Aims

The metabolic equivalent of task (MET) score examines patient performance in relation to energy expenditure before and after knee arthroplasty. This study assesses its use in a knee arthroplasty population in comparison with the widely used Oxford Knee Score (OKS) and EuroQol five-dimension index (EQ-5D), which are reported to be limited by ceiling effects.

Dislocation is one of the most common complications in total hip arthroplasty (THA) and is primarily driven by bony or prosthetic impingement. The aim of this study was two-fold. First, to develop a simulation that incorporates the functional position of the femur and pelvis and instantaneously determines range of motion (ROM) limits. Second, to assess the number of patients for whom their functional bony alignment escalates impingement risk.

468 patients underwent a preoperative THA planning protocol that included functional x-rays and a lower limb CT scan. The CT scan was segmented and landmarked, and the x-rays were measured for pelvic tilt, femoral rotation, and preoperative leg length discrepancy (LLD). All patients received 3D templating with the same implant combination (Depuy; Corail/Pinnacle). Implants were positioned according to standardised criteria.

Each patient was simulated in a novel ROM simulation that instantaneously calculates bony and prosthetic impingement limits in functional movements. Simulated motions included flexion and standing-external rotation (ER). Each patient's ROM was simulated with their bones oriented in both functional and neutral positions.

13% patients suffered a ROM impingement for functional but not neutral extension-ER. As a result, 48% patients who failed the functional-ER simulation would not be detected without consideration of the functional bony alignment. 16% patients suffered a ROM impingement for functional but not neutral flexion. As a result, 65% patients who failed the flexion simulation would not be detected without consideration of the functional bony alignment.

We have developed a ROM simulation for use with preoperative planning for THA surgery that can solve bony and prosthetic impingement limits instantaneously. The advantage of our ROM simulation over previous simulations is instantaneous impingement detection, not requiring implant geometries to be analysed prior to use, and addressing the functional position of both the femur and pelvis.

In 2021, Vigdorchik et al. published a large multicentre study validating their simple Hip-Spine Classification for determining patient-specific acetabular component positioning in total hip arthroplasty (THA). The purpose of our study was to apply this Hip-Spine Classification to a sample of Australian patients undergoing THA surgery to determine the local acetabular component positioning requirements. Additionally, we propose a modified algorithm for adjusting cup anteversion requirements.

790 patients who underwent THA surgery between January 2021 and June 2022 were assessed for anterior pelvic plane tilt (APPt) and sacral slope (SS) in standing and relaxed seated positions and categorized according to their spinal stiffness and flatback deformity. Spinal stiffness was measured using pelvic mobility (PM); the ΔSS between standing and relaxed seated. Flatback deformity was defined by APPt <−13° in standing. As in Vigdorchik et al., PM of <10° was considered a stiff spine. For our algorithm, PM of <20° indicated the need for increased cup anteversion. Using this approach, patient-specific cup anteversion is increased by 1° for every degree the patient's PM is <20°.

According to the Vigdorchik simple Hip-Spine classification groups, we found: 73% Group 1A, 19% Group 1B, 5% Group 2A, and 3% Group 2B. Therefore, under this classification, 27% of Australian THA patients would have an elevated risk of dislocation due to spinal deformity and/or stiffness. Under our modified definition, 52% patients would require increased cup anteversion to address spinal stiffness.

The Hip-Spine Classification is a simple algorithm that has been shown to indicate to surgeons when adjustments to acetabular cup anteversion are required to account for spinal stiffness or flatback deformity. We investigated this algorithm in an Australian population of patients undergoing THA and propose a modified approach: increasing cup anteversion by 1° for every degree the patient's PM is <20°.

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.

Ankle fractures in the elderly are common and have a mortality rate of 12% within the first year. Treatment is challenging due to osteoporotic bone and patient co-morbidities. Many patients struggle with non-weight-bearing (NWB) and presently there is no consensus in the literature regarding optimum management of these injuries.

We hypothesised that early weight-bearing in frail patients, Clinical Frailty scale (CFS) score of 4 or more will reduce morbidity and allow patients to return to their usual place of residence faster without jeopardising clinical outcome.

We conducted a retrospective analysis of 80 patients aged over 65 years managed at Fiona Stanley Hospital for ankle fractures between January 2016 and 2018. Patients were divided into two cohorts: 40 patients managed NWB and 40 who were permitted to weight-bear as tolerated (WBAT). Patients were stratified as fit (CFS 1–3) or frail (CFS 4+). Primary outcomes were one-year mortality, return to primary residence at six weeks and complications. Secondary outcomes included length of acute hospital stay and rehab stay.

For frail patients, those managed NWB stayed in rehab for 19 days longer (p=0.03) and had 28% more complications (p=0.03). By 6 weeks, fewer patients returned to full weight-bearing (p=0.03) and fewer patients had returned home (p=0.01). For fit patients, there were no significant differences in primary outcomes between NWB and WBAT.

Our novel study categorising patients by CSF demonstrates that early mobilisation in frail patients results in improved outcomes. Currently there is no formal treatment protocol for the management of ankle fractures in the elderly, and we hope that our proposed algorithm will assist surgeons at our institution and elsewhere.

Our study suggests that WBAT may benefit frail patients. We propose a protocol to assist in the management of geriatric ankle fracture patients based on clinical frailty scores.

The purpose of this study was to determine whether there have been changes in the complexity of femoral fragility fractures presenting to our Dunedin Orthopaedic Department, New Zealand, over a period of ten years.

Patients over the age of 60 presenting with femoral fragility fractures to Dunedin Hospital in 2009 −10 (335 fractures) were compared with respect to demographic data, incidence rates, fracture classification and treatment details to the period 2018-19 (311 fractures). Pathological and high velocity fractures were excluded.

The gender proportion and average age (83.1 vs 83.0 years) was unchanged. The overall incidence of femoral fractures in people over 60 years in our region fell by 27% (p<0.001). Intracapsular fractures (31 B1 and B2) fell by 29% (p=0.03) and stable trochanteric fractures by 56% (p<0.001). The incidence of unstable trochanteric fractures (31A2 and 31A3) increased by 84.5% from 3.5 to 6.4/10,000 over 60 years (p = 0.04). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 8% to 37% (p <0.001). Fewer intracapsular fractures were treated by internal fixation (p<0.001) and the rate of acute total hip joint replacements increased from 13 to 21% (p=0.07). The incidence of femoral shaft fractures did not change significantly with periprosthetic fractures comprising 70% in both cohorts.

While there has been little difference in the numbers there has been a decrease in the incidence of femoral fragility fractures likely due to the increasing use of bisphosphonates. However, the incidence of unstable trochanteric fractures is increasing. This has led to the increased use of IM nails which are increasingly used for stable fractures as well.

The increasing complexity of femoral fragility fractures is likely to have an impact on implant use, theatre time and cost.

Imageless computer navigation systems have the potential to improve acetabular cup position in total hip arthroplasty (THA), thereby reducing the risk of revision surgery. This study aimed to evaluate the accuracy of three alternate registration planes in the supine surgical position generated using imageless navigation for patients undergoing THA via the direct anterior approach (DAA).

Fifty-one participants who underwent a primary THA for osteoarthritis were assessed in the supine position using both optical and inertial sensor imageless navigation systems. Three registration planes were recorded: the anterior pelvic plane (APP) method, the anterior superior iliac spines (ASIS) functional method, and the Table Tilt (TT) functional method. Post-operative acetabular cup position was assessed using CT scans and converted to radiographic inclination and anteversion. Two repeated measures analysis of variance (ANOVA) and Bland-Altman plots were used to assess errors and agreement of the final cup position.

For inclination, the mean absolute error was lower using the TT functional method (2.4°±1.7°) than the ASIS functional method (2.8°±1.7°, ρ = .17), and the ASIS anatomic method (3.7°±2.1, ρ < .001). For anteversion, the mean absolute error was significantly lower for the TT functional method (2.4°±1.8°) than the ASIS functional method (3.9°±3.2°, ρ = .005), and the ASIS anatomic method (9.1°±6.2°, ρ < .001). All measurements were within ± 10° for the TT method, but not the ASIS functional or APP methods.

A functional registration plane is preferable to an anatomic reference plane to measure intra-operative acetabular cup inclination and anteversion accurately. Accuracy may be further improved by registering patient location using their position on the operating table rather than anatomic landmarks, particularly if a tighter target window of ± 5° is desired.

To determine whether spinal facet osteoblasts at the curve apex display a different phenotype to osteoblasts from outside the curve in patients with adolescent idiopathic scoliosis (AIS). Intrinsic differences in the phenotype of spinal facet bone tissue and in spinal osteoblasts have been implicated in the pathogenesis of AIS. However, no study has compared the phenotype of facet osteoblasts at the curve apex with the facet osteoblasts from outside the curve in patients with AIS.

Facet bone tissue was collected from three sites, the concave and convex side at the curve apex and from outside the curve from three female patients with AIS (aged 13–16 years). Micro-CT analysis was used to determine the density and trabecular structure. Osteoblasts were then cultured from the sampled bone. Osteoblast phenotype was investigated by assessing cellular proliferation (MTS assay), cellular metabolism (alkaline phosphatase and Seahorse Analyser), bone nodule mineralisation (Alizarin red assay), and the mRNA expression of Wnt signalling genes (quantitative RT-PCR).

Convex bone showed greater bone mineral density and trabecular thickness than did concave bone. The convex side of the curve apex exhibited a significantly higher proliferative and metabolic phenotype and a greater capacity to form mineralised bone nodules than did concave osteoblasts. mRNA expression of SKP2 was significantly greater in both concave and convex osteoblasts than in non-curve osteoblasts. The expression of SFRP1 was significantly downregulated in convex osteoblasts compared with either concave or non-curve.

Intrinsic differences that affect osteoblast function are exhibited by spinal facet osteoblasts at the curve apex in patients with AIS.

Aims

Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD.

With the rising rates, and associated costs, of total knee arthroplasty (TKA), enhanced clarity regarding patient appropriateness for TKA is warranted. Towards addressing this gap, we elucidated in qualitative research that surgeons and osteoarthritis (OA) patients considered TKA need, readiness/willingness, health status, and expectations of TKA most important in determining patient appropriateness for TKA. The current study evaluated the predictive validity of pre-TKA measures of these appropriateness domains for attainment of a good TKA outcome.

This prospective cohort study recruited knee OA patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those receiving primary, unilateral TKA completed questionnaires pre-TKA assessing TKA need (WOMAC-pain, ICOAP-pain, NRS-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, prior OA treatment), TKA readiness/willingness (Patient Acceptable Symptom State (PASS), willingness to undergo TKA), health status (PHQ-8, BMI, MSK and non-MSK comorbidities), TKA expectations (HSS KR Expectations survey items) and contextual factors (e.g., age, gender, employment status). One-year post-TKA, we assessed for a ‘good outcome’ (yes/no), defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with TKA results. Multiple logistic regression, stepwise variable selection, and best possible subsets regression was used to identify the model with the smallest number of independent variables and greatest discriminant validity for our outcome. Receiver Operating Characteristic (ROC) curves were generated to compare the discriminative ability of each appropriateness domain based on the ‘area under the ROC curve’ (AUC). Multivariable robust Poisson regression was used to assess the relationship of the variables to achievement of a good outcome.

f 1,275 TKA recipients, 1,053 (82.6%) had complete data for analyses (mean age 66.9 years [SD 8.8]; 58.6% female). Mean WOMAC pain and KOOS-PS scores were 11.5/20 (SD 3.5) and 52.8/100 (SD 17.1), respectively. 78.1% (95% CI 75.4–80.5%) achieved a good outcome. Stepwise variable selection identified optimal discrimination was achieved with 13 variables. The three best 13-variable models included measures of TKA need (WOMAC pain, KOOS-PS), readiness/willingness (PASS, TKA willingness), health status (PHQ-8, troublesome hips, contralateral knee, low back), TKA expectations (the importance of improved psychological well-being, ability to go up stairs, kneel, and participate in recreational activities as TKA outcomes), and patient age. Model discrimination was fair for TKA need (AUC 0.68, 95% CI 0.63-0.72), TKA readiness/willingness (AUC 0.61, 95% CI 0.57-0.65), health status (AUC 0.59, 95% CI 0.54-0.63) and TKA expectations (AUC 0.58, 95% CI 0.54-0.62), but the model with all appropriateness variables had good discrimination (AUC 0.72, 95% CI 0.685-0.76). The likelihood of achieving a good outcome was significantly higher for those with greater knee pain, disability, unacceptable knee symptoms, definite willingness to undergo TKA, less depression who considered improved ability to perform recreational activities or climb stairs ‘very important’ TKA outcomes, and lower in those who considered it important that TKA improve psychological wellbeing or ability to kneel.

Beyond surgical need (OA symptoms) and health status, assessment of patients’ readiness and willingness to undergo, and their expectations for, TKA, should be incorporated into assessment of patient appropriateness for surgery.

Background

Involving research users in setting priorities for research is essential to ensure research outcomes are patient-centred and to maximise research value and impact. The Musculoskeletal (MSK) Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across MSK disorders.

Children undergoing posterior spinal fusion (PSF) for neuromuscular and syndromic scoliosis were admitted to the paediatric intensive care (PIC) until about 6 years ago, at which time we created a new unit, a hospital floor-based spinal high-dependency unit-plus (SHDU-plus), in response to frequent bed-shortage cancellations. This study compares postoperative management on PIC with HDU-plus for these non-hospital floor suitable children with syndromic and neuromuscular scoliosis undergoing PSF.

Retrospective review of 100 consecutive children with syndromic and neuromuscular scoliosis undergoing PSF between June 2016 and January 2022. Inclusion criteria were: 1) diagnosis of syndromic or neuromuscular scoliosis, 2) underwent PSF, 3) not suitable for immediate postoperative hospital floor-based care. Exclusion criteria were children with significant cardio-respiratory co-morbidity requiring PIC postoperatively.

55 patients were managed postoperatively on PIC and 45 on SHDU-plus. No significant difference between groups was found with respect to age, weight, ASA grade, preoperative Cobb angles, operative duration, number of levels fused and estimated blood loss. 4 patients in the PIC group and 1 in the SHDU-plus group were readmitted back to PIC or HDU following step-down to the hospital floor. Average length of stay was 2 days on PIC and 1 day on SHDU-plus. Average total length of hospital stay was 16.5 days in the PIC group and 10.5 days in the HDU-plus group. 19 (35%) patients developed complications in the PIC group, compared to 18 (40%) in SHDU-plus. Mean specialist unit charge per day was less on SHDU-plus compared with PIC. There were no bed-shortage cancellations in the SHDU-plus group, compared to 11 in the PIC group.

For children with neuromuscular or syndromic scoliosis undergoing PSF and deemed not suitable for post-operative care on the hospital floor, creation of a SHDU-plus was associated with fewer readmissions back to PIC or HDU, shorter hospital stays, an equivalent complication rate, significant cost-saving and fewer cancellations. Level of Evidence: Therapeutic Level III.

We previously reported that osteoblasts at the curve apex in adolescent idiopathic scoliosis (AIS) exhibit a differential phenotype, compared to non-curve osteoblasts(1). However, the Hueter-Volkmann principle on vertebral body growth in spinal deformities (2) suggests this could be secondary to altered biomechanics. This study examined whether non-curve osteoblasts subjected to mechanical strain resemble the transcriptomic phenotype of curve apex osteoblasts.

Facet spinal tissue was collected perioperatively from three sites, (i) the concave and (ii) convex side at the curve apex and (iii) from outside the curve (non-curve) from six AIS female patients (age 13–18 years; NRES 19/WM/0083). Non-curve osteoblasts were subjected to strain using a 4-point bending device. Osteoblast phenotype was determined by RNA sequencing and bioinformatic pathway analysis.

RNAseq revealed that curve apex osteoblasts exhibited a differential transcriptome, with 1014 and 1301 differentially expressed genes (DEGs; p<0.05, fold-change >1.5) between convex/non-curve and concave/non-curve sites respectively. Non-curve osteoblasts subjected to strain showed increased protein expression of the mechanoresponsive biomarkers COX2 and C-Fos. Comparing unstimulated vs strain-induced non-curve osteoblasts, 423 DEGs were identified (p<0.05, fold-change >1.5). Of these DEGs, only 5% and 6% were common to the DEGs found at either side of the curve apex, compared to non-curve cells. Bioinformatic analysis of these strain-induced DEGs revealed a different array of canonical signalling pathways and cellular processes, to those significantly affected in cells at the curve apex.

Mechanical strain of AIS osteoblasts in vitro did not induce the differential transcriptomic phenotype of AIS osteoblasts at the curve apex.

The lordosis distribution index (LDI) describes distribution of lumbar lordosis, measured as the % of lower lumbar lordosis (L4-S1) compared to global lordosis (L1-S1) with normal value 50–50%. Maldistributed LDI is associated with higher revision in short lumbar fusions, 4 vertebrae1. We hypothesise maldistributed LDI is also associated with mechanical failure in longer fusions.

Retrospective review of 29 consecutive ASD patients, aged 55+, undergoing long lumbar fusion, 4 levels, with >3-years follow-up. LDI, pelvic incidence (PI) and sagittal vertical axis (SVA) were measured on pre- and post-op whole spine standing X-rays (Fig A and B). Patients were categorized according to their pelvic incidence (PI) and postoperative LDI: Normal (LDI 50 80), Hypolordotic (LDI < 50), or Hyperlordotic (LDI > 80) and assessed for failure rate compared to normal LDI and PI <60.

Mean follow-up 4.5 years. 19 patients had mechanical failures including junctional failure and metalware fracture. PI >60o was associated with higher mechanical failure rates (Chi^2 p<0.05). Hypolordotic LDI was associated with 82% mechanical failure (Chi^2 p<0.001), Hyperlordotic 88% mechanical failure (Chi^2 p<0.001) and Normal 8% mechanical failure (Table 1).

Maldistributed LDI, whether Hyperlordotic or Hypolordotic, correlated with 10× greater mechanical failure rate compared to Normal LDI in long fusions. LDI is a useful measurement that should be considered, especially in high PI patients.

Abstract

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The Poole Traction Splint (PTS) is a non-invasive technique that applies dynamic traction to the affected digit using materials readily available in the outpatient department. The primary aim of this study was to document the outcome of the PTS for hand phalangeal fractures.

Over a four-year period (2017–2021), suitable patients were reviewed and referred for PTS to the hand physiotherapists. Functional outcome measures included range of motion (ROM), return to work, and a DASH score. In addition, a healthcare cost analysis was carried out.

A total of 63 patients were treated with a PTS from 2017 to 2021. Data was analysed for 54 patients with 55 digits. The mean age was 43 years (17–72) and 53.7% (n=29) were female. There were 43 fractures involving the proximal phalanx and 12 involving the middle phalanx. The mean final composite range of movement averaged 209˚ (110–270°), classified as ‘good/excellent’ by ASSH criteria. The mean DASH score was 13.6 (0-43.2; n=45). All patients were able to return to work. Only two (3.7%) digits required conversion to surgical fixation. The PTS resulted in approximate savings of £2,452 per patient.

The PTS is a cost-effective non-invasive low risk outpatient treatment method which provides a functional ROM and good functional outcomes in the treatment of complex phalangeal hand fractures, with minimal risk of surgical intervention being required.

Aims

The aim of this study was to compare any differences in the primary outcome (biphasic flexion knee moment during gait) of robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) at one year post-surgery.

Introduction

The burden of prosthetic joint infection (PJI) in total knee arthroplasty (TKA) has been rising in line with the number of primary operations performed. Current estimates suggest an infection rate of 1–2.4%. Two-stage revision has traditionally been considered the gold standard of treatment; however, some studies suggest comparable results can be achieved with single-stage procedures. The potential advantages include less time in hospital, a single anaesthetic, reduced costs, and greater patient satisfaction.

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs).

Abstract

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Shoulder replacements have evolved and current 4th generation implants allow intraoperative flexibility to perform anatomic, reverse, trauma, and revision shoulder arthroplasty. Despite high success rates with shoulder arthroplasty, complication rates high as 10–15% have been reported and progressive glenoid loosening remains a concern.

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Imageless computer navigation systems in total hip arthroplasty (THA) improve acetabular cup position, thereby reducing the risk of revision surgery for all causes as well as dislocation. We aimed to evaluate the registration accuracy of 3 alternate registration planes.

A prospective, observational study was conducted with 45 THA in the supine position using two imageless navigation systems and 3 registration planes. Patient position was registered sequentially using an optical system (Stryker OrthoMap) and an inertial sensor-based system (Navbit Sprint) with 3 planes of reference: (Plane 1) an anatomical plane using the anterior superior iliac spines (ASISs) and the pubic symphysis; (Plane 2) a functional plane parallel to the line between the ASISs and the table plane; and, (Plane 3) a functional plane that was perpendicular to the gravity vector and aligned with the longitudinal axis of the patient. The 3 measurements of acetabular cup inclination and anteversion were compared with the measurements from postoperative computed tomography (CT) scans.

For inclination, the mean absolute error was significantly lower for Plane 3 (1.80°) than for Plane 2 (2.74°), p = .038 and was lower for both functional planes than for the anatomical plane (3.75°), p < .001.

For anteversion, the mean absolute error was significantly lower for Plane 3 (2.00°) than for Plane 2 (3.69°), p = .004 and was lower for both functional planes than for the anatomical plane (8.58°), p < .001.

Patient registration using functional planes more accurately measured the acetabular cup position than registration using anatomic planes.

Aims

The aim of this study was to compare the clinical outcomes of robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) during the first six weeks and at one year postoperatively.

Cemented total hip replacement (THR) provides excellent outcomes and is cost-effective. Polished taper-slip (PTS) stems demonstrate successful results and have overtaken traditional composite-beam (CB) stems. Recent reports indicate they are associated with a higher risk of postoperative periprosthetic femoral fracture (PFF) compared to CB stems. This study evaluates risk factors influencing fracture characteristics around PTS and CB cemented stems.

Data were collected for 584 PFF patients admitted to eight UK centres from 25/05/2006-01/03/2020. Radiographs were assessed for Unified Classification System (UCS) grade and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (PTS versus CB). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI).

Median (IQR) age was 79.1 (72.0–86.0) years, 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The commonest AO/OTA type was spiral (352, 60.3%). Metaphyseal-split fractures occurred only with PTS stems with an incidence of 10.1%. Male gender was associated with a five-fold reduction in odds of a type C fracture (OR 0.22, 95% CI 0.12 to 0.41, p<0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51, 95% CI 3.72 to 24.34, p <0.001) and wedge fracture (OR 3.72, 95% CI 1.16 to 11.95, p <0.05) compared to PTS stems.

This is the largest study investigating PFF characteristics around cemented stems. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal-split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems had higher odds of bending type fractures (transverse and wedge) compared to PTS stems. Biomechanical testing is needed for validation and investigation of modifiable factors which may reduce the risk of unstable fracture patterns requiring complex revision surgery over internal fixation.

The Exeter^™ V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

A systematic literature search was performed adhering to PRISMA criteria. In parallel we performed a retrospective single centre study of Exeter^™ V40 femoral stem prosthetic fractures between April 2003– June 2020.

There are 25 reported cases of such prosthetic fractures confined to small case series and case reports within the literature. We report an additional 19 cases to the literature (mean age 66.3 ± 11.7 years; 12 female [63%]; body mass index 32.9 ± 5.9 kg/m²). The mean time from index procedure to fracture was 7.8 years (2.5–16.3, ±3.6). Exeter V40 stem fracture incidence was 0.27%. Incidence was significantly higher in 125 mm length stems compared to ≥150 mm length stems (1.26% vs 0.13%, respectively, p <0.001) and revision arthroplasty (1.209% vs 0.149%, p <0.001). When comparing different stem length cohorts, 125-mm short-stem were associated with stem body fractures (92% vs 29%, p = 0.0095), earlier time to fracture (6.2 vs 11.0 years, p = 0.0018), younger patient age at time of fracture (62.7 vs 72.6 years old, p = 0.037) and female sex (75% vs 43%, p = 0.33).

This case series in conjunction with the systematic review provides evidence stem morphology plays a role in femoral implant fracture. This complication remains rare, although we report a significantly higher incidence at up to 17 years follow-up than in the literature. As femoral geometries remain the same, increasing BMIs in THR patients should raise concern. Short 125 mm length Exeter V40 stems undoubtedly have a role in restoring anatomy and biomechanics in smaller femoral geometries, although the surgeon has to appreciate the higher risk of stem fracture and the associated predisposing factors which may necessitate meticulous surgical technique and planning.

Periprosthetic fractures (PPF) of the femur following total hip arthroplasty represent a significant complication with a rising incidence. The commonest subtype is Vancouver B2 type, for which revision to a long uncemented tapered fluted stem is a widely accepted management. In this study we compare this procedure to the less commonly performed cement-in-cement revision.

All patients undergoing surgical intervention for a Vancouver B2 femoral PPF in a cemented stem from 2008 – 2018 were identified. We collated patient age, gender, ASA score, BMI, operative time, blood transfusion requirement, change in haemoglobin (Hb) level, length of hospital stay and last Oxford Hip Score (OHS). Radiographic analysis was performed to assess time to fracture union and leg length discrepancy. Complications and survivorship of implant and patients were recorded.

43 uncemented and 29 cement-in-cement revisions were identified. There was no difference in patient demographics between groups. A significantly shorter operative time was found in the cement-in-cement group, but there was no difference in transfusion requirement, Hb change, or length of hospital stay. OHS was comparable between groups. A non-significant increase in overall complication rates was found in the revision uncemented group, with a significantly higher dislocation rate. Time of union was comparable and there were no non-unions in the cement-in-cement group. A greater degree of stem subsidence was found in the uncemented group. There was no difference in any revision surgery required in either group. Three patients in the uncemented group died in the perioperative period, compared to none in the cement-in-cement group.

With appropriate patient selection, both cement-in-cement and long uncemented tapered stem revision represent appropriate treatment options for Vancouver B2 fractures.

Aims

Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics.

Aims

This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty.

Aims

The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures.

Aims

The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

Aims

Unicompartmental knee arthroplasty (UKA) is a bone-preserving treatment option for osteoarthritis localized to a single compartment in the knee. The success of the procedure is sensitive to patient selection and alignment errors. Robotic arm-assisted UKA provides technological assistance to intraoperative bony resection accuracy, which is thought to improve ligament balancing. This paper presents the five-year outcomes of a comparison between manual and robotically assisted UKAs.

INTRODUCTION

Determining proper joint tension in reverse total shoulder arthroplasty (rTSA) can be a challenging task for shoulder surgeons. Often, this is a subjective metric learned by feel during fellowship training with no real quantitative measures of what proper tension encompasses. Tension too high can potentially lead to scapular stress fractures and limitation of range of motion (ROM), whereas tension too low may lead to instability. New technologies that detect joint load intraoperatively create the opportunity to observe rTSA joint reaction forces in a clinical setting for the first time. The purpose of this study was to observe the differences in rTSA loads in cases that utilized two different humeral liner sizes.

Aims

Once knee arthritis and deformity have occurred, it is currently not known how to determine a patient’s constitutional (pre-arthritic) limb alignment. The purpose of this study was to describe and validate the arithmetic hip-knee-ankle (aHKA) algorithm as a straightforward method for preoperative planning and intraoperative restoration of the constitutional limb alignment in total knee arthroplasty (TKA).

Aims

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up.

Aims

The aim of this prospective cohort study was to evaluate the early migration of the TriFit cementless proximally coated tapered femoral stem using radiostereometric analysis (RSA).

Aims

The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory, which has led to a variable level of engagement in the UK. In 2019 NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR.

Abstract

Abstract