primary outcome of interest is oral morphine equivalent (OME) consumption up to 6 weeks postoperatively. The secondary outcomes are postoperative pain scores, patient satisfaction, quantity of OMEs prescribed and number of opioid refills. Patients are followed at both 2 and 6 weeks postoperatively. Data analysts and outcome assessors are blinded to the treatment groups.

As of December 1, 2021 we have enrolled 166 patients, reaching 83% of target enrolment. Based on the current recruitment rate, we anticipate that enrolment will be completed by the end of January 2022 with final follow-up and study close out completed by March of 2022. The final results will be released at the Canadian Orthopaedic Association Meeting in June 2022 and be presented as follows. The mean difference in OME consumption was XX (95%CI: YY-YY, p=X). The mean difference in OMEs prescribed was XX (95%CI: YY-YY, p=X). The mean difference in Visual Analogue Pain Scores (VAS) and patient satisfaction are XX (95%CI: YY-YY, p=X). The absolute difference in opioid refills was XX (95%CI: YY-YY, p=X).

The results of the current study will demonstrate whether an opioid sparing approach to postoperative outpatient pain management is effective at reducing opioid consumption while adequately addressing postoperative pain in patients undergoing outpatient shoulder and knee arthroscopy. This study is novel in the field of arthroscopic surgery, and its results will help to guide appropriate postoperative analgesic management following these widely performed procedures.

Abstract

Aim

The duration of systemic antibiotic therapy following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, use high concentration targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy in the management of PJI of the hip using our two-stage protocol.

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery.

Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test.

A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point.

In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases.

The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities, or health-related quality-of-life (HRQoL) weights. An instrument designed for cervical myelopathy disease would increase the sensitivity and specificity of HRQoL assessments. The objective of this study is to develop a multi-attribute utility function for the modified Japanese Orthopedic Association (mJOA) Score.

We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment (DCE), participants rated 8 choice sets based on mJOA health states. A multi-attribute utility function was estimated using a mixed multinomial-logit regression model (MIXL). The sample was partitioned into a training set used for model fitting and validation set used for model evaluation.

The regression model demonstrated good predictive performance on the validation set with an AUC of 0.81 (95% CI: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter function, upper extremity sensation.

This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should use these findings in order to offer treatments that maximize function in the attributes viewed most important by patients.

Abstract

Abstract

Extended Trochanteric Osteotomy (ETO) improves surgical exposure and aids femoral stem and bone cement removal in Revision Total Hip Replacement (RTHR) surgery. The aim of this study was to identify healing rates and complications of ETO in RTHR.

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users.

This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses.

Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state.

Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables.

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.

Individuals with multi-compartment knee osteoarthritis (KOA) frequently experience challenges in activities of daily living (ADL) such as stair ambulation. The Levitation “Tri-Compartment Offloader” (TCO) knee brace was designed to reduce pain in individuals with multicompartment KOA. This brace uses novel spring technology to reduce tibiofemoral and patellofemoral forces via reduced quadriceps forces. Information on brace utility during stair ambulation is limited. This study evaluated the effect of the TCO during stair descent in patients with multicompartment KOA by assessing knee flexion moments (KFM), quadriceps activity and pain.

Nine participants (6 male, age 61.4±8.1 yrs; BMI 30.4±4.0 kg/m2) were tested following informed consent. Participants had medial tibiofemoral and patellofemoral OA (Kellgren-Lawrence grades two to four) diagnosed by an orthopaedic surgeon.

Joint kinetics and muscle activity were evaluated during stair descent to compare three bracing conditions: 1) without brace (OFF); 2) brace in low power (LOW); and 3) brace in high power (HIGH). The brace spring engages from 60° to 120° and 15° to 120° knee flexion in LOW and HIGH, respectively. Individual brace size and fit were adjusted by a trained researcher.

Participants performed three trials of step-over-step stair descent for each bracing condition. Three-dimensional kinematics were acquired using an 8-camera motion capture system. Forty-one spherical reflective markers were attached to the skin (on each leg and pelvis segment) and 8 markers on the brace. Ground reaction forces and surface EMG from the vastus medialis (VM) and vastus lateralis (VL) were collected for the braced leg. Participants rated knee pain intensity performing the task following each bracing condition on a 10cm Visual Analog Scale ranging from “no pain” (0) to “worst imaginable pain” (100).

Resultant brace and knee flexion angles and KFM were analysed during stair contact for the braced leg. The brace moment was determined using brace torque-angle curves and was subtracted from the calculated KFM. Resultant moments were normalized to bodyweight and height. Peak KFMs were calculated for the loading response (Peak1) and push-off (Peak2) phases of support. EMG signals were normalized and analysed during stair contact using wavelet analysis. Signal intensities were summed across wavelets and time to determine muscle power.

Results were averaged across all 3 trials for each participant. Paired T-tests were used to determine differences between bracing conditions with a Bonferroni adjustment for multiple comparisons (α=0.025).

Peak KFM was significantly lower compared to OFF with the brace worn in HIGH during the push-off phase (p Table 1: Average peak knee flexion moments, quadriceps muscle power and knee pain during stair descent in 3 brace conditions (n=9).

Quadriceps activity, knee flexion moments and pain were significantly reduced with TCO brace wear during stair descent in KOA patients. These findings suggest that the TCO assists the quadriceps to reduce KFM and knee pain during stair descent. This is the first biomechanical evidence to support use of the TCO to reduce pain during an ADL that produces especially high knee forces and flexion moments.

For any figures or tables, please contact the authors directly.

Reconstruction of the anterior cruciate ligament (ACL) allows to restore stability of the knee, in order to facilitate the return to activity (RTA). Although it is understood that the tendon autograft undergoes a ligamentous transformation postoperatively, knowledge about longitudinal microstructural differences in tissue integrity between types of tendon autografts (ie, hamstring vs. patella) remains limited.

Diffusion tensor imaging (DTI) has emerged as an objective biomarker to characterize the ligamentization process of the tendon autograft following surgical reconstruction. One major limitation to its use is the need for a pre-injury baseline MRI to compare recovery of the graft, and inform RTA. Here, we explore the relationship for DTI biomarkers (fractional anisotropy, FA) between knees bilaterally, in healthy participants, with the hypothesis that agreement within a patient's knees may support the use of the contralateral knee as a reference to monitor recovery of the tendon autograft, and inform RTA.

Fifteen participants with no previous history of knee injuries were enrolled in this study (age, 26.7 +/− 4.4 years; M/F, 7/8). All images were acquired on a 3T Prisma Siemens scanner using a secured flexible 18-channel coil wrapped around the knee. Both knees were scanned.

A 3D anatomical Double Echo Steady State (DESS) sequence was acquired on which regions of interest (ROI) were placed consistent with the footprints of the ACL (femur, posteromedial corner on medial aspect of lateral condyle; tibia, anteromedial to intercondylar eminence). Diffusion images were acquired using fat saturation based on optimized parameters in-house.

All diffusion images were pre-processed using the FMRIB FSL toolbox. The footprint ROIs of the ACL were then used to reconstruct the ligament in each patient with fiber-based probabilistic tractography (FBPT), providing a semi-automated approach for segmentation. Average FA was computed for each subject, in both knees, and then correlated against one another using a Pearson correlation to assess the degree of similarity between the ACLs.

A total of 30 datasets were collected for this study (1/knee/participant; N=15). The group averaged FA (+/− standard deviation) for the FBPT segmented ACLs were found to equal 0.1683 +/− 0.0235 (dominant leg) and 0.1666 +/− 0.0225 (non-dominant leg). When comparing both knees within subjects, reliable agreement was found for the FBPT-derived ACL with a linear correlation coefficient (rho) equal to 0.87 (P < 0 .001).

We sought to assess the degree of concordance in FA between the knees of healthy participants with hopes to provide a method for using the contralateral “healthy” knee in the comparison of autograft-dependent longitudinal changes in microstructural integrity, following ACL reconstruction. Our results suggest that good agreement in anisotropy can be achieved between the non-dominant and dominant knees using DTI and the FBPT segmentation method.

Contralateral anisotropy of the ACL, assuming no previous injuries, may be used as a quantitative reference biomarker for monitoring the recovery of the tendon autograft following surgical reconstruction, and gather further insight as to potential differences between chosen autografts. Clinically, this may also serve as an index to supplement decision-making with respect to RTA, and reduce rates of re-injuries.

As the field of hip arthroscopy continues to develop, functional measures and testing become increasingly important in patient selection, managing patient expectations prior to surgery, and physical readiness for return to athletic participation. The Hip Sport Test (HST) was developed to assess strength, coordination, agility, and range of motion prior to and following hip arthroscopy as a functional assessment. However, the relationship between HST and hip strength, range of motion, and hip-specific patient reported outcome (PRO) measures have not been investigated. The purpose of this study was to evaluate the correlation between the HST scores and measurements of hip strength and range of motion prior to undergoing hip arthroscopy.

Between September 2009 and January 2017, patients aged 18-40 who underwent primary hip arthroscopy for the treatment of femoroacetabular impingement with available pre-operative HST, dynamometry, range of motion, and functional scores (mHHS, WOMAC, HOS-SSS) were identified. Patients were excluded if they were 40 years old, had a Tegner activity score < 7, or did not have HST and dynamometry evaluations within one week of each other. Muscle strength scores were compared between affected and unaffected side to establish a percent difference with a positive score indicating a weaker affected limb and a negative score indicating a stronger affected limb. Correlations were made between HST and strength testing, range of motion, and PROs.

A total of 350 patients met inclusion criteria. The average age was 26.9 ± 6.5 years, with 34% females and 36% professional athletes. Total and component HST scores were significantly associated with measure of strength most strongly for flexion (rs = −0.20, p < 0 .001), extension (rs = −0.24, p<.001) and external rotation (rs = −0.20, p < 0 .001). Lateral and diagonal agility, components of HST, were also significantly associated with muscle strength imbalances between internal rotation versus external rotation (rs = −0.18, p=0.01) and flexion versus extension (rs = 0.12, p=0.03). In terms of range of motion, a significant correlation was detected between HST and internal rotation (rs = −0.19, p < 0 .001). Both the total and component HST scores were positively correlated with pre-operative mHHS, WOMAC, and HOS-SSS (p<.001 for all rs).

The Hip Sport Test correlates with strength, range of motion, and PROs in the preoperative setting of hip arthroscopy. This test alone and in combination with other diagnostic examinations can provide valuable information about initial hip function and patient prognosis.

Abstract

Optimal acetabular component position in Total Hip Arthroplasty is vital for avoiding complications such as dislocation and impingement, Transverse acetabular ligament (TAL) have been shown to be a reliable landmark to guide optimum acetabular cup position. Reports of iliopsoas impingement caused by acetabular components exist. The Psoas fossa (PF) is not a well-regarded landmark for Component positioning. Our aim was to assess the relationship of the TAL and PF in relation to Acetabular Component positioning.

A total of 22 cadavers were implanted on 4 occasions with the an uncemented acetabular component. Measurements were taken between the inner edge of TAL and the base of the acetabular component and the distance between the lower end of the PF and the most medial end of TAL.

The distance between the edge of the acetabular component and TAL was a mean of 1.6cm (range 1.4–18cm). The distance between the medial end of TAL and the lowest part of PF was a mean of 1.cm (range 1,3–1.8cm) It was evident that the edge of PF was not aligned with TAL.

Optimal acetabular component position is vital to the longevity and outcome following THA. TAL provides a landmark to guide acetabular component position. However we feel the PF is a better landmark to allow appropriate positioning of the acetabular component inside edge of the acetabulum inside the bone without exposure of the component rim and thus preventing iliopsoas impingement at the psoas notch and resultant groin pain.

Giant cell tumors of bone (GCTs) are locally aggressive tumors with recurrence potential that represent up to 10% of primary tumors of the bone. GCTs pathogenesis is driven by neoplastic mononuclear stromal cells that overexpress receptor activator of nuclear factor kappa-B/ligand (RANKL). Treatment with specific anti-RANKL antibody (denosumab) was recently introduced, used either as a neo-adjuvant in resectable tumors or as a stand-alone treatment in unresectable tumors. While denosumab has been increasingly used, a percentage of patients do not improve after treatment. Here, we aim to determine molecular and histological patterns that would help predicting GCTs response to denosumab to improve personalized treatment.

Nine pre-treatment biopsies of patients with spinal GCT were collected at 2 centres. In 4 patients denosumab was used as a neo-adjuvant, 3 as a stand-alone and 2 received denosumab as adjuvant treatment. Clinical data was extracted retrospectively. Total mRNA was extracted by using a formalin-fixed paraffin-embedded extraction kit and we determined the transcript profile of 730 immune-oncology related genes by using the Pan Cancer Immune Profiling panel (Nanostring). The gene expression was compared between patients with good and poor response to Denosumab treatment by using the nSolver Analysis Software (Nanostring). Immunohistochemistry was performed in the tissue slides to characterize cell populations and immune response in CGTs.

Two out of 9 patients showed poor clinical response with tumor progression and metastasis. Our analysis using unsupervised hierarchical clustering determined differences in gene expression between poor responders and good responders before denosumab treatment. Poor responding lesions are characterized by increased expression of inflammatory cytokines as IL8, IL1, interferon a and g, among a myriad of cytokines and chemokines (CCL25, IL5, IL26, IL25, IL13, CCL20, IL24, IL22, etc.), while good responders are characterized by elevated expression of platelets (CD31 and PECAM), coagulation (CD74, F13A1), and complement classic pathway (C1QB, C1R, C1QBP, C1S, C2) markers, together with extracellular matrix proteins (COL3A1, FN1,. Interestingly the T-cell response is also different between groups. Poor responding lesions have increased Th1 and Th2 component, but good responders have an increased Th17 component. Interestingly, the checkpoint inhibitor of the immune response PD1 (PDCD1) is increased ~10 fold in poor responders.

This preliminary study using a novel experimental approach revealed differences in the immune response in GCTs associated with clinical response to denosumab. The increased activity of checkpoint inhibitor PD1 in poor responders to denosumab treatment may have implications for therapy, raising the potential to investigate immunotherapy as is currently used in other neoplasms. Further validation using a larger independent cohort will be required but these results could potentially identify the patients who would most benefit from denosumab therapy.

Abstract

Background

A few patients undergoing a total hip replacement need a subsequent revision of the cup. In some of these cases, the treating surgeon may be confronted with Unexpected Positive Intraoperative Cultures (UPIC). The exact incidence of this finding is unclear. Moreover, it is unknown what the clinical outcome of these patients is when the stem is left in situ. The aim of our study was to describe the incidence of UPIC in patients undergoing cup revision and to determine the need for total revision in this patient group during follow-up.

Abstract

Patients receiving reverse total shoulder arthroplasty (RTSA) often have osseous erosions because of glenohumeral arthritis, leading to increased surgical complexity. Glenoid implant fixation is a primary predictor of the success of RTSA and affects micromotion at the bone-implant interface. Augmented implants which incorporate specific geometry to address superior erosion are currently available, but the clinical outcomes of these implants are still considered short-term. The objective of this study was to investigate micromotion at the glenoid-baseplate interface for a standard, 3 mm and 6 mm lateralized baseplates, half-wedge, and full-wedge baseplates. It was hypothesized that the mechanism of load distribution from the baseplate to the glenoid will differ between implants, and these varying mechanisms will affect overall baseplate micromotion.

Clinical CT scans of seven shoulders (mean age 69 years, 10°-19° glenoid inclinations) that were classified as having E2-type glenoid erosions were used to generate 3D scapula models using MIMICS image processing software (Materialise, Belgium) with a 0.75 mm mesh size. Each scapula was then repeatedly virtually reconstructed with the five implant types (standard,3mm,6mm lateralized, and half/full wedge; Fig.1) positioned in neutral version and inclination with full backside contact. The reconstructed scapulae were then imported into ABAQUS (SIMULIA, U.S.) finite element software and loads were applied simulating 15°,30°,45°,60°,75°, and 90° of abduction based on published instrumented in-vivo implant data. The micromotion normal and tangential to the bone surface, and effective load transfer area were recorded for each implant and abduction angle. A repeated measures ANOVA was used to perform statistical analysis.

Maximum normal micromotion was found to be significantly less when using the standard baseplate (5±4 μm), as opposed to the full-wedge (16±7 μm, p=0.004), 3 mm lateralized (10±6 μm, p=0.017), and 6 mm lateralized (16±8 μm, p=0.007) baseplates (Fig.2). The half-wedge baseplate (11±7 μm) also produced significantly less micromotion than the full-wedge (p=0.003), and the 3 mm lateralized produced less micromotion than the full wedge (p=0.026) and 6 mm lateralized (p=0.003). Similarly, maximum tangential micromotion was found to be significantly less when using the standard baseplate (7±4 μm), as opposed to the half-wedge (12±5 μm, p=0.014), 3 mm lateralized (10±5 μm, p=0.003), and 6 mm lateralized (13±6 μm, p=0.003) baseplates (Fig.2). The full wedge (11±3 μm), half-wedge, and 3 mm lateralized baseplate also produced significantly less micromotion than the 6 mm lateralized (p=0.027, p=012, p=0.02, respectively). Both normal and tangential micromotion were highest at the 30° and 45° abduction angles (Fig.2). The effective load transfer area (ELTA) was lowest for the full wedge, followed by the half wedge, 6mm, 3mm, and standard baseplates (Fig.3) and increased with abduction angle.

Glenoid baseplates with reduced lateralization and flat backside geometries resulted in the best outcomes with regards to normal and tangential micromotion. However, these types of implants are not always feasible due to the required amount of bone removal, and medialization of the bone-implant interface. Future work should study the acceptable levels of bone removal for patients with E-type glenoid erosion and the corresponding best implant selections for such cases.

For any figures or tables, please contact the authors directly.

Aim

The prevalence of unexpected positive cultures (UPC) in aseptic revision surgery of the joint with a prior septic revision procedure in the same joint remain unknown. The purpose of this study was to determine the prevalence of UPC in aseptic revisions performed in patients with a previous septic revision in the same joint. As secondary outcome measure, we explore possible risk factors associated with UPC and the re-revision rates.

Anterior cruciate ligament (ACL) injuries have been increasing, especially amongst adolescents. These injuries can increase the risk for early-onset knee osteoarthritis (OA). The consequences of late-stage knee OA include structural joint change, functional limitations and persistent pain. Interleukin-6 (IL-6) is a pro-inflammatory biomarker reflecting knee joint healing, and increasing evidence suggests that IL-6 may play a critical role in the development of pathological pain. The purpose of this study was to determine the relationship between subjective knee joint pain and function, and synovial fluid concentrations of the pro-inflammatory cytokine IL-6, in adolescents undergoing anterior cruciate ligament reconstruction surgery.

Seven youth (12-17 yrs.) undergoing anterior cruciate ligament (ACL) reconstruction surgery participated in this study. They completed the Pedi International Knee Documentation Committee (Pedi-IKDC) questionnaire on knee joint pain and function. At the time of their ACL reconstruction surgery, synovial fluid samples were collected through aspiration to dryness with a syringe without saline flushing. IL-6 levels in synovial fluid (sf) were measured using enzyme linked immunosorbent assay. Spearman's rho correlation coefficient was used to determine the correlation between IL-6 levels and scores from the Pedi-IKDC questionnaire.

There was a statistically significant correlation between sfIL-6 levels and the Pedi-IKDC Symptoms score (-.929, p=0.003). The correlations between sfIL-6 and Pedi-IKDC activity score (.546, p = .234) and between sfIL-6 and total Pedi-IKDC score (-.536, p = .215) were not statistically significant.

This is the first study to evaluate IL-6 as a biomarker of knee joint healing in an adolescent population, reported a very strong correlation (-.929, p=0.003) between IL-6 in knee joint synovial fluid and a subjective questionnaire on knee joint pain. These findings provide preliminary scientific evidence regarding the relationship between knee joint pain, as determined by a validated questionnaire and the inflammatory and healing status of the patient's knee. This study provides a basis and justification for future longitudinal research on biomarkers of knee joint healing in patients throughout their recovery and rehabilitation process. Incorporating physiological and psychosocial variables to current return-to-activity (RTA) criteria has the potential to improve decision making for adolescents following ACL reconstruction to reduce premature RTA thereby reducing the risk of re-injury and risk of early-onset knee OA in adolescents.

Abstract

Aim

To date, the value of culture results after a debridement, antibiotics and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At one year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIRs after primary total hip or knee arthroplasty. The secondary aim was to explore differences in patient characteristics, infection characteristics and outcomes between these two groups.

The aim of the this study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient reported outcomes, graft stability, extension loss and re-operation following anatomic single-bundle ACL reconstruction.

All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single bundle ACL reconstruction using patellar tendon autograft and randomized to tibial fixation of the ACL graft at either 0o (n=85) or 30o (n=84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) two years following surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of re-operation, and physical exam findings at one year including KT-1000 and side to side differences in knee extension.

The follow-up rate was 82% (n=139) for the primary outcome. Graft failure rate at two years was 1% (n=2, 1 per group). ACL tibial graft fixation at 0o or 30o did not have a significant effect on KOOS scores at two years following ACLR. Patients whose graft was fixed at a knee flexion angle of 0o had greater scores on the Marx Activity Scale (mean 9.6 [95%CI 8.5-10.6] versus 8.0 [95%CI 6.9-9.1, p=0.04) and a greater proportion of patients who achieved the minimal clinical important difference (MCID) for the KOOS pain subscale (94% vs 81%, p=0.04). There was no significant difference in knee extension loss, KT-1000 measurements or re-operation between the two groups.

In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores among patients fixed at 0o and 30o. Patient fixed in full extension did demonstrate higher activity scores at 2 years following surgery and a greater likelihood of achieving the MCID for KOOS pain.

The opposable thumb is one of the defining characteristics of human anatomy and is involved in most activities of daily life. Lack of optimal thumb motion results in pain, weakness, and decrease in quality of life. First carpometacarpal (CMC1) osteoarthritis (OA) is one of the most common sites of OA. Current clinical diagnosis and monitoring of CMC1 OA disease are primarily aided by X-ray radiography; however, many studies have reported discrepancies between radiographic evidence of CMC1 OA and patient-related outcomes of pain and disability. Radiographs lack soft-tissue contrast and are insufficient for the detection of early characteristics of OA such as synovitis, which play a key role in CMC OA disease progression. Magnetic resonance imaging (MRI) and two-dimensional ultrasound (2D-US) are alternative options that are excellent for imaging soft tissue pathology. However, MRI has high operating costs and long wait-times, while 2D-US is highly operator dependent and provides 2D images of 3D anatomical structures. Three-dimensional ultrasound imaging may be an option to address the clinical need for a rapid and safe point of care imaging device. The purpose of this research project is to validate the use of mechanically translated 3D-US in CMC OA patients to assess the measurement capabilities of the device in a clinically diverse population in comparison to MRI.

Four CMC1-OA patients were scanned using the 3D-US device, which was attached to a Canon Aplio i700 US machine with a 14L5 linear transducer with a 10MHz operating frequency and 58mm. Complimentary MR images were acquired using a 3.0 T MRI system and LT 3D coronal photon dense cube fat suppression sequence was used. The volume of the synovium was segmented from both 3D-US and MR images by two raters and the measured volumes were compared to find volume percent differences. Paired sample t-test were used to determine any statistically significant differences between the volumetric measurements observed by the raters and in the measurements found using MRI vs. 3D-US. Interclass Correlation Coefficients were used to determine inter- and intra-rater reliability.

The mean volume percent difference observed between the two raters for the 3D-US and MRI acquired synovial volumes was 1.77% and 4.76%, respectively. The smallest percent difference in volume found between raters was 0.91% and was from an MR image. A paired sample t-test demonstrated that there was no significant difference between the volumetric values observed between MRI and 3D-US. ICC values of 0.99 and 0.98 for 3D-US and MRI respectively, indicate that there was excellent inter-rater reliability between the two raters.

A novel application of a 3D-US acquisition device was evaluated using a CMC OA patient population to determine its clinical feasibility and measurement capabilities in comparison to MRI. As this device is compatible with any commercially available ultrasound machine, it increases its accessibility and ease of use, while proving a method for overcoming some of the limitations associated with radiography, MRI, and 2DUS. 3DUS has the potential to provide clinicians with a tool to quantitatively measure and monitor OA progression at the patient's bedside.

The purpose of this study was to determine the incidence of graft-tunnel mismatch (GTM) when performing anatomic anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BPTB) grafts and anteromedial portal drilling.

Beginning in November 2018, 100 consecutive patients who underwent ACLR by two sports fellowship-trained, orthopedic surgeons using BPTB autograft and anteromedial portal drilling were prospectively identified. The BPTB graft dimensions and the femoral tunnel distance, tibial tunnel distance, intra-articular distance, and total distance were measured. Surgeons determined the depth and angle of tunnels based on the patella tendon graft length dimensions in each case. After passage of the graft, the distance from the distal graft tip to the tibial cortex aperture was measured. GTM was defined as the need for additional measures to obtain satisfactory tibial graft fixation (< 1 5e20 mm of bone fixation).

The incidence of mismatch was 6/100 (6%). Five cases involved the graft being too long, with the tibial bone plug protruding excessively from the tibial tunneld4/5 had a patella tendon length ? 50 mm. Three cases were managed with femoral tunnel recession, and two were treated with a free bone plug technique. One patient with a patella tendon length of 35 mm had a graft that was too short, with the tibial bone plug recessed in the tibial tunnel. Of patients whose tibial tunnel distance was within 5 mm of the patella tendon length, only 1/46 (2%) patients had mismatch, whereas 5/54 (9%) of patients who had >5 mm difference had mismatch.

The incidence of grafttunnel mismatch after anatomic ACLR using BTPB and anteromedial portal drilling in this study is 6%. To limit the occurrence of GTM where the graft is too long, surgeons should drill tibial tunnel distances within 5 mm of the patella tendon length.

Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position.

A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions.

Aim

The current antibiotic treatment of periprosthetic joint infection (PJI) is optimized by measuring concentrations in plasma. However, it remains unclear whether effective concentrations of the antibiotics are reached at the site of PJI. Nonetheless, adequate target site concentrations are important to achieve effective eradication of the micro-organism. In order to determine the efficacy of cefuroxime and flucloxacillin in synovial fluid, synovial tissue and bone tissue in relation to the minimal inhibitory concentration (MIC) of the pathogen causing the PJI, we perform a pharmacokinetic/pharmacodynamic (PK/PD) study. Therefore, we aimed to develop validated analytical methods for analysis of cefuroxime and flucloxacillin in synovial fluid, synovial tissue and bone tissue.

Aim

The aim of the present work was (i) to survey the situation of healthcare regarding the use of antibiotics in orthopaedics and trauma surgery in Germany, (ii) to determine which empiric antibiotic regimens are preferred in the treatment of periprosthethic joint infections (PJI) and (iii) to evaluate the hypothetical antibiotic adequacy of the applied empirical antibiotic therapy regimens based on a patient collective of a German university hospital.

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization.

The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week.

One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups.

Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone.

Aim

There is a lack of data supporting the use of doxycycline as a single agent after removing infected orthopaedic metalwork. We evaluated the efficacy and safety of doxycycline compared with other single antibiotic regimens used at our specialist orthopaedic hospital.

Distal radius fractures (DRF) are common and the indication for surgical treatment remain controversial in patients higher than 60 years old. The purpose of the study was to review and analyze the current evidence-based literature.

We performed a systematic review and meta-analysis according to PRISMA guidelines in order to evaluate the efficacy of volar locking plating (VLP) and conservative treatment in DRF in patients over 60 years old. Electronic databases including MEDLINE, CENTRAL, Embase, Web of science and Clinical Trial.gov were searched from inception to October 2020 for randomized controlled trials. Relevant article reference lists were also passed over.

Two reviewers independently screened and extracted the data. Main outcomes included functional status: wrist range of motion, validated scores and grip strength. Secondary outcomes include post-operative complications and radiologic assessment.

From 3009 screened citations, 5 trials (539 patients) met the inclusion criteria. All trials of this random effect meta-analysis were at moderate risk of bias due to lack of blinding. Differences in the DASH score (MD −5,91; 95% CI, −8,83; −3,00), PRWE score (MD −9.07; 95% CI, −14.57, −3.57) and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs. No effect was observed in terms of range of motion. Adverse events are frequent in both treatment groups, reoperation rate is higher in the VLP group.

VLP may provide better functional outcomes in patients higher than 60 years old. More RCT are still needed to evaluate if the risks and complications of VLP outweigh the benefits.

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs.

Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures.

We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons).

We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries.

The widely used Fracture Risk Assessment Tool (FRAX) estimates a 10-year probability of major osteoporotic fracture (MOF) using age, sex, body mass index, and seven clinical risk factors, including prior history of fracture. Prior fracture is a binary variable in FRAX, although it is now clear that prior fractures affect future MOF risk differently depending on their recency and site. Risk of MOF is highest in the first two years following a fracture and then progressively decreases with time – this is defined as imminent risk. Therefore, the FRAX tool may underestimate true fracture risk and result in missed opportunities for earlier osteoporosis management in individuals with recent MOF. To address this, multipliers based on age, sex, and fracture type may be applied to baseline FRAX scores for patients with recent fractures, producing a more accurate prediction of both short- and long-term fracture risk. Adjusted FRAX estimates may enable earlier pharmacologic treatment and other risk reduction strategies. This study aimed to report the effect of multipliers on conventional FRAX scores in a clinical cohort of patients with recent non-hip fragility fractures.

After obtaining Research Ethics Board approval, FRAX scores were calculated both before and after multiplier adjustment, for patients included in our outpatient Fracture Liaison Service who had experienced a non-hip fragility fracture between June 2020 and November 2021. Patients age 50 years or older, with recent (within 3 months) forearm (radius and/or ulna) or humerus fractures were included. Exclusion criteria consisted of patients under the age of 50 years or those with a hip fracture. Age- and sex-based FRAX multipliers for recent forearm and humerus fractures described by McCloskey et al. (2021) were used to adjust the conventional FRAX score. Low, intermediate and high-risk of MOF was defined as less than 10%, 10-20%, and greater than 20%, respectively. Data are reported as mean and standard deviation of the mean for continuous variables and as proportions for categorical variables.

A total of 91 patients with an average age of 64 years (range = 50-97) were included. The majority of patients were female (91.0%), with 73.6% sustaining forearm fractures and 26.4% sustaining humerus fractures. In the forearm group, the average MOF risk pre- and post-multiplier was 16.0 and 18.8, respectively. Sixteen percent of patients (n = 11) in the forearm group moved from intermediate to high 10-year fracture risk after multiplier adjustment. Average FRAX scores before and after adjustment in the humerus group were 15.7 and 22.7, respectively, with 25% (n = 6) of patients moving from an intermediate risk to a high-risk score.

This study demonstrates the clinically significant impact of multipliers on conventional FRAX scores in patients with recent non-hip fractures. Twenty-five percent of patients with humerus fractures and 16% of patients with forearm fractures moved from intermediate to high-risk of MOF after application of the multiplier. Consequently, patients who were previously ineligible for pharmacologic management, now met criteria. Multiplier-adjusted FRAX scores after a recent fracture may more accurately identify patients with imminent fracture risk, facilitating earlier risk reduction interventions.

Conferences centered around surgery suffers from gender disparity with male faculty having a more dominant presence in meetings compared to female faculty. Orthopedic Surgery possibly suffers the most from this problem of all surgical specialties, and is reflective of a gender disparity in the field. The objective of this study was to investigate the prevalence of “manels”, or male-only sessions, in eight major Orthopedic Surgery meetings hosted in 2021 and to quantify the differences in location of practice, academic position, years of practice, and research qualifications between male and female faculty.

Eight Orthopedic conferences organized by major Orthopedic associations (AAOS, COA, OTA, EFORT, AAHKS, ORS, NASS, and AOSSM) from February 2021 to November 2021 were analyzed. Meeting information was retrieved from the conference agendas, and details of chairs and speakers were obtained from Linkedin, Doximity, CPSO, personal websites, and Web of Science. Primary outcomes included: one) percentage of male faculty in all included sessions and two) overall percentage of manels. Secondary outcomes included one) percentage of male speakers and chairs in all included sessions, two) overall percentage of male-chair and male-speaker only sessions. Comparisons for outcomes were made between conferences and session topics (adult reconstruction hip, adult reconstruction knee, practice management/rehabilitation, trauma, sports, general, pediatrics, upper extremity, musculoskeletal oncology, foot and ankle, spine, and miscellaneous). Mean number of sessions for male and female were compared after being stratified into quartiles based on publications, sum of times cited, and H-indexes. Data was analyzed with non-parametric analysis, chi-square tests, or independent samples t-tests using SPSS version 28.0.0.0 with a p-value of < 0 .05 being considered statistically significant.

Of 193 included sessions, 121 (62.3%) were manels and the mean percentage of included faculty that was male was 88.9% Apart from the topics of practice management/rehabilitation and musculoskeletal oncology, male representation was very high. Additionally, most included conferences had an extremely high percentage of male representation apart from meetings hosted by the COA and ORS. Non-manel sessions had a greater mean number of chairs (p=0.006), speakers (p < 0 .001), and faculty (p < 0 .001) than manel sessions. Of 1080 total included faculty members, 960 (88.9%) were male. Male faculty were more likely to be Orthopedic surgeons than female faculty (p < 0 .001) while also more likely to hold academic rank as a professor. Mean number of sessions between male and female faculty within their respective quartiles of H-indexes, sum of times cited, and number of publications did not reach statistical significance. Mean years of practice between male and female faculty was also not significantly different.

There is a high prevalence of manels and an overall lack of female representation in Orthopedic meetings. Orthopedic associations should aim to make efforts to increase gender equity in future meetings.

7% of adolescent idiopathic scoliosis (AIS) patients also present with a pars defect. To date, there are no available data on the results of fusion ending proximal to a spondylolysis in the setting of AIS. The aim of this study was to analyze the outcomes of posterior spinal fusion (PSF) in this patient cohort, to investigate if maintaining the lytic segment unfused represents a safe option.

Retrospective review of all patients who received PSF for AIS, presented with a spondylolysis or spondylolisthesis and had a min. 2-years follow-up. Demographic data, instrumented levels and preoperative radiographic data were collected. Mechanical complications, coronal or sagittal parameters, amount of slippage and pain levels were evaluated.

Data from 22 patients were available (age 14.4 ± 2.5 years), 18 Lenke 1–2 and four Lenke 3–6. Five patients (24%) had an isthmic spondylolisthesis, all Meyerding I. The mean preoperative Cobb angle of the instrumented curves was 58 ± 13°. For 18 patients the lowest instrumented vertebra (LIV) was the last touched vertebra (LTV); for two LIV was distal to the LTV; for two, LIV was one level proximal to the LTV. The number of segments between the LIV and the lytic vertebra ranged from 1 to 6. At the last follow-up, no complications were observed. The residual curve below the instrumentation measured 8.5 ± 6.4°, the lordosis below the instrumented levels was 51.4 ± 13°. The magnitude of the isthmic spondylolisthesis remained constant for all included patients. Three patients reported minimal occasional low back pain.

The LTV can be safely used as LIV when performing PSF for the management of AIS in patients with L5 spondylolysis

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:

Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age.

The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001).

Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care.

Abstract

Cemented total hip arthroplasty (THA) in the younger patient has historically been associated with higher wear and revision rates. We carried out a retrospective study of a prospectively collected database of patients at Wrightington hospital undergoing cemented THA under 55 years of age to determine acetabular wear and revision rates.

Between August 2005 and December 2021 a cohort of 110 patients, 56 males and 54 females, underwent Cemented Total Hip Replacement through a posterior approach. Mean age at operation was 50yrs (35–55). The mean follow up was 6 years 9 months (0–16 years). 3 patients were lost to follow-up. Of the remaining 107 patients, Conventional and cross lined polyethylene were used in 54 and 53 patients respectively. Ceramic heads were used in 102 patients. 22.225mm and 28mm heads were used in 60 and 47 patients respectively. Clinical outcomes were assessed by Merle d'Aubigne and Postel scores which showed significant functional improvement. Linear wear was measured on plain radiographs using TRAUMA CAD and cup loosening was assessed by classification of Hodgkinson et al.

No cases were revised during the observed follow up period. The mean wear rate in conventional and crosslinked polyethylene cups were 2.31mm (0.1–4.6) and 1.02mm (0.1–2.6) respectively.

Cemented THA with both conventional and crosslinked polyethylene provides excellent survival rates in adults under the age of 55 years and crosslinked polyethylene may further improve these results due to improved wear rates.

Knowledge of the premorbid glenoid shape and the morphological changes the bone undergoes in patients with glenohumeral arthritis can improve surgical outcomes in total and reverse shoulder arthroplasty. Several studies have previously used scapular statistical shape models (SSMs) to predict premorbid glenoid shape and evaluate glenoid erosion properties. However, current literature suggests no studies have used scapular SSMs to examine the changes in glenoid surface area in patients with glenohumeral arthritis. Therefore, the purpose of this study was to compare the glenoid articular surface area between pathologic glenoid cavities from patients with glenohumeral arthritis and their predicted premorbid shape using a scapular SSM. Furthermore, this study compared pathologic glenoid surface area with that from virtually eroded glenoid models created without influence from internal bone remodelling activity and osteophyte formation. It was hypothesized that the pathologic glenoid cavities would exhibit the greatest glenoid surface area despite the eroded nature of the glenoid and the medialization, which in a vault shape, should logically result in less surface area.

Computer tomography (CT) scans from 20 patients exhibiting type A2 glenoid erosion according to the Walch classification [Walch et al., 1999] were obtained. A scapular SSM was used to predict the premorbid glenoid shape for each scapula. The scapula and humerus from each patient were automatically segmented and exported as 3D object files along with the scapular SSM from a pre-operative planning software. Each scapula and a copy of its corresponding SSM were aligned using the coracoid, lateral edge of the acromion, inferior glenoid tubercule, scapular notch, and the trigonum spinae. Points were then digitized on both the pathologic humeral and glenoid surfaces and were used in an iterative closest point (ICP) algorithm in MATLAB (MathWorks, Natick, MA, USA) to align the humerus with the glenoid surface. A Boolean subtraction was then performed between the scapular SSM and the humerus to create a virtual erosion in the scapular SSM that matched the erosion orientation of the pathologic glenoid. This led to the development of three distinct glenoid models for each patient: premorbid, pathologic, and virtually eroded (Fig. 1). The glenoid surface area from each model was then determined using 3-Matic (Materialise, Leuven, Belgium).

Figure 1. (A) Premorbid glenoid model, (B) pathologic glenoid model, and (C) virtually eroded glenoid model.

The average glenoid surface area for the pathologic scapular models was 70% greater compared to the premorbid glenoid models (P < 0 .001). Furthermore, the surface area of the virtual glenoid erosions was 6.4% lower on average compared to the premorbid glenoid surface area (P=0.361).

The larger surface area values observed in the pathologic glenoid cavities suggests that sufficient bone remodelling exists at the periphery of the glenoid bone in patients exhibiting A2 type glenohumeral arthritis. This is further supported by the large difference in glenoid surface area between the pathologic and virtually eroded glenoid cavities as the virtually eroded models only considered humeral anatomy when creating the erosion.

For any figures or tables, please contact the authors directly.

Aim

The treatment of fracture-related infections (FRI) focuses on obtaining fracture healing and eradicating infection to prevent osteomyelitis. Treatment guidelines include removal, exchange, or retention of the implants used according to the stability of the fracture and the time from the infection. Infection of a fracture in the process of healing with a stable fixation may be treated with implant retention, debridement, and antibiotics. Nonetheless, the retention of an intramedullary nail is a potential risk factor for failure, and it is recommended to exchange or remove the nail. This surgical approach implies additional life-threatening risks in elderly fragile hip fracture patients.

Our study aimed to analyze the results of implant retention for the treatment of infected nails in elderly hip fracture patients.

The benefits of HXLPE in total knee arthroplasty (TKA) have not been as evident as total hip arthroplasty (THA). A systematic review and meta-analysis to assess the impact of highly-crosslinked polyethylene (HXLPE) on TKA outcomes compared to conventional polyethylene (CPE) is described.

All studies comparing HXLPE with CPE for primary TKA were included for analysis. The minimum dataset included revision rates, indication for revision, aseptic component loosening and follow-up time. The primary outcome variables were all-cause revision, aseptic revision, revision for loosening, radiographic component loosening, osteolysis and incidence of radiolucent lines. Secondary outcome measures included postoperative functional knee scores. A random-effects meta-analysis allowing for all missing data was performed for all primary outcome variables.

Six studies met the inclusion criteria. In total, there were 2,234 knees (1,105 HXLPE and 1,129 CPE). The combined mean follow-up for all studies was 6 years. The aseptic revision rate in the HXLPE group was 1.02% compared to 1.97% in the CPE group. There was no difference in the rate of all-cause revision (p = 0.131), aseptic revision (p = 0.298) or revision for component loosening (p = 0.206) between the two groups. Radiographic loosening (p = 0.200), radiolucent lines (p = 0.123) and osteolysis (p = 0.604) was similar between both groups. Functional outcomes were similar between groups.

The use of HXLPE in TKA yields similar results for clinical and radiographic outcomes when compared to CPE at midterm follow-up. HXLPE does not confer the same advantages to TKA as seen in THA.

Aim

Culture-based conventional methods are still the gold standard to identify microorganisms in hip and knee PJIs diagnosis. However, such approach presents some limitations due to prior antimicrobial treatment or the presence of unusual and fastidious organisms. Molecular techniques, in particular specific real-time and broad-range polymerase chain reaction (PCR), are available for diagnostic use in a suspected PJI. However, limited data is available on their sensitivity and specificity.

This study aimed to evaluate the performance of a rapid and simple Investigational Use Only (IUO) version of the BioFire® JI multiplex PCR panel when compared to traditional microbiological procedures.

We recently performed a clinical trial comparing motor sparing blocks (MSB) to periarticular infiltration (PAI) following total knee arthroplasty (TKA). We found that MSBs provided longer analgesia (8.8 hours) than PAI with retention of quadriceps strength, and with similar function, satisfaction, and length of hospital stay. However, its potential increased cost could serve as a barrier to its adoption. Therefore, our aim was to compare the costs of MSBs to PAI following TKA.

We conducted a retrospective review of data from our previous RCT. There were 82 patients included in the RCT (n=41 MSB group, n=41 PAI group). We compared the mean total costs associated with each group until hospital discharge including intervention costs, healthcare professional service fees, intraoperative medications, length of stay, and postoperative opioid use.

Seventy patients were included (n=35 MSB group, n=35 PAI group). The mean total costs for the MSB group was significantly higher ($1959.46 ± 755.4) compared to the PAI group ($1616.25 ± 488.33), with a mean difference of $343.21 (95% CI = $73.28 to $664.11, p = 0.03). The total perioperative intervention costs for performing the MSB was also significantly higher however postoperative inpatient costs including length of stay and total opioid use did not differ significatnly.

Motor sparing blocks had significantly higher mean total and perioperative costs compared to PAI with no significant difference in postoperative inpatient costs. However, its quadricep sparing nature and previously demonstrated prolonged postoperative analgesia can be used to facilitate an outpatient TKA pathway thereby offsetting its increased costs.

Aim

Prompt recognition and identification of the causative microorganism in acute septic arthritis of native and prosthetic joints is vital to increase the chances of successful treatment. The aim of this study was to independently assess the diagnostic accuracy of the multiplex BIOFIRE® Joint Infection (JI) Panel (investigational use only) in synovial fluid for rapid diagnosis

Abstract

The diagnosis of infection following shoulder arthroplasty is notoriously difficult. The prevalence of prosthetic shoulder infection after arthroplasty ranges from 3.9 – 15.4% and the most common infective organism is Cutibacterium acnes. Current preoperative diagnostic tests fail to provide a reliable means of diagnosis including WBC, ESR, CRP and joint aspiration. Fluoroscopic-guided percutaneous synovial biopsy (PSB) has previously been reported in the context of a pilot study and demonstrated promising results. The purpose of this study was to determine the diagnostic accuracy of percutaneous synovial biopsy compared with open culture results (gold standard).

This was a multicenter prospective cohort study involving four sites and 98 patients who underwent revision shoulder arthroplasty. The cohort was 60% female with a mean age was 65 years (range 36-83 years). Enrollment occurred between June 2014 and November 2021. Pre-operative fluoroscopy-guided synovial biopsies were carried out by musculoskeletal radiologists prior to revision surgery. A minimum of five synovial capsular tissue biopsies were obtained from five separate regions in the shoulder. Revision shoulder arthroplasty was performed by fellowship-trained shoulder surgeons. Intraoperative tissue samples were taken from five regions of the joint capsule during revision surgery.

Of 98 patients who underwent revision surgery, 71 patients underwent both the synovial biopsy and open biopsy at time of revision surgery. Nineteen percent had positive infection based on PSB, and 22% had confirmed culture positive infections based on intra-operative tissue sampling. The diagnostic accuracy of PSB compared with open biopsy results were as follows: sensitivity 0.37 (95%CI 0.13-0.61), specificity 0.81 (95%CI 0.7-0.91), positive predictive value 0.37 (95%CI 0.13 – 0.61), negative predictive value 0.81 (95%CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77.

A patient with a positive pre-operative PSB undergoing revision surgery had an 37% probability of having true positive infection. A patient with a negative pre-operative PSB has an 81% chance of being infection-free. PSB appears to be of value mainly in ruling out the presence of peri-prosthetic infection. However, poor likelihood ratios suggest that other ancillary tests are required in the pre-operative workup of the potentially infected patient.

Tourniquet use in total knee arthroplasty (TKA) remains a subject of considerable debate. A recent study questioned the need for tourniquets based on associated risks. However, the study omitted analysis of crucial tourniquet-related parameters which have been demonstrated in numerous studies to be associated with safe tourniquet use and reduction of adverse events. The current utilization and preferences of tourniquet use in Canada remain unknown. Our primary aim was to determine the current practices, patterns of use, and opinions of tourniquet use in TKA among members of the Canadian Arthroplasty Society (CAS). Additionally, we sought to determine the need for updated best practice guidelines to inform optimal tourniquet use and to identify areas requiring further research.

A self-administered survey was emailed to members of the CAS in October 2021(six-week period). The response rate was 57% (91/161). Skip logic branching was used to administer a maximum of 59 questions related to tourniquet use, beliefs, and practices. All respondents were staff surgeons and 88% were arthroplasty fellowship trained. Sixty-five percent have been in practice for ≥11 years and only 16% for 50 TKA/year, 59% have an academic practice, and >67% prefer cemented TKA.

Sixty-six percent currently use tourniquets, 25% no longer do but previously did, and 9% never used tourniquets. For those not using tourniquets, the most common reasons are potential harm/risks and publications/conferences. Among current users, 48% use in all cases and an additional 37% use in 76-99% of cases. The top reason for use was improved visualization/bloodless field (88%), followed by performing a cemented TKA, used in training, and faster operative times. The main patient factor influencing selective tourniquet use was peripheral vascular disease and main surgical factors were operative duration and cementless TKA. The most frequent adverse events reported were bruising/pinching under the tourniquet and short-term pain, which majority believed were related to improper tourniquet use (prolonged time, high-pressures, poor cuff fit), yet only 8% use contoured tourniquets and 32% don't use limb protection. Despite substantial evidence in literature that tourniquet safety and probability of harm are affected by tourniquet time and pressure, only 83% and 72% of respondents believe reducing tourniquet time and pressure respectively reduce the probability of harm. In addition, no surgeon utilizes personalized limb occlusion pressure which has been demonstrated to substantially reduce tourniquet pressure while being safe and effective. Furthermore, 62% always use fixed pressure and 37% will modify the pressure based on patient parameters, most often systolic blood pressure and limb size. Almost all (88%) were interested in new evidence-based guidelines regarding these parameters.

Tourniquet use in TKA remains prevalent among arthroplasty surgeons in the CAS; however tremendous practice variability regarding several key parameters required for optimal use exists. Current best practices of tourniquet use regarding personalized pressures, time, and type are not being utilized across Canada. There is considerable interest and need for further research and updated guidelines regarding key parameters of safe tourniquet usage to optimize tourniquet use in TKA.

Although day surgery has a good patient satisfaction and safety profile, accurate episode-of-care costs (EOCC) calculation for of this procedure compared to standard same-day admission (SDA), while considering functional outcomes, is not well known. This study assesses the EOCC for patients with a THA while comparing DS and Same Day Admission (SDA) (with a 1-day hospitalization) pathways.

The episode-of-care cost (EOCC) of 50 consecutive day surgery and SDA patients who underwent a THA was evaluated. The episode-of-care cost was determined using a bottom-up Time Driven- Activity Based Funding method. Functional outcomes were measured using preoperative and postoperative Harris Hip Score (HHS).

Overall, the SDA THA cost 11% more than a DS THA. The mean total EOCC of DS THA was 9 672 CAD compared to 10 911 CAD in the SDA THA group. Both groups showed an improvement in HHS score following the procedure but patients in the DS group had a significantly higher postoperative HHS score and a significantly greater improvement in their HHS score postoperatively.

Day surgery THA is cost-effective, safe and associated with high patient satisfaction due to functional improvement. Providing policymakers the information to develop optimal financing methods is paramount for clinicians wishing to develop modern protocols, increase productivity while providing the optimal care for patients.

Hip resurfacing may be a useful surgical procedure when patient selection is correct and only implants with superior performance are used. In order to establish a body of evidence in relation to hip resurfacing, pseudotumour formation and its genetic predisposition, we performed a case-control study investigating the role of HLA genotype in the development of pseudotumour around MoM hip resurfacings.

All metal-on-metal (MoM) hip resurfacings performed in the history of the institution were assessed. A total of 392 hip resurfacings were performed by 12 surgeons between February 1st 2005 and October 31st 2007. In all cases, pseudotumour was confirmed in the preoperative setting on Metal Artefact Reduction Sequencing (MARS) MRI. Controls were matched by implant (ASR or BHR) and absence of pseudotumour was confirmed on MRI. Blood samples from all cases and controls underwent genetic analysis using Next Generation Sequencing (NGS) assessing for the following alleles of 11 HLA loci (A, B, C, DRB1, DRB3/4/5, DQA1, DQB1, DPB1, DPA1). Statistical significance was determined using a Fisher's exact test or Chi-Squared test given the small sample size to quantify the clinical association between HLA genotype and the need for revision surgery due to pseudotumour.

Both groups were matched for implant type (55% ASR, 45% BHR in both the case and control groups). According to the ALVAL histological classification described by Kurmis et al., the majority of cases (63%, n=10) were found to have group 2 histological findings. Four cases (25%) had group 3 histological findings and 2 (12%) patients had group 4 findings. Of the 11 HLA loci analysed, 2 were significantly associated with a higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) and 4 were noted to be protective against pseudotumour formation (DQA1*03:01:01, DRB1*04:04:01, C*01:02:01, B*27:05:02).

These findings further develop the knowledge base around specific HLA genotypes and their role in the development of pseudotumour formation in MoM hip resurfacing. Specifically, the two alleles at higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) in MoM hip resurfacing should be noted, particularly as patient-specific genotype-dependent surgical treatments continue to develop in the future.

Abstract

The aim is to describe the safety and efficacy of TAL in out-patient clinics when managing diabetic forefoot ulcers.

Demand for total knee arthroplasty (TKA) is increasing as it remains the gold-standard treatment for end-stage osteoarthritis (OA) of the knee. While magnetic-resonance imaging (MRI) scans of the knee are not indicated for diagnosing knee OA, they are commonly ordered prior to the referral to an orthopaedic surgeon. The purpose of this study was to determine the proportion of patients who underwent an MRI in the two years prior to their primary TKA for OA. Secondary outcomes included determining patient and physician associations with increased MRI usage.

This is a population-based cohort study using billing codes in Ontario, Canada. All patients over 40 years-old who underwent a primary TKA between April 1, 2008 and March 31, 2017 were included. Statistical analyses were performed using SAS and included the Cochran-Armitage test for trend of MRI prior to surgery, and predictive multivariable regression model. Significance was set to p<0.05.

There were 172,689 eligible first-time TKA recipients, of which 34,140 (19.8%) received an MRI in the two years prior to their surgery. The majority of these (70.8%) were ordered by primary care physicians, followed by orthopaedic surgeons (22.5%). Patients who received an MRI were younger and had fewer comorbidities than patients who did not (p<0.001). MRI use prior to TKA increased from 15.9% in 2008 to 20.1% in 2017 (p<0.0001).

Despite MRIs rarely being indicated for the work-up of knee OA, nearly one in five patients have an MRI in the two years prior to their TKA. Reducing the use of this prior to TKA may help reduce wait-times for surgery.