The reverse total shoulder replacement (rTSR) has excellent clinical outcomes and prosthesis longevity, and thus, the indications have expanded to a younger age group. The use of a stemless humeral implant has been established in the anatomic TSR; and it is postulated to be safe to use in rTSR, whilst saving humeral bone stock for younger patients. The Lima stemless rTSR is a relatively new implant, with only one paper published on its outcomes. This is a single-surgeon retrospective matched case control study to assess short term outcomes of primary stemless Lima SMR rTSR with 3D planning and Image Derived Instrumentation (IDI), in comparison to a matched case group with a primary stemmed Lima SMR rTSR with 3D planning and IDI. Outcomes assessed: ROM, satisfaction score, PROMs, pain scores; and plain radiographs for loosening, loss of position, notching. Complications will be collated. Patients with at least 1 year of follow-up will be assessed. With comparing the early radiographic and clinical outcomes of the stemless rTSR to a similar patient the standard rTSR, we can assess emerging trends or complications of this new device. 41 pairs of stemless and standard rTSRs have been matched, with 1- and 2-year follow up data. Data is currently being collated. Our hypothesis is that there is no clinical or radiographical difference between the Lima stemless rTSR and the traditional Lima stemmed rTSR.
Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores. A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated. There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort.
THA in patients with acetabular bone defects is associated with a high risk of dislocation. Dual mobility (DM) cups are known to prevent and treat chronic instability. The aim of this study was to evaluate the dislocation rate and survival of jumbo DM cups. This was a retrospective, continuous, multicenter study of all the cases of jumbo DM cup implantation between 2010 and 2017 in patients with acetabular bone loss (Paprosky 2A: 46%, 2B: 32%, 2C: 15% and 3A: 6%). The indications for implantation were revisions for aseptic loosening of the cup (n=45), aseptic loosening of the femoral stem (n=3), bipolar loosening (n=11), septic loosening (n=10), periprosthetic fracture (n=5), chronic dislocation (n=4), intraprosthetic dislocation (n=2), cup impingement (n=1), primary posttraumatic arthroplasty (n=8), and acetabular dysplasia (n=4). The jumbo cups used were COPTOS TH (SERF), which combines press-fit fixation with supplemental fixation (acetabular hook, two superior flanges with one to four screws, two acetabular pegs). A bone graft was added in 74 cases (80%). The clinical assessment consisted of the Harris hip score. The primary endpoint was surgical revision for aseptic acetabular loosening or the occurrence of a dislocation episode. In all, 93 patients were reviewed at a mean follow-up of 5.3 ± 2.3 years [0, 10]. As of the last follow-up, the acetabular cup had been changed in five cases: three due to aseptic loosening (3.2%) and two due to infection (2.1%). The survivorship free of aseptic loosening was 96.8%. Three patients (3%) suffered a dislocation. At the last follow-up visit, the mean HSS scores were 72.15, (p < 0.05). Use of a jumbo DM cup in cases of acetabular bone defects leads to satisfactory medium-term results with low dislocation and loosening rates.
This study aimed to identify the success rate of debridement, antibiotics and implant retention (DAIR) for prosthetic joint infection (PJI) in a large prospective cohort of patients undergoing total knee arthroplasty (TKA). The ability for different PJI classification systems to predict DAIR success was assessed. A prospective, multicenter study of PJIs occurring between July 2014 and December 2017 in 27 hospitals across Australia and New Zealand was performed. First time PJIs following primary TKA that were managed with DAIR were analyzed. DAIR success was defined as the patient being alive with documented absence of clinical or microbiological evidence of infection and no ongoing antibiotics for the index joint at 2-year follow-up. Multivariate analysis was performed for multiple PJI classification systems to assess their ability to predict DAIR success using their respective definitions of “early” PJI (Coventry ≤1 month, International Consensus Meeting ≤90 days or Auckland <1 year), or as hematogenous versus chronic PJI (Tsukayama). 189 PJIs were managed with DAIR, with an overall success rate of 45% (85/189). Early PJIs had a higher rate of DAIR success when analyzed according to the Coventry system (adjusted odds ratio = 3.85, p = 0.008), the ICM system (adjusted odds ratio = 3.08, p = 0.005) and the Auckland system (adjusted odds ratio = 2.60, p = 0.01). DAIR success was lower in both hematogenous (adjusted odds ratio = 0.36, p = 0.034) and chronic PJIs (adjusted odds ratio = 0.14, p = 0.003) occurring more than one year since the primary TKA. DAIR success is highest when performed in infections occurring within one year of the primary TKA. Late infections had a high DAIR failure rate irrespective of their classification as hematogenous or chronic. Time since primary is a useful predictor of DAIR success.
The optimal timing of when to perform manipulation under anesthesia (MUA) for stiffness following total knee arthroplasty (TKA) is unclear. This study aimed to identify the risk factors for MUA following primary TKA and whether performing an “early” MUA within 3 months results in a greater improvement in range of motion. Primary TKAs performed between January 2013 and December 2018 at three tertiary New Zealand hospitals were reviewed. International Classification of Diseases discharge coding was used to identify patients who underwent an MUA. Multivariate Cox regression was performed to identify patient and surgical risk factors for MUA. Pre- and post-MUA knee flexion angles were identified through manual review of operation notes. Multivariate linear regression was performed to compare the mean flexion angles pre- and post-MUA, as well as the mean gain in flexion, between patients undergoing “early” (<3 months) versus “late” MUA (>3 months). 7386 primary TKAs were analyzed in which 131 underwent subsequent MUA (1.8%). Patients aged <65 years were two times more likely to undergo MUA compared to patients aged ≥65 years (2.5% versus 1.3%, adjusted hazard ratio = 2.1, p<0.001). Gender, body mass index, patient comorbidities or a history of cancer were not associated with the risk of MUA. There was no difference in the final post-MUA flexion angle between patients who underwent early versus late MUA (104.7 versus 104.1 degrees, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3 versus 79.6 degrees, p = 0.012), and subsequently had a greater overall gain in flexion compared to patients who underwent late MUA (mean gain 33.1 versus 24.3 degrees, p<0.001). Younger age was the only patient risk factor for MUA. A greater overall gain in flexion was achieved in patients who underwent early MUA within 3 months.
The bone-patellar tendon-bone (BTB) autograft has a lower rate of graft failure but a higher rate of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction. Subsequent contralateral injury may be a marker of success of the BTB graft, but it is unclear whether the type of graft influences the rate of return to sport. This study aimed to compare the rates of return to weekly sport and return to preinjury activity levels between the BTB and hamstring tendon autografts following primary ACL reconstruction. Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014-November 2019 were analyzed. The primary outcome was return to weekly sport, defined as a Marx activity score of 8, at 2-year follow-up. The secondary outcome was return to preinjury activity level, defined as a post-operative Marx activity score that was equal or greater to the patient's preinjury Marx score. Return to sport was compared between the BTB and hamstring tendon autografts via multivariate binary logistic regression with adjustment for patient demographics. 4259 patients were analyzed, of which 50.3% were playing weekly sport (n = 2144) and 28.4% had returned to their preinjury activity level (n = 1211) at 2-year follow-up. A higher rate of return to weekly sport was observed with the BTB autograft compared to the hamstring tendon autograft (58.7% versus 47.9%, adjusted odds ratio = 1.23, p = 0.009). Furthermore, the BTB autograft had a higher rate of return to preinjury activity levels (31.5% versus 27.5%, adjusted odds ratio = 1.21, p = 0.025). The BTB autograft is associated with a higher return to sport and may explain the higher rate of contralateral ACL injury following primary ACL reconstruction.
First rib fractures (FRFs) have historically been a marker for severe trauma and poor outcomes. The aim of this study was to assess whether an association still exists between a fractured first rib and global trauma scores suffered by the patient, examine mortality rate and identify other commonly associated injuries. This study examined patients who presented to the Rockhampton Hospital with a traumatic FRF between the dates of July 2015 to June 2020. Patient demographics, mortality rate and additional injuries sustained by the patients were collected. The Injury Severity Score (ISS) was utilised and calculated for each patient. Analysis was conducted to determine associations between trauma scores and FRFs, mortality rate and other injuries sustained at the time of rib fracture. In total, 545 patients had a rib fracture with 48 patients identified as having an FRF. Median age was 50 years. Thirty-seven (77%) were male. The most common mechanism of FRF was motor vehicle/motorbike accidents (71%). Fifty percent of patients with an observed FRF had the highest global ISS of very severe, with 13% severe, 22% moderate and 15% mild. No patients died from their injuries. Of those with an FRF, 79% experienced fractures other than ribs, 75% had other rib fractures and 52% had chest injuries. A larger than expected proportion of FRFs were not associated with severe trauma scores or high mortality. These findings suggest that patients with an FRF may have a greater chance of surviving their traumatic FRF than previously reported. Clinicians should be aware of the potential for severity and other associated injuries, such as chest wall fractures and thoracic injuries, when treating a patient with a fracture of their first rib.
Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study.
The extracortical single-button (SB) inlay repair is one of the most preferred distal biceps tendon repair techniques. However, specific complications such as neurovascular injury and non-anatomic repairs have led to the development of techniques that utilize intracortical double-button (DB) fixation. To compare the biomechanical stability of the extracortical SB repair with the anatomical DB repair technique. Controlled laboratory study. The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SBor anatomical DB group. Both groups were cyclically loaded with 60N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap-formation and construct stiffness during cyclic loading, and ultimate load to failure was analysed. After 1000 cycles, the anatomical DB technique compared with the extracortical SB technique showed significantly less gap-formation (mean difference 1.2 mm; p=0.017) and significantly more construct stiffness (mean difference 31 N/mm; p=0.023). Ultimate load to failure was not significantly different comparing both groups (SB, 277 N ±92 vs. DB, 285 N ±135; p=0.859). The failure mode in the anatomical DB group was significantly different compared with the extracortical SB technique (p=0.002) and was due to fracture avulsion of the BicepsButton in 7 out of 9 specimens (vs. none in SB group). Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to the SB technique. The DB repair technique reduces the risk of nerve injury and better restores the anatomical footprint of biceps tendon. The DB technique may offer a clinically viable alternative to the SB repair technique.
Glenoid bone grafting in reverse total shoulder arthroplasty (RTSA) has emerged as an effective method of restoring bone stock in the presence of complex glenoid bone loss, yet there is limited published evidence on efficacy. The aim of this study was to conduct an analysis of clinical and radiographic outcomes associated with glenoid bone grafting in primary RTSA. Patients who underwent a primary RTSA with glenoid bone grafting were retrospectively identified from the databases of two senior shoulder surgeons. Inclusion criteria included minimum of 12 months clinical and/or radiographical follow up. Patients underwent preoperative clinical and radiographic assessment. Graft characteristics (source, type, preparation), range of movement (ROM), patient-reported outcome measures (Oxford Shoulder Scores [OSS]), and complications were recorded. Radiographic imaging was used to analyse implant stability, graft incorporation, and notching by two independent reviewers. Between 2013 and 2021, a total of 53 primary RTSA procedures (48 patients) with glenoid bone grafting were identified. Humeral head autograft was used in 51 (96%) of cases. Femoral head allograft was utilised in two cases. Depending on the morphology of glenoid bone loss, a combination of structural (corticocancellous) and non-structural (cancellous) grafts were used to restore glenoid bone stock and the joint line. All grafts were incorporated at review. The mean post-operative OSS was significantly higher than the pre-operative OSS (40 vs. 22, p < 0.001). ROM was significantly improved post-operatively. One patient is being investigated for residual activity-related shoulder pain. This patient also experienced scapular notching resulting in the fracturing of the inferior screw. One patient experienced recurrent dislocations but was not revised. Overall, at short term follow up, glenoid bone grafting was effective in addressing glenoid bone loss with excellent functional and clinical outcomes when used for complex bone loss in primary RTSA. The graft incorporation rate was high, with an associated low complication rate.
Acromial morphology has been implicated as a risk factor for unidirectional posterior shoulder instability. Studies utilising plain film radiographic landmarks have identified an increased risk of posterior shoulder dislocation in patients with higher acromion positioning. The aims of this study were to develop a reproducible method of measuring this relationship on cross sectional imaging and to evaluate acromial morphology in patients with and without unidirectional posterior shoulder instability. We analysed 24 patients with unidirectional posterior instability. These were sex and age matched with 61 patients with unidirectional anterior instability, as well as a control group of 76 patients with no instability. Sagittal T1 weighted MRI sequences were used to measure posterior acromial height relative to the scapular body axis (SBA) and long head of triceps insertion axis (LTI). Two observers measured each method for inter-observer reliability, and the intraclass correlation coefficient (ICC) calculated. LTI method showed good inter-observer reliability with an ICC of 0.79. The SBA method was not reproducible due suboptimal MRI sequences. Mean posterior acromial height was significantly greater in the posterior instability group (14.2mm) compared to the anterior instability group (7.7mm, p=0.0002) as well when compared with the control group (7.0mm, p<0.0001). A threshold of 7.5mm demonstrated a significant increase in the incidence of posterior shoulder instability (RR = 9.4). We conclude that increased posterior acromial height is significantly associated with posterior shoulder instability. This suggests that the acromion has a role as an osseous restraint to posterior shoulder instability.
Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand Outcomes following knee arthroplasty are typically defined as implant survivorship at defined timepoints, or revision incidence over time. These estimates are difficult to conceptualise, and lack context for younger patients with more remaining years of life. We therefore aimed to determine a ‘lifetime’ risk of revision as a more useful metric for total (TKA) and unicompartmental knee arthroplasty (UKA). The New Zealand Joint Registry was used to identify 96,497 primary TKAs and 13,481 primary UKAs performed between 1999 and 2019. Patient mortality and revision incidence were also extracted. Estimates of lifetime risk were calculated using an actuarial lifetable method. The estimates were stratified by age and gender. Reasons for revision were categorised using previously published standardised definitions. The lifetime risk of UKA revision was two-fold higher than TKA across all age groups (range 3.7-40.4% UKA, 1.6-22.4% TKA). Revision risk was higher for males with TKA (range 3.4%-25.2% males, 1.1%-20% females), but higher for females with UKA (range 4.3%-43.4% vs. 2.9%-37.4% for males). Revision due to infections were higher for TKA (1.5% males, 0.7% females) compared with UKA (0.4% males, 0.1% females). The increased risk in younger UKA patients was associated with higher incidence of aseptic loosening (UKA 2%, TKA 1%) and ‘unexplained pain’ (UKA 2%, TKA 0.2%). The risk for UKA was two-fold higher than TKA, and this was partially explained by a higher proportion of revisions due to ‘unexplained pain’. For TKA, males had higher risk of revision, in contrast to UKA where females had higher risk; this gender difference was associated with higher incidence of infections with TKA. Younger age, gender and higher ASA status were also associated with increased lifetime risk of UKA revision. Lifetime risk of revision can provide a meaningful measure of arthroplasty outcomes to aid patient counselling.
Joint registries suggest a downward trend in the use of uncemented Total Knee Replacements (TKR) since 2003, largely related to reports of early failures of uncemented tibial and patella components. Advancements in uncemented design such as trabecular metal may improve outcomes, but there is a scarcity of high-quality data from randomised trials. 319 patients <75 years of age were randomised to either cemented or uncemented TKR implanted using computer navigation. Patellae were resurfaced in all patients. Patient outcome scores, re-operations and radiographic analysis of radiolucent lines were compared. Two year follow up was available for 287 patients (144 cemented vs 143 uncemented). There was no difference in operative time between groups, 73.7 v 71.1 mins (p= 0.08). There were no statistical differences in outcome scores at 2 years, Oxford knee score 42.5 vs 41.8 (p=0.35), International Knee Society 84.6 vs 84.0 (p=0.76), Forgotten Joint Score 66.7 vs 66.4 (p=0.91). There were two revisions, both for infection one in each group (0.33%). 13 cemented and 8 uncemented knees underwent re-operation, the majority of these being manipulation under anaesthetic (85.7%), with no difference (8.3% vs 5.3%, 95% CI -2.81% to 8.89%, p = 0.31). No difference was found in radiographic analysis at 2 years, 1 lucent line was seen in the cemented group and 3 in the uncemented group (0.67% v 2.09%, 95%CI -4.1% to 1.24%, p = 0.29). We found no difference in clinical or radiographic outcomes between cemented and uncemented TKR including routine patella resurfacing at two years. Early results suggest there is no difference between cemented and uncemented TKR at 2 years with reference to survivorship, patient outcomes and radiological parameters.
The 2021 Australian Orthopaedic Association National Joint Replacement Registry report indicated that total shoulder replacement using both mid head (TMH) length humeral components and reverse arthroplasty (RTSA) had a lower revision rate than stemmed humeral components in anatomical total shoulder arthroplasty (aTSA) - for all prosthesis types and diagnoses. The aim of this study was to assess the impact of component variables in the various primary total arthroplasty alternatives for osteoarthritis in the shoulder. Data from a large national arthroplasty registry were analysed for the period April 2004 to December 2020. The study population included all primary aTSA, RTSA, and TMH shoulder arthroplasty procedures undertaken for osteoarthritis (OA) using either cross-linked polyethylene (XLPE) or non-cross-linked polyethylene (non XLPE). Due to the previously documented and reported higher revision rate compared to other anatomical total shoulder replacement options, those using a cementless metal backed glenoid components were excluded. The rate of revision was determined by Kaplan-Meir estimates, with comparisons by Cox proportional hazard models. Reasons for revision were also assessed. For a primary diagnosis of OA, aTSA with a cemented XLPE glenoid component had the lowest revision rate with a 12-year cumulative revision rate of 4.7%, compared to aTSA with cemented non-XLPE glenoid component of 8.7%, and RTSA of 6.8%. The revision rate for TMH was lower than aTSA with cemented non-XLPE, but was similar to the other implants at the same length of follow-up. The reason for revision for cemented aTSR was most commonly component loosening, not rotator cuff deficiency. Long stem humeral components matched with XLPE in aTSA achieve a lower revision rate compared to shorter stems, long stems with conventional polyethylene, and RTSA when used to treat shoulder OA. In all these cohorts, loosening, not rotator cuff failure was the most common diagnosis for revision.
Escalating health care expenditure worldwide is driving the need for effective resource decision-making, with medical practitioners increasingly making complex resource decisions within the context of patient care. Despite raising serious legal and ethical issues in practice, this has attracted little attention in Australia, or internationally. In particular, it is unknown how orthopaedic surgeons perceive their obligations to the individual patient, and the wider community, when rationing care, and how they reconcile competing obligations. This research explores legal and ethical considerations, and resource allocation by Australian orthopaedic surgeons, as a means of achieving public health cost containment driven by macro-level policy and funding decisions. This research found that Australian orthopaedic surgeon's perceptions, and resource allocation decision making, can be explained by understanding how principles of distributive justice challenge, and shift, the traditional medical paradigm. It found that distributive justice, and challenges of macro level health policy and funding decisions, have given rise to two new medical paradigms. Each which try to balance the best interests of individual patients with demands in respect of the sustainability of the health system, in a situation where resources may be constrained. This research shows that while bedside rationing has positioned the medical profession as the gate keepers of resources, it may have left them straddling an increasingly irreconcilable void between the interests of the individual patient and the wider community, with the sustainability of the health system hanging in the balance.
Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity. Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week. Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages. New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance.
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°.
Pelvic tilt (PT) is always described as the pelvic orientation along the transverse axis, yet four PT definitions were established based on different radiographic landmarks: anterior pelvic plane (PTa), the centres of femoral heads and sacral plate (PTm), pelvic outlet (PTh), and sacral slope (SS). These landmarks quantify a similar concept, yet understanding of their relationships is lacking. Some studies referred to the words “pelvic tilt” for horizontal comparisons, but their PT definitions might differ. There is a demand for understanding their correlations and differences for education and research purposes. This study recruited 105 sagittal pelvic radiographs (68 males and 37 females) from a single clinic awaiting their hip surgeries. Hip hardware and spine pathologies were examined for sub-group analysis. Two observers annotated four PTs in a gender-dependent manner and repeated it after six months. The linear regression model and intraclass correlation coefficient (ICC) were applied with a 95% significance interval. The SS showed significant gender differences and the lowest correlations to the other parameters in the male group (-0.3< r <0.2). The correlations of SS in scoliosis (n = 7) and hip implant (female, n = 18) groups were statistically different, yet the sample sizes were too small. PTm demonstrated very strong correlation to PTh (r > 0.9) under the linear model PTm = 0.951 × PTh - 68.284. The PTm and PTh are interchangeable under a simple linear regression model, which enables study comparisons between them. In the male group, SS is more of a personalised spinal landmark independent of the pelvic anatomy. Female patients with hip implant may have more static spinopelvic relationships following a certain pattern, yet a deeper study using a larger dataset is required. The understanding of different PTs improves anatomical education.
Tendon injuries after distal radius fractures Introduction: Tendon injuries after distal radius fractures are a well-documented complication that can occur in fractures managed both operatively and non-operatively. The extensor tendons, in particular the extensor pollicis longus (EPL) tendon, can be damaged and present late after initial management in a cast, or by long prominent screws that penetrate the dorsal cortex and cause attrition. Similarly, a prominent or distally placed volar plate can damage the flexor pollicis longus tendon (FPL). The aim of our study was to evaluate the incidence of tendon injuries associated with distal radius fractures. We conducted a single centre prospective observational study. Patients aged 18–99 who presented with a distal radius fracture between May 2018 to April 2020 were enrolled and followed-up for 24 months. Tendon injuries in the group were prospectively evaluated. Results: 199 patients with distal radius fractures were enrolled. 119 fractures (59.8%) had fixation and 80 (40.2%) were managed incast. In the non-operative group, 2 (2.5%) had EPL ruptures at approximately 4 weeks post injury. There were no extensor tendon ruptures in the operative group. In the operative group, there were 6 (5%) patients that required removal of metalware for FPL irritation. At the time of operation, there were no tendon ruptures noted. Within the operative group we evaluated plate prominence using a previously described classification (Soong et al.). 5 of the 6 patients (83%) with FPL irritation had Grade 3 prominence. The incidence of both flexor and extensor tendon injury in our cohort was 4%, extensor tendon rupture was 1% and flexor tendon rupture was avoided by early metalware removal. This study demonstrates tendon injuries are not uncommon after distal radius fractures, and close examination and follow-up are necessary to prevent eventual rupture. Plate prominence at the time of fixation should be minimised to reduce the risk of rupture.
Current recommendations advocate for surgery within 48 hours from time of injury as a keystone in care for elderly patients with hip fractures. A spare population density within regional Australia provides physical challenges to meet time critical care parameters. This study aims to review the impact of delays to timely surgery for elderly hip fracture patients within a regional Australian population. A retrospective, comparative analysis was undertaken of 140 consecutive hip fracture patients managed at a single rural referral hospital, from June 2020 until June 2021. Factors such as age, time to transfer, time to surgery, 30-day complication and 6-month complication rates were collected. Statistical analysis was performed where applicable. Mean time to surgery was 33.9 hours. A greater proportion of patients whom directly presented underwent surgery within the recommended 48 hours (91.5% vs 75.3%). The statistically significant delay in time to surgery was found to be 6.4 hours. Lower 180-day morbidity and mortality rates were observed in patients undergoing surgery within 48 hours (13.8% vs 36%), This is in comparison to the overall mortality rate of 19.2%. Delay to surgery for elderly hip fracture patients was associated with an increase 30-day and 180-day morbidity and mortality rate. A greater proportion of patients transferred from peripheral hospitals experienced a delay in surgery. Early transfer and prioritization of such patients is recommended to achieve comparative outcomes for rural and remote Australians.
Osteoarthritis (OA) is a disease of the synovial joint with synovial inflammation, capsular contracture, articular cartilage degradation, subchondral sclerosis and osteophyte formation contributing to pain and disability. Transcriptomic datasets have identified genetic loci in hip and knee OA demonstrating joint specificity. A limited number of studies have directly investigated transcriptional changes in shoulder OA. Further, gene expression patterns of periarticular tissues in OA have not been thoroughly investigated. This prospective case control series details transcriptomic expression of shoulder OA by analysing periarticular tissues in patients undergoing shoulder replacement for OA as correlated with a validated patient reported outcome measure of shoulder function, an increasing (clinically worsening) QuickDASH score. We then compared transcriptomic expression profiles in capsular tissue biopsies from the OA group (N=6) as compared to patients undergoing shoulder stabilisation for recurrent instability (the control group, N=26). Results indicated that top ranked genes associated with increasing QuickDASH score across all tissues involved inflammation and response to stress, namely interleukins, chemokines, complement components, nuclear response factors and immediate early response genes. Some of these genes were upregulated, and some downregulated, suggestive of a state of flux between inflammatory and anti-inflammatory signalling pathways. We have also described gene expression pathways in shoulder OA not previously identified in hip and knee OA, as well as novel genes involved in shoulder OA.
Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability, and contribute to significant morbidity and healthcare costs. Previous studies have shown evidence of socio-demographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socio-economic status, in order to inform future healthcare strategies. Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age and socioeconomic deprivation index of the claimant. During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totalled over $960 million New Zealand Dollars. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%) and “Other” (1.1%). Asian, Māori (Indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socio-economic deprivation. This large nation-wide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified socio-demographic disparities which need to be addressed in order to achieve equity in health outcomes.
Prosthetic joint infection (PJI) remains one of the most challenging complications to manage following total joint arthroplasty (TJA). There is a paucity of published data on the management of PJI in smaller, rural hospital settings. In this study, we investigate [1] the success rate of surgical management for PJI following TJA and [2] the microbiology of infecting organisms in this unique geographical environment. We performed a retrospective single-centre study at a rural hospital (Southland Hospital, Invercargill, New Zealand) over a 3-year period (2019 to 2022). All patients presenting with a first episode of PJI fulfilling Musculoskeletal Infection Society criteria after hip or knee arthroplasty were included. All patients had a minimum follow up of 6 months. Treatment success was defined eradication of infection. Twenty-one cases (14 hips and 7 knees) were identified. These were managed with Debridement, antibiotics, and implant retention (DAIR) procedure (n=14, 67%), single-stage revision (n=6, 29%), or long-term suppressive antibiotics (n=1, 4%). Of the DAIR patients, infection recurred in 50% and underwent subsequent revision. Of the single-stage revision patients, 17% failed and underwent subsequent revision. The overall success rate was 90%. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most isolated pathogen (57%,) with no methicillin-resistance Staphylococcus aureus (MRSA) identified. Overall, 90% of infecting organisms were cefazolin sensitive. These results suggest that management of PJI is a safe and viable treatment option when performed in a rural hospital setting, with comparable treatment success rates to urban centres. The incidence of MRSA is low in this setting. Rates of antibiotic resistance were relatively low and most organisms were sensitive to cefazolin, the routine antibiotic used in prophylaxis.
Glenoid baseplate positioning for reverse total shoulder replacements (rTSR) is key for stability and longevity. 3D planning and image-derived instrumentation (IDI) are techniques for improving implant placement accuracy. This is a single-blinded randomised controlled trial comparing 3D planning with IDI jigs versus 3D planning with conventional instrumentation. Eligible patients were enrolled and had 3D pre-operative planning. They were randomised to either IDI or conventional instrumentation; then underwent their rTSR. 6 weeks post operatively, a CT scan was performed and blinded assessors measured the accuracy of glenoid baseplate position relative to the pre-operative plan. 47 patients were included: 24 with IDI and 23 with conventional instrumentation. The IDI group were more likely to have a guidewire placement within 2mm of the preoperative plan in the superior/inferior plane when compared to the conventional group (p=0.01). The IDI group had a smaller degree of error when the native glenoid retroversion was >10° (p=0.047) when compared to the conventional group. All other parameters (inclination, anterior/posterior plane, glenoids with retroversion <10°) showed no significant difference between the two groups. Both IDI and conventional methods for rTSA placement are very accurate. However, IDI is more accurate for complex glenoid morphology and placement in the superior-inferior plane. Clinically, these two parameters are important and may prevent long term complications of scapular notching or glenoid baseplate loosening. Image-derived instrumentation (IDI) is significantly more accurate in glenoid component placement in the superior/inferior plane compared to conventional instrumentation when using 3D pre-operative planning. Additionally, in complex glenoid morphologies where the native retroversion is >10°, IDI has improved accuracy in glenoid placement compared to conventional instrumentation. IDI is an accurate method for glenoid guidewire and component placement in rTSA.
The attitudes of orthopaedic surgeons regarding radiology reporting is not well-described in the literature. We surveyed Orthopaedic Surgeons in Australia and New Zealand to assess if they routinely review formal radiology reports. An anonymized, 14 question online survey was distributed to consultant surgeons of the Australian and New Zealand Orthopaedic Associations (AOA, NZOA). Two hundred respondents completed the survey (Total number of Fellows: 283 NZOA, 1185 AOA). 18.5% of respondents always reviewed the formal Radiology report, 44.5% most of the time, 35% sometimes and 2% never. By imaging modality, MRI reports were the most frequently reviewed (92%), followed by ultrasound (74%) and nuclear medicine (63%). Only 10% of surgeons consulted formal reports for plain radiography. 55% of surgeons were still likely to disagree with the MRI report, followed by 46% for plain radiography. In cases of disagreement, only 21% of surgeons would always contact the reporting radiologist. The majority of Surgeons (85.5%) think there should be more collaboration between the disciplines, although only 50.5% had regular attendance of a Radiologist at their departmental audit. This survey reveals that the majority of orthopaedic surgeons are not routinely reading radiology reports. This points towards a need for further interdisciplinary collaboration. To our knowledge, this is the first survey directly assessing attitudes of orthopaedic surgeons towards radiology reports.
Roentgen Stereophotogrammetric Analysis (RSA) is the gold standard for measuring implant micromotion thereby predicting implant loosening. Early migration has been associated with the risk of long-term clinical failure. We used RSA to assess the stability of the Australian designed cementless hip stem (Paragon TM) and now report our 5-year results. Fifty-three patients were prospectively and consecutively enrolled to receive a Paragon hip replacement. Tantalum beads were inserted into the bone as per RSA protocol and in the implant. RSA x-rays were taken at baseline 1–4 days post-surgery, at 6 weeks, 6 months, 12 months, 2 years, and 5 years. RSA was completed by an experienced, independent assessor. We reported the 2-year results on 46 hips (ANZJS 91 (3) March 2021 p398) and now present the 5-year results on 27 hips. From the 2-year cohort 5 patients had died, 8 patients were uncontactable, 1 patient was too unwell to attend, 5 patients had relocated too far away and declined. At 5 years the mean axial subsidence of the stem was 0.66mm (0.05 to 2.96); the mean rotation into retroversion was 0.49˚ (−0.78˚ to 2.09˚), rotation of the stem into valgus was −0.23˚ (−0.627˚ to 1.56˚). There was no detectable increase in subsidence or rotation between 6 weeks and 5 years. We compared our data to that published for the Corail cementless stem and a similar pattern of migration was noted, however greater rotational stability was achieved with the Paragon stem over a comparable follow-up period. The RSA results confirm that any minor motion of the Paragon cementless stem occurs in the first 6 weeks after which there is sustained stability for the next 5 years. The combination of a bi-planar wedge and transverse rectangular geometry provide excellent implant stability that is comparable to or better than other leading cementless stems.
Dual mobility is a French concept that appeared in the 1970s and was initially intended to reduce dislocation rates. In recent years, this concept has evolved with new HA titanium spray coatings, new external macrostructures, and better-quality polyethylene. This has allowed to extend the indications to younger and therefore active populations. The objective of our work is to analyze at least 10 years a homogeneous and continuous series of 170 primary total hip replacements associating a latest generation Novae Sunfit® dual mobility cup with a straight femoral stem. Only primary arthroplasties for osteoarthritis or necrosis were included. Total hip arthroplasty was always performed through a posterolateral approach. All patients had regular clinical and radiological follow-up. The average follow-up in our series was 11.5 years. The average age of the population is 71 years. At the last follow-up, there were 17 deaths, 6 losses to follow up and 9 adverse events, including 1 cup change for psoas impingement and 1 dislocation. The low rate of dislocation at 11 years confirms the high stability of the dual mobility, which should be recommended for primary procedure for patients at high risk of postoperative instability. The lack of intraprosthetic dislocation due to wear at 11 years of follow-up highlights the good quality of the latest generation of polyethylene, and the need to combine high-polished surfaces and a refined femoral neck with a dual mobility cup. Finally, the lack of aseptic loosening confirms the quality of the secondary fixation of these implants and justifies their wider use in all patients.
Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction. Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis. 9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis. Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction.
The optimal method of tibial fixation when using a hamstring tendon autograft in anterior cruciate ligament (ACL) reconstruction is unclear. This study aimed to compare the risk of revision ACL reconstruction between suspensory and interference devices on the tibial side. Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. Only patients with a hamstring tendon autograft fixed with a suspensory device on the femoral side were included. The rate of revision ACL reconstruction was compared between suspensory and interference devices on the tibial side. Univariate Chi-Square test and multivariate Cox regression was performed to compute hazard ratios (HR) and 95% confidence intervals (CI) with adjustment for age, gender, time-to-surgery, activity at the time of injury, number of graft strands and graft diameter. 6145 cases were analyzed, of which 59.6% were fixed with a suspensory device on the tibial side (n = 3662), 17.6% fixed with an interference screw with a sheath (n = 1079) and 22.8% fixed with an interference screw without a sheath (n = 1404). When compared to suspensory devices (revision rate = 3.4%), a higher risk of revision was observed when using an interference screw with a sheath (revision rate = 6.2%, adjusted HR = 2.05, 95% CI 1.20 – 3.52, p = 0.009) and without a sheath (revision rate = 4.6%, adjusted HR = 1.81, 95% CI 1.02 – 3.23, p = 0.044). The number of graft strands and a graft diameter of ≥8 mm did not influence the risk of revision. When reconstructing the ACL with a hamstring tendon autograft, the use of an interference screw, with or without a sheath, on the tibial side has a higher risk of revision when compared to a suspensory device.
Source of the study: University of Auckland, Auckland, New Zealand Unicompartmental knee arthroplasty (UKA) has benefits for patients with appropriate indications. However, UKA has a higher risk of revision, particularly for low-usage surgeons. The introduction of robotic-arm assisted systems may allow for improved outcomes but is also associated with a learning curve. We aimed to characterise the learning curve of a robotic-arm assisted system (MAKO) for UKA in terms of operative time, limb alignment, component sizing, and patient outcomes. Operative times, pre- and post-surgical limb alignments, and component sizing were prospectively recorded for consecutive cases of primary medial UKA between 2017 and 2021 (n=152, 5 surgeons). Patient outcomes were captured with the Oxford Knee Score (OKS), EuroQol-5D (EQ-5D), Forgotten Joint Score (FJS-12) and re-operation events up to two years post-UKA. A Cumulative Summation (CUSUM) method was used to estimate learning curves and to distinguish between learning and proficiency phases. Introduction of the system had a learning curve of 11 cases. There was increased operative time of 13 minutes between learning and proficiency phases (learning 98 mins vs. proficiency 85 mins; p<0.001), associated with navigation registration and bone preparation/cutting. A learning curve was also found with polyethylene insert sizing (p=0.03). No difference in patient outcomes between the two phases were detected for patient-reported outcome measures, implant survival (both phases 98%; NS) or re-operation (learning 100% vs. proficiency: 96%; NS). Implant survival and re-operation rates did not differ between low and high usage surgeons (cut-off of 12 UKAs per year). Introduction of the robotic-arm assisted system for UKA led to increased operative times for navigation registration and bone preparation, but no differences were detected in terms of component placement or patient outcomes regardless of usage. The short learning curve regardless of UKA usage indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons.
Using a reverse engineering capability to quantify the factors that control the rigid body mechanics of the wrist, a mathematical forward animation capability and model of wrist motion that allows the carpus to move under its own rules is being developed. This characterises the isometric connections, from which was developed the Stable Central Column Theory of Carpal Mechanics - which incorporates the Law of Rules Based Motion. This work has now advanced to the ability to reapply the extracted rules to allow rules-based rigid body reanimation of an individual wrist. As each wrist is unique, there is a given reality that each reanimation must be based on an individual wrist's unique rules, and the aspiration to create a standard or normal wrist is unrealistic. Using In the preliminary application of this biomechanics environment, by using the reverse engineering / forward reanimation process, wrist motion can be recreated - based purely on the unique rules, extracted from individual wrists. Instability of the proximal scaphoid was evident in several of the animations, and there was confirmation that the spatial attachment points of the isometric constraints are very exacting. The actual attachment and specific morphology of the carpal bones varied between individual wrists. Using a reverse engineering and then forward reanimation process, we have been able to recreate wrist motion using the rigid body mechanics based on the Law of Rules Based Motion. Further work is required, but the potential to apply “what if” virtual surgery options to an individual injured wrist and more precisely characterise and test solutions to wrist dysfunction are becoming realised.
Arthroscopic electrosurgical tools for ablative, desiccating or coagulative effect are delivered as monopolar or bipolar probes. Monopolar electrosurgery delivers various profiles of heat energy directly to the tissue within a non-conductive irrigant (such as water or glycine) whereas bipolar electrosurgery creates an energy source by producing an electrical arc between the bipolar electrodes on the instrument head within an electro-conductive irrigation solution (saline) - and the heat generated is then transferred to the target tissues. This study investigated the heat generation within the simulated in-vitro test model to review the level of local heat production and potential local tissue heat. In a simulated In-vitro testing environment the local heat generation using bipolar or monopolar electrosurgical probes at standard power setting in either saline or water was tested, both touching and not touching a simulated tissue target, and for variable on-times. Monopolar generated relatively little heat when used in water and not touching the tissue. By contrast the bipolar wand generated potentially damaging local tissue temperature rises when used in saline and not touching the tissue. Both probes generated high local tissue heat when touching the tissue in their recommended irrigation solution. Monopolar electrosurgery delivered high localized temperature to the simulated tissue surface, but produced relatively little heat when not touching the tissue in a water solution. Bipolar however created high local temperature within the fluid adjacent to the probe irrespective if it was touching the tissue or not. Activation of the bipolar probe away from the tissue in saline irrigation may create a potential harmful temperature within the fluid medium without delivering therapeutic thermal effect to the target tissues. Monopolar electrosurgery appears to deliver a more controlled thermal effect, and only when in contact with the target tissues – potentially creating a reduced collateral thermal footprint.
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.
This study was performed at Assiut University, Assiut, Egypt. Anterior distal femoral hemiepiphysiodesis (ADFH) using intra-articular plates for the correction of paediatric fixed knee flexion deformities (FKFD) has two main documented complications: postoperative knee pain and implant loosening. This study describes a biomechanical analysis and a preliminary report of a novel extra-articular technique for ADFH. Sixteen femoral sawbones were osteotomized at the level of the distal femoral physis and fixed by rail frames to allow linear distraction simulating longitudinal growth. Each sawbone was tested twice: first using the conventional technique with medial and lateral parapatellar eight plates (group A) and then with the plates inserted in the proposed novel location at the most anterior part of the medial and lateral surfaces of the femoral condyles with screws in the coronal plane (group B). Gradual distraction was performed, and the resulting angular correction was measured. Strain gauges were attached to the plates, and the amount of strain (and equivalent stress) over the plates was recorded. This technique was then applied to 9 paediatric FKFDs of different aetiologies. The preoperative FKFD and the amount of subsequent angular correction were measured. The amount of angular correction was higher in group B at 5, 10-, and 15-mm of distraction (p<0.001). The maximum and overall stresses measured throughout the distraction process were higher in group A (p<0.001). The mean FKFD improved from 24 ± 9° preoperatively to 9 ± 7° after 10 ± 3° months (p<0.001). The correction rate was 1.81 ± 0.65° per month. During ADFH, the fixation of the eight plates in the coronal plane at the anterior part of the femoral condyles may produce greater correction and lower stresses over the implants as compared to the conventional technique. Preliminary results from our initial series seem to support the effectiveness of this technique with respect to the degree of angular correction achieved.
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.
Classification systems for tibial plateau fractures suffer from poor interobserver agreement, and their value in preoperative assessment to guide surgical fixation strategies is limited. For tibial plateau fractures four major characteristics are identified: lateral split fragment, posteromedial fragment, anterior tubercle fragment, and central zone of comminution. These fracture characteristics support preoperative assessment of fractures and guide surgical decision-making as each specific component requires a respective fixation strategy. We aimed to evaluate the additional value of 3D-printed models for the identification of tibial plateau fracture characteristics in terms of the interobserver agreement on different fracture characteristics. Preoperative images of 40 patients were randomly selected. Nine trauma surgeons, eight senior and eight junior registrars indicated the presence or absence of four fracture characteristics with and without 3D-printed models. The Fleiss kappa was used to determine interobserver agreement for fracture classification and for interpretation, the Landis and Koch criteria were used. 3D-printed models lead to a categorical improvement in interobserver agreement for three of four fracture characteristics: lateral split (Kconv = 0.445 versus K3Dprint = 0.620; P < 0.001), anterior tubercle fragment (Kconv = 0.288 versus K3Dprint = 0.449; P < 0.001) and zone of comminution (Kconv = 0.535 versus K3Dprint = 0.652; P < 0.001). The overall interobserver agreement improved for three of four fracture characteristics after the addition of 3D printed models. For two fracture characteristics, lateral split and zone of comminution, a substantial interobserver agreement was achieved. Fracture characteristics seem to be a more reliable way to assess tibial plateau fractures and one should consider including these in the preoperative assessment of tibial plateau fractures compared to the commonly used classification systems.
Sarcopenia has been observed to be a predictor of mortality in international studies of patients with metastatic disease of the spine. This study aimed to validate sarcopenia as a prognostic tool in a New Zealand setting. A secondary aim of this study was to assess the intra-observer reliability of measurements of psoas and vertebral body cross sectional areas on computed tomography imaging. A cohort of patients who had presented to Waikato Hospital with secondary neoplasia in the spinal column from 2014 to 2018 was selected. Cross sectional psoas and vertebral body areas were measured at the mid-pedicle L3 level, followed by calculation of the psoas to vertebral body cross sectional area ratio. Psoas to vertebral body cross sectional area ratio was compared with survivorship. The strength of the correlation between sarcopenia and survivorship was compared with the correlation between serum albumin and survivorship, as well as the correlation between the Metastatic Spine Risk Index (MSRI) and survivorship. A total of 110 patients who received operative (34) and non-operative (76) were included. The results demonstrate that psoas to vertebral body cross sectional area ratio is not statistically significantly correlated with survivorship (p=0.53). Serum albumin is significantly correlated with survivorship (p<0.0001), as was the MSRI. There is good intra-observer and inter-observer reliability for measurements of psoas to vertebral body cross sectional area. This study failed to demonstrate the utility for the psoas to vertebral body cross sectional area ratio that other studies have demonstrated in estimating survivorship. Serum albumin levels remain a useful prognostic indicator in patients with secondary tumours in the vertebral column.
This study aimed to analyze the effect of two different techniques of cement application: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term effect of radiolucent lines (RLL) in primary fully cemented total knee arthroplasties (TKA) with patella resurfacing. 379 fully cemented TKAs (318 patients) were included in this monocentric study. Preoperative and postoperative at week 4 and 12 month after surgery all patients had a clinical and radiological examination and were administered the Oxford Knee Score (OKS). Cement was applied in two different ways among the two study groups: cement on bone surface (CoB group) or cement on bone surface and implant surface (CoBaI group). The evaluation of the presence of RLL or osteolysis was done as previously described using the updated Knee Society Radiographic Evaluation System. The mean OKS and range of motion improved significantly in both groups at the 4-week and 12-month follow-up, with no significant difference between the groups (CoB vs. CoBaI). RLL were present in 4.7% in the whole study population and were significantly higher in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up RLL were seen in 29.8% of the TKAs in the CoBaI group, whereas the incidence was lower in the CoB group (24.0% (n.s.)). There were two revisions in each group. None of these due to aseptic loosening. Our study indicated that the application of bone cement on bone surface only might be more beneficial than onto the bone surface and onto the implant surface as well in respect to the short-term presence of RLL in fully cemented primary TKA. The long-term results will be of interest, especially in respect to aseptic loosening and might guide future directions of bone cement applications in TKA.
The optimum indications for debridement, antibiotics and implant retention (DAIR) are unclear. Previous studies have demonstrated higher success rate of DAIR within one year of the primary arthroplasty. This study aimed to compare the success rate of DAIR vs revision in “early” and “late” infections to provide guidance for clinical decision making. The Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort prospectively recorded PJIs between July 2014 and December 2017 in 27 hospitals. This study included PIANO patients with first time PJIs occurring after primary TKA. Treatment success was defined as the patient being alive, free from further revision and without clinical or microbiological evidence of reinfection at two years follow-up. “Early” and “late” infections were analyzed separately. Univariate analysis compared demographic and disease specific factors between the DAIR and Revision groups. Multivariate binary logistic regression identified whether treatment strategy and other risk factors were associated with treatment success in “early” and “late” infections. In 117 “early” (<1 year) infections, treatment success rate was 56% in the DAIR group and 54% in the revision group (p=0.878). No independent risk factors were associated with treatment outcome on multivariate analysis. In 134 “late” (>1 year) infections, treatment success rate was 34.4% in the DAIR group and 60.5% in the revision group (OR 3.07 p=0.006). On multivariate analysis, revision was associated with 2.47x higher odds of success (p=0.041) when compared to DAIR, patients with at least one significant co-morbidity (OR 2.27, p=0.045) or with Staphylococcus aureus PJIs (OR 2.5, p=0.042) had higher odds of failure. In “late” PJIs occurring >1 year following primary TKA, treatment strategy with revision rather than DAIR was associated with greater success. Patients with significant comorbidities and Staphylococcus aureus PJIs were at higher risk of failure regardless of treatment strategy.
Higher levels of socioeconomic deprivation have been associated with worse health outcomes. The influence of socioeconomic deprivation on patients undergoing periacetabular osteotomy (PAO) has not previously been investigated. A total of 217 patients (171 female, 46 male; median age 23.4 years) who underwent PAO by a single surgeon were identified. Patients were categorised into three groups according to their New Zealand Deprivation (NZDep) Index: minimal deprivation (NZDep Index 1–3, n=89), moderate deprivation (NZDep Index 4–6, n=94), and maximal deprivation (NZDep Index 7–10, n=34). The three groups were compared with respect to baseline variables, surgical details, complications, and pre-operative and two-year post-operative functional scores (including International Hip Outcome Tool (iHOT-12), EQ-5D quality of life score, and University of California Los Angeles (UCLA) activity score). Multivariate regression was undertaken to assess for the effect of NZDep Index on patient outcomes. Patients in the maximal deprivation group were more likely to be Māori (p<0.001) and have surgery in a public rather than a private hospital (p=0.004), while the minimal deprivation group demonstrated a lower BMI (p=0.005). There were otherwise no other significant differences in baseline variables, surgical details, complications, nor pre-operative or two-year post-operative functional scores between the three groups (all p>0.05). Multivariate analysis identified a higher NZDep Index to be independently predictive of a lower pre-operative UCLA activity score (p=0.014) and a higher two-year iHOT-12 score (p<0.001). Our results demonstrate an inequality in access to PAO, with patients exposed to higher levels of socioeconomic deprivation under-represented in our study population. When provided access to PAO, these vulnerable patients achieve significant functional improvement at least as great as patients with less socioeconomic deprivation. Initiatives to improve access to hip preservation care in socioeconomically deprived populations appear warranted.
Inverse Kinematic Alignment (iKA) and Gap Balancing (GB) aim to achieve a balanced TKA via component alignment. However, iKA aims to recreate the native joint line versus resecting the tibia perpendicular to the mechanical axis. This study aims to compare how two alignment methods impact 1) gap balance and laxity throughout flexion and 2) the coronal plane alignment of the knee (CPAK). Two surgeons performed 75 robotic assisted iKA TKA's using a cruciate retaining implant. An anatomic tibial resection restored the native joint line. A digital joint tensioner measured laxity throughout flexion prior to femoral resection. Femoral component position was adjusted using predictive planning to optimize balance. After femoral resection, final joint laxity was collected. Planned GB (pGB) was simulated for all cases posthoc using a neutral tibial resection and adjusting femoral position to optimize balance. Differences in ML balance, laxity, and CPAK were compared between planned iKA (piKA) and pGB. ML balance and laxity were also compared between piKA and final (fiKA). piKA and pGB had similar ML balance and laxity, with mean differences <0.4mm. piKA more closely replicated native MPTA (Native=86.9±2.8°, piKA=87.8±1.8°, pGB=90±0°) and native LDFA (Native=87.5±2.7°, piKA=88.9±3°, pGB=90.8±3.5°). piKA planned for a more native CPAK distribution, with the most common types being II (22.7%), I (20%), III (18.7%), IV (18.7%) and V (18.7%). Most pGB knees were type V (28.4%), VII (37.8%), and III (16.2). fiKA and piKA had similar ML balance and laxity, however fiKA was more variable in midflexion and flexion (p<0.01). Although ML balance and laxity were similar between piKA and pGB, piKA better restored native joint line and CPAK type. The bulk of pGB knees were moved into types V, VII, and III due to the neutral tibial cut. Surgeons should be cognizant of how these differing alignment strategies affect knee phenotype.
Identifying and restoring alignment is a primary aim of total knee arthroplasty (TKA). In the coronal plane, the pre-pathological hip knee angle can be predicted using an arithmetic method (aHKA) by measuring the medial proximal tibial angle (MPTA) and lateral distal femoral angle (aHKA=MPTA - LDFA). The aHKA is shown to be predictive of coronal alignment prior to the onset of osteoarthritis; a useful guide when considering a non-mechanically aligned TKA. The aim of this study is to investigate the intra- and inter-observer accuracy of aHKA measurements on long leg standing radiographs (LLR) and preoperative Mako CT planning scans (CTs). Sixty-eight patients who underwent TKA from 2020–2021 with pre-operative LLR and CTs were included. Three observers (Surgeon, Fellow, Registrar) measured the LDFA and MPTA on LLR and CT independently on three separate occasions, to determine aHKA. Statistical analysis was undertaken with Bland-Altman test and coefficient of repeatability. An average intra-observer measurement error of 3.5° on LLR and 1.73° on CTs for MPTA was detected. Inter-observer errors were 2.74° on LLR and 1.28° on CTs. For LDFA, average intra-observer measurement error was 2.93° on LLR and 2.3° on CTs, with inter-observer errors of 2.31° on LLR and 1.92° on CTs. Average aHKA intra-observer error was 4.8° on LLR and 2.82° on CTs. Inter-observer error of 3.56° for LLR and 2.0° on CTs was measured. The aHKA is reproducible on both LLR and CT. CT measurements are more reproducible both between and within observers. The difference between measurements using LLR and CT is small and hence these two can be considered interchangeable. CT may obviate the need for LLRs and may overcome difficulties associated with positioning, rotation, body habitus and flexion contractures when assessing coronal alignment.
Total knee arthroplasty with a rotating hinge knee with carbon-fibre-reinforced (CFR)-PEEK as an alternative bushing material with enhanced creep, wear and fatigue behaviour has been clinically established [1-4]. The objective of our study was to compare results from in vitro biotribological characterisation to ex vivo findings on a retrievals. A modified in vitro wear simulation based on ISO 14243-1 was performed for 5 million cycles on rotating hinge knee (RHK) designs (EnduRo®) out of cobalt-chromium and ZrN-multilayer ceramic coating. The rotational & flexion axles-bushings and the flanges are made of CFR-PEEK with 30% polyacrylonitrile fibre content. Analysis of 12 retrieved EnduRo® RHK systems in cobalt-chromium and ZrN-multilayer in regard to loosening torques, microscopic surface analysis, distinction between different wear modes and classification with a modified HOOD-score has been performed. For the RHK design with the polyethylene gliding surface and bushings and flanges made out of CFR-PEEK, a cumulative volumetric wear was measured to be 12.9±3.95 mm3 in articulation to cobalt-chromium and 1.3±0.21 mm3 to ZrN-multilayer coating - a significant 9.9-fold decrease (p=0.0072). For the CFR-PEEK flexion bushing and flanges the volumetric wear rates were 2.3±0.48 mm3/million cycles (cobalt-chromium) and 0.21±0.02 mm3/million cycles (ZrN-multilayer) (p=0.0016). The 5 million cycles of in vitro wear testing reflect a mean in vivo service life of 2.9 years, which is in accordance to the time in vivo of 12–60 months of the retrieved RHK components [5]. The main wear modes were comparable between retrievals and in vitro specimens, whereby the size of affected area on the retrieved components showed a higher variation. For the EnduRo® RHK design the findings on retrieved implants demonstrate the high suitability of CFR-PEEK as a biomaterial for highly loaded bearings, such as RHK bushings and flanges in articulation to cobalt-chromium and to a ZrN-multilayer coating.
A method is proposed to assess risk parameters of anterior cruciate ligament (ACL) injury using human pose estimation (HPE) and a single stereo depth camera. Detectron2 is used to identify key points of a subject performing a single leg jump test. This allows dynamic pivot of the knee to be assessed during landing using four risk parameters: knee valgus, knee translation in the coronal plane, pelvic tilt, and head-ankle alignment (body sway). Results show the model has an accuracy of 7° in angular measurements and 38 mm in linear measurements. Compared to previous studies, which only consider front-on analysis, this method has partially reduced accuracy in linear measurements and half the accuracy in angular measurements. Despite this, coupling information from multiple risk parameters reduces the accuracy required on any one parameter and the use of a single depth camera enables reliable analysis at a subject orientation of ±45° relative to the camera. These factors create a novel solution, proposing the ability for broad evaluation of ACL risk parameters in environments outside a testing laboratory, which has not been done before.
Scapular notching is a common problem following reverse shoulder arthroplasty (RSA). This is due to impingement between the humeral polyethylene cup and scapular neck in adduction and external rotation. Various glenoid component strategies have been described to combat scapular notching and enhance impingement-free range of motion (ROM). There is limited data available detailing optimal glenosphere position in RSA with an onlay configuration. The purpose of this study was to determine which glenosphere configurations would maximise impingement free ROM using an onlay RSA prosthesis. A three-dimensional (3D) computed tomography (CT) scan of a shoulder with Walch A1, Favard E0 glenoid morphology was segmented using validated software. An onlay RSA prosthesis was implanted and a computer model simulated external rotation and adduction motion of the virtual RSA prosthesis. Four glenosphere parameters were tested; diameter (36mm, 41mm), lateralization (0mm, 3mm, 6mm), inferior tilt (neutral, 5 degrees, 10 degrees), and inferior eccentric positioning (0.5mm, 1.5mm. 2.5mm, 3.5mm, 4.5mm). Eighty-four combinations were simulated. For each simulation, the humeral neck-shaft angle was 147 degrees and retroversion was 30 degrees. The largest increase in impingement-free range of motion resulted from increasing inferior eccentric positioning, gaining 15.0 degrees for external rotation and 18.8 degrees for adduction. Glenosphere lateralization increased external rotation motion by 13. 6 degrees and adduction by 4.3 degrees. Implanting larger diameter glenospheres increased external rotation and adduction by 9.4 and 10.1 degrees respectively. Glenosphere tilt had a negligible effect on impingement-free ROM. Maximizing inferior glenosphere eccentricity, lateralizing the glenosphere, and implanting larger glenosphere diameters improves impingement-free range of motion, in particular external rotation, of an onlay RSA prosthesis. Surgeons’ awareness of these trends can help optimize glenoid component position to maximise impingement-free ROM for RSA. Further studies are required to validate these findings in the context of scapulothoracic motion and soft tissue constraints.
Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery.
This study aims to implement and assess the inter and intra-reliability of a modernised radiolucency assessment system; the Radiolucency In cemented Stemmed Knee (RISK) arthroplasty classification. Furthermore, we assessed the distribution of regions affected by radiolucency in patients undergoing stemmed cemented knee arthroplasty. Stemmed knee arthroplasty cases over 7-year period at a single institution were retrospectively identified and reviewed. The RISK classification system identifies five zones in the femur and five zones in the tibia in both the anteroposterior (AP) and lateral planes. Post-operative and follow-up radiographs were scored for radiolucency by four blinded reviewers at two distinct time points four weeks apart. Reliability was assessed using the kappa statistic. A heat map was generated to demonstrate the reported regions of radiolucency. 29 cases (63 radiographs) of stemmed knee arthroplasty were examined radiographically using the RISK system. Intra-reliability (0.83) and Inter-reliability (0.80) scores were both consistent with a strong level of agreement using the kappa scoring system. Radiolucency was more commonly associated with the tibial component (76.6%) compared to the femoral component (23.3%), and the tibial anterior-posterior (AP) region 1 (medial plateau) was the most affected (14.9%). The RISK classification system is a reliable assessment tool for evaluating radiolucency around stemmed knee arthroplasty using defined zones on both AP and lateral radiographs. Zones of radiolucency identified in this study may be relevant to implant survival and corresponded well with zones of fixation, which may help inform future research.
Approximately 20% of patients feel unsatisfied 12 months after primary total knee arthroplasty (TKA). Current predictive tools for TKA focus on the clinician as the intended user rather than the patient. The aim of this study is to develop a tool that can be used by patients without clinician assistance, to predict health-related quality of life (HRQoL) outcomes 12 months after total knee arthroplasty (TKA). All patients with primary TKAs for osteoarthritis between 2012 and 2019 at a tertiary institutional registry were analysed. The predictive outcome was improvement in Veterans-RAND 12 utility score at 12 months after surgery. Potential predictors included patient demographics, co-morbidities, and patient reported outcome scores at baseline. Logistic regression and three machine learning algorithms were used. Models were evaluated using both discrimination and calibration metrics. Predictive outcomes were categorised into deciles from 1 being the least likely to improve to 10 being the most likely to improve. 3703 eligible patients were included in the analysis. The logistic regression model performed the best in out-of-sample evaluation for both discrimination (AUC = 0.712) and calibration (gradient = 1.176, intercept = -0.116, Brier score = 0.201) metrics. Machine learning algorithms were not superior to logistic regression in any performance metric. Patients in the lowest decile (1) had a 29% probability for improvement and patients in the highest decile (10) had an 86% probability for improvement. Logistic regression outperformed machine learning algorithms in this study. The final model performed well enough with calibration metrics to accurately predict improvement after TKA using deciles. An ongoing randomised controlled trial (ACTRN12622000072718) is evaluating the effect of this tool on patient willingness for surgery. Full results of this trial are expected to be available by April 2023. A free-to-use online version of the tool is available at
Conventional fracture courses utilise prefabricated sawbones that are not realistic or patient specific. The aim of this study is to determine the feasibility of creating 3D fracture models and utilising them in fracture courses to teach surgical technique. We selected an AO type 2R3C2 fracture that underwent open reduction internal fixation. De-identified CT scan images were converted to a stereolithography (STL) format. This was then processed using Computer Aided Design (CAD) to create a virtual 3D model. The model was 3D printed using a combination of standard thermoplastic polymer (STP) and a porous filler to create a realistic cortical and cancellous bone. A case-based sawbone workshop was organised for residents, unaccredited registrars, and orthopaedic trainees comparing the fracture model with a prefabricated T-split distal radius fracture. Pre-operative images aided discussion of fixation, and post-operative x-rays allowed comparison between the participants fixation. Participants were provided with identical reduction tools. We created a questionnaire for participants to rate their satisfaction and experience using a Likert scale. The 3D printed fracture model aided understanding and appreciation of the fracture pattern and key fragments amongst residents and unaccredited trainees. Real case-based models provided a superior learning experience and environment to aid teaching. The generic sawbone provided easier drilling and inserting of screws. Preliminary results show that the cost of 3D printing can be comparable to generic sawbones. It is feasible to create a fracture model with a real bone feel. Further research and development is required to determine the optimum material to use for a more realistic feel. The use of 3D printed fracture models is feasible and provides an alternative to generic sawbone fracture models in providing surgical training to residents.
The Femoral Neck System (FNS) was introduced as an alternative device for the fixation of neck of femur fractures (NOFFs). The purported advantages include superior angular and rotatory stability compared to multiple cancellous screws, via a minimally invasive instrumentation that is simpler than conventional fixed angle devices. There were limited clinical studies regarding the utility of this device. We aimed to study the outcomes of NOFFs fixed with the FNS. This was a single-institution, retrospective review of all undisplaced elderly (≥60 years old) undisplaced young, and displaced young NOFFs fixed with the FNS. Demographics, surgical parameters, radiographic parameters, and clinical outcomes including complications were reviewed. Thirty-six subjects with a median age of 75 [44,89] years old, had NOFF fixation using the FNS. Thirty-one (86.1%) had undisplaced fractures. There were 6 (16.7%), 26 (72.2%), and 4 (11.1%) subjects with Pauwels types 1, 2, and 3 respectively. Thirty-two (88.9%) had posterior tilt of <20º. The mean duration of surgery was 71±18 minutes. Excluding 4 patients whom required revision surgery, 2 patients whom demised, and 10 patients whom defaulted reviews, the mean follow-up duration was 55±13 weeks. Four complications were recorded, namely implant cut out at the femoral head at week 8, breaking of the locking screw at the run-off region at week 22, avascular necrosis at week 25, and a refracture following near fall, causing the fracture to fail in varus at week 7 postoperation. While reasonably fast to instrument, failures still occur and it is likely multifactorial. However, the rate of reoperation is lower than what has been reported for NOFFs fixed with the a fixed-angle device or 3 cancellous screws. In conclusion, the FNS is a reasonably safe instrument to use. Surgeons’ discretion is still needed in patient selection, keeping in mind the need for satisfactory radiological parameters.
Most studies comparing medial pivot to the posterior stabilised (PS) systems sacrifice the PCL. It is unknown whether retaining the PCL in the Medial Congruent (MC) system may provide further benefit compared to the more commonly used PS system. A retrospective review of a single-surgeon's registry data comparing 44 PS and 25 MC with PCL retained (MC-PCLR) TKAs was performed. Both groups had similar baseline demographics in terms of age, gender, body mass index, and American Society for Anaesthesiology score. There was no significant difference in their preoperative range of motion (ROM) (104º±20º The MC provides stability in the medial compartment while allowing a degree of freedom in the lateral compartment. Preserving the PCL when using MC may paradoxically cause an undesired additional restrain that slows the recovery process of the patients after TKA. In conclusion, compared to MC-PCLR, a PS TKA may expect significantly faster improvement at 3 months post operation, although they will achieve similar outcomes at 1-year post operation.
Evaluation of patient specific spinopelvic mobility requires the detection of bony landmarks in lateral functional radiographs. Current manual landmarking methods are inefficient, and subjective. This study proposes a deep learning model to automate landmark detection and derivation of spinopelvic measurements (SPM). A deep learning model was developed using an international multicenter imaging database of 26,109 landmarked preoperative, and postoperative, lateral functional radiographs (HREC: Bellberry: 2020-08-764-A-2). Three functional positions were analysed: 1) standing, 2) contralateral step-up and 3) flexed seated. Landmarks were manually captured and independently verified by qualified engineers during pre-operative planning with additional assistance of 3D computed tomography derived landmarks. Pelvic tilt (PT), sacral slope (SS), and lumbar lordotic angle (LLA) were derived from the predicted landmark coordinates. Interobserver variability was explored in a pilot study, consisting of 9 qualified engineers, annotating three functional images, while blinded to additional 3D information. The dataset was subdivided into 70:20:10 for training, validation, and testing. The model produced a mean absolute error (MAE), for PT, SS, and LLA of 1.7°±3.1°, 3.4°±3.8°, 4.9°±4.5°, respectively. PT MAE values were dependent on functional position: standing 1.2°±1.3°, step 1.7°±4.0°, and seated 2.4°±3.3°, p< 0.001. The mean model prediction time was 0.7 seconds per image. The interobserver 95% confidence interval (CI) for engineer measured PT, SS and LLA (1.9°, 1.9°, 3.1°, respectively) was comparable to the MAE values generated by the model. The model MAE reported comparable performance to the gold standard when blinded to additional 3D information. LLA prediction produced the lowest SPM accuracy potentially due to error propagation from the SS and L1 landmarks. Reduced PT accuracy in step and seated functional positions may be attributed to an increased occlusion of the pubic-symphysis landmark. Our model shows excellent performance when compared against the current gold standard manual annotation process.
Use of anticoagulants for thromboembolic prophylaxis is strongly supported by evidence. However, the use of these medications beyond the prophylactic period is poorly understood. We identified anticoagulant naïve patients that underwent hip or knee replacement between 2012 and 2019 from an arthroplasty registry and probabilistically linked 3,018 surgeries with nationwide pharmaceutical claims data. Rates of anticoagulation use were examined during the early (<= 60 days post-discharge), mid-term (61–180 days post-discharge) and long-term (181–360 days post-discharge) periods. Multivariable logistic regression analysis was performed to identify patient- and surgery-related factors associated with long-term anticoagulant use. Anticoagulants were supplied to 20% of arthroplasties within 60 days of discharge, 7% between 61–180 days, and 10% between 181–360 days. Older age, obesity, increased comorbidity burden, a longer length of stay, occurrence of a complication necessitating anticoagulation and dispensation of an anticoagulant within 60 days of discharge were all risk factors for long-term anticoagulant use. Given the risks associated with unnecessary use of these medications, certain patients who are prescribed anticoagulants beyond prophylactic period may benefit from specialist medication review in the months following surgery.
Total Knee Arthroplasty (TKA) is an effective surgery performed for knee osteoarthritis. Despite this success up to 20% of patients are less than fully satisfied. Rotating platform (RP) bearings have demonstrated significant reduction in rates of wear in laboratory studies but thus far have failed to demonstrate a clinical difference compared to fixed bearing (FB) arthroplasty in patients. This may be due to studies limited by small sample size and single centre design. Additionally, no studies have utilised modern patient-reported outcome measures (PROMs) such as PKIP to investigate differences between these bearings. A non-randomised, prospective, multi-centre study was conducted across centres in Australia, United Kingdom and the United States from November 2012 to May 2015. Knee prosthesis included were the RP and FB models of the PFC Sigma Knee (Depuy, Synthes) and the ATTUNE Knee (Depuy, Synthes). Data was collected on pre-arthroplasty interventions, demographics and PROMs. PROMs included were the KOOS, OKS, EQ53DL and PKIP. Participants were followed-up for 2 years. A total of 1,718 patients were recruited across 27 centres. 959 participants underwent a FB TKA, 759 participants underwent a RP TKA. No significant difference was found between RP and FB in change from baseline at 2 years across any parameter in all PROMs investigated at 2 years. Body Mass Index pre-operatively was the biggest indicator of change from baseline at 2 years. Our data demonstrates similar improvements in the short-term in both RP and TKA across all PROMs. Patients reported similar scores in satisfaction, confidence, mobility and stability in the PKIP PROM for both RP and FB groups. We have not found any evidence to suggest that RP TKA is disadvantageous at 2 years, and this is reassuring for any surgeon looking to utilise this bearing type in practice. Our data does not demonstrate a clinical advantage in RP TKA over FB TKA at 2 years in any PROM.
Several different algorithms attempt to estimate life expectancy for patients with metastatic spine disease. The Skeletal Oncology Research Group (SORG) has recently developed a nomogram to estimate survival of patients with metastatic spine disease. Whilst the use of the SORG nomogram has been validated in the international context, there has been no study to date that validates the use of the SORG nomogram in New Zealand. This study aimed to validate the use of the SORG nomogram in Aotearoa New Zealand. We collected data on 100 patients who presented to Waikato Hospital with a diagnosis of spinal metastatic disease. The SORG nomogram gave survival probabilities for each patient at each time point. Receiver Operating Characteristic (ROC) Area Under Curve (AUC) analysis was performed to assess the predictive accuracy of the SORG score. A calibration curve was also performed, and Brier scores calculated. A multivariate Cox regression analysis was performed. The SORG score was correlated with 30 day (AUC = 0.72) and 90-day mortality (AUC = 0.71). The correlation between the SORG score and 90-day mortality was weaker (AUC = 0.69). Using this method, the nomogram was correct for 79 (79%) patients at 30-days, 59 patients (59%) at 90-days, and 42 patients (42%) at 365-days. Calibration curves demonstrated poor forecasting of the SORG nomogram at 30 (Brier score = 0.65) and 365 days (Brier score = 0.33). The calibration curve demonstrated borderline forecasting of the SORG nomogram at 90 days (Brier score = 0.28). Several components of the SORG nomogram were not found to be correlated with mortality. In this New Zealand cohort the SORG nomogram demonstrated only acceptable discrimination at best in predicting life 30-, 90- or 356-day mortality in patients with metastatic spinal disease.
We present the indications and outcomes of a series of custom 3D printed titanium acetabular implants used over a 9 year period at our institution (Sydney, Australia), in the setting of revision total hip arthroplasty. Individualised image-based case planning with additive manufacturing of pelvic components was combined with screw fixation and off-the-shelf femoral components to treat patients presenting with failed hip arthroplasty involving acetabular bone loss. Retrospective chart review was performed on the practices of three contributing surgeons, with an initial search by item number of the Medicare Benefits Scheme linked to a case list maintained by the manufacturer. An analysis of indications, patient demographics and clinical outcome was performed. The cohort comprised 65.2% female with a median age of 70 years (interquartile range 61–77) and a median follow up of 32.9 months (IQR 13.1 - 49.7). The indications for surgery were infection (12.5%); aseptic loosening (78.1%) and fracture (9.4%), with 65.7% of cases undergoing previous revision hip arthroplasty. A tumour prosthesis was implanted into the proximal femur in 21.9% of cases. Complications were observed in 31.3% of cases, with four cases requiring revision procedures and no deaths reported in this series. Kaplan-Meier analysis of all-cause revision revealed an overall procedure survival of 88.7% at two years (95%confidence interval 69 - 96.2) and 83.8% (95%CI 62 - 93.7) at five years, with pelvic implant-specific survival of 98% (95%CI 86.6 - 99.7) at two and five year follow up. We conclude that an individualised planning approach for custom 3D printed titanium acetabular implants can provide high overall and implant-specific survival at up to five years follow up in complex cases of failed hip arthroplasty and acetabular bone loss.
Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand Patient reported outcome measures (PROMs) are predictors of knee arthroplasty revision. Unicompartmental knee arthroplasty (UKA) is effective for patients with the correct indications, however has higher revision rates than total knee arthroplasty (TKA). Different revision thresholds for the procedures have been postulated. Our aims were to investigate: 1) if PROMs could predict knee arthroplasty revision within two years of the score at six months, five years and ten years follow-up, and 2) if revision ‘thresholds’ differed between TKA and UKA. All TKAs and UKAs captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months (TKA n=27,708, UKA n=8,415), five years (TKA n=11,519, UKA n=3,365) or ten years (TKA n=6,311, UKA n=1,744) were included. were propensity-score matched 2:1 with UKAs for comparison of revision thresholds. Logistic regression indicated that for every one-unit decrease in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at six months, 10% and 12% at five years and 9% and 5% at ten years. Fewer TKA patients with ‘poor’ outcomes (≤25) subsequently underwent revision compared with UKA at six months (5.1% vs. 19.6%, p<0.001), five years (4.3% vs. 12.5%, p<0.001) and ten years (6.4%vs. 15.0%, p=0.02). Compared with TKA, UKA patients were 2.5 times more likely to undergo revision for ‘unknown’ reasons, bearing dislocations and disease progression. The OKS is a strong predictor of subsequent knee arthroplasty revision within two years of the score from early to late term. A lower revision threshold was found with UKA when compared with a matched TKA cohort. Higher revision rates of UKA are associated with both lower clinical thresholds for revision and additional modes of UKA failure.
Accurate measurement of pelvic tilt (PT) is critical in diagnosing hip and spine pathologies. Yet a sagittal pelvic radiograph with good quality is not always available. Studies explored the correlation between PT and sacro-femoral-pubic (SFP) angle from anteroposterior (AP) radiographs yet demonstrated conflicting conclusions about its feasibilities. This study aims to perform a cohort-controlled meta-analysis to examine the correlation between the SFP angle and PT and proposes an application range of the method. This study searched PubMed, Embase, Cochrane, and Web of Science databases for studies that evaluated the correlation between SFP angle and PT. The Pearson's correlation coefficient r from studies were tabulated and compared. Pooled r for overall and gender/age (teenage or adult) controlled subgroup were reported using Fisher's Z transformation. Heterogeneity and publication bias were evaluated using Egger's regression test for the funnel plot asymmetry. Eleven studies were recruited, with nine reported r (totalling 1,247 patients). The overall pooled r was 0.61 with high inter-study heterogeneity (I2 = 75.95%). Subgroup analysis showed that the adult group had a higher r than the teenage group (0.70 versus 0.56, p < 0.001). Although statistically insignificant (p = 0.062), the female group showed a higher r than the male group (0.72 versus 0.65). The SFP method must be used with caution and should not be used in the male teenage group. The current studies did not demonstrate that the SFP method was superior to other AP landmarks correlating to PT. Identical heterogeneity was observed among studies, indicating that more ethnicity-segregated and gender-specific subgroup studies might be necessary. More data input analysing the errors will be useful.
The treatment of paediatric supracondylar humeral fractures is likely one of the first procedures involving X-ray guided wire insertion that trainee orthopaedic surgeons will encounter. Pinning is a skill that requires high levels of anatomical knowledge, spatial awareness, and hand-eye coordination. We developed a simulation model using silicone soft-tissue and 3D-printed bones to allow development and practice of this skill at no additional risk to patients. For this model, we have focused on reusability and lowering raw-material costs without compromising fidelity. To achieve this, the initial bone model was extracted from open-source computed tomography scans and modified from adult to paediatric size. Muscle of appropriate robustness was then sculpted around the bones using 3D modelling software. A cutaneous layer was developed to mimic oedema using clay sculpturing on a plaster-casted paediatric forearm. These models were then used for 3D-printing and silicone casting respectively. The bone models were printed with settings to imitate cortical and cancellous densities and give high-fidelity tactile feedback upon drilling. Each humerus costs NZD $0.30 in material to print and can be used 1–3 times. Silicone casting of the soft-tissue layers imitates differing relative densities between muscle and oedematous cutaneous tissue, thereby increasing skill necessary to accurately palpate landmarks. Each soft-tissue sleeve cost NZD $70 in material costs to produce and can be used 20+ times. The resulting model is modular, reusable, and replaceable, with each component standardised and easily reproduced. It can be used to practice land-mark palpation and Kirschner wire pinning and is especially valuable in smaller centres which may not be able to afford traditional Saw Bones models. This low-cost model thereby improves equity while maintaining quality of simulation training.
Most previous studies investigating autograft options (quadriceps, hamstring, bone-patella-tendon-bone) in primary anterior cruciate ligament (ACL) reconstruction are confounded by concomitant knee injuries. This study aims to investigate the differences in patient reported outcome measures and revision rates for quadriceps tendon in comparison with hamstring tendon and bone-patella-tendon-bone autografts. We use a cohort of patients who have had primary ACL reconstruction without concomitant knee injuries. All patients from the New Zealand ACL Registry who underwent a primary arthroscopic ACL reconstruction with minimum 2 year follow-up were considered for the study. Patients who had associated ipsilateral knee injuries, previous knee surgery, or open procedures were excluded. The primary outcome was Knee Injury and Osteoarthritis Outcome Score (KOOS) and MARX scores at 2 years post-surgery. Secondary outcomes were all-cause revision and time to revision with a total follow-up period of 8 years (time since inception of the registry). 2581 patients were included in the study; 1917 hamstring tendon, 557 bone-patella-tendon-bone, and 107 quadriceps tendon. At 2 years, no significant difference in MARX scores were found between the three groups (2y mean score; 7.36 hamstring, 7.85 bone-patella-tendon-bone, 8.05 quadriceps, P = 0.195). Further, no significant difference in KOOS scores were found between the three groups; with the exception of hamstring performing better than bone-patella-tendon-bone in the KOOS sports and recreation sub-score (2y mean score; 79.2 hamstring, 73.9 bone-patella-tendon-bone, P < 0.001). Similar revision rates were reported between all autograft groups (mean revision rate per 100 component years; 1.05 hamstring, 0.80 bone-patella-tendon-bone, 1.68 quadriceps, P = 0.083). Autograft revision rates were independent of age and gender variables. Quadriceps tendon is a comparable autograft choice to the status quo for primary ACL reconstruction without concomitant knee injury. Further research is required to quantify the long-term outcomes for quadriceps tendon use.
Source of the study: University of Auckland, Auckland, New Zealand Unicompartmental knee arthroplasty (UKA) is effective for patients with isolated compartment osteoarthritis, however the procedure has higher revision rates. Long-term survivorship and accurate characterisation of revision reasons are limited by a lack of long-term data and standardised revision definitions. We aimed to identify survivorship, risk factors and revision reasons in a large UKA cohort with up to 20 years follow-up. Patient, implant and revision details were recorded through clinical and radiological review for 2,137 consecutive patients undergoing primary medial UKA across Auckland, Canterbury, Counties Manukau and Waitematā DHB between 2000 and 2017. Revision reasons were determined from review of clinical, laboratory, and radiological records for each patient using a standardised protocol. To ensure complete follow-up data was cross-referenced with the New Zealand Joint Registry to identify patients undergoing subsequent revision outside the hospitals. Implant survival, revision risk and revision reasons were analysed using Cox proportional-hazards and competing risk analyses. Implant survivorship at 15 years was comparable for cemented fixed-bearing (cemFB; 91%) and uncemented mobile-bearing (uncemMB; 91%), but lower for cemented mobile-bearing (cemMB; 80%) implants. There was higher incidence of aseptic loosening with cemented implants (3–4% vs. 0.4% uncemented, p<0.01), osteoarthritis (OA) progression with cemMB implants (9% vs. 3% cemFB/uncemMB; p<0.05) and bearing dislocations with uncemMB implants (3% vs. 2% cemMB, p=0.02). Compared with the oldest patients (≥75 years), there was a nearly two-fold increase in risk for those aged 55–64 (hazard ratio 1.9; confidence interval 1.1-3.3, p=0.03). No association was found with gender, BMI or ASA. Cemented mobile-bearing implants and younger age were linked to lower implant survivorship. These were associated with disease progression and bearing dislocations. The use of cemented fixed-bearing and uncemented mobile-bearing designs have superior comparable long-term survivorship.
This paper presents an ongoing review of the use of a wedge-shaped porous metal augments in the shoulder to address glenoid retroversion as part of anatomical total shoulder arthroplasty (aTSA). Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42 to 85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients received either a 15º or 30º PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Standardized Shoulder Assessment Form [ASES], visual analogue scale [VAS] pain scores and forward elevation [FE]) preoperatively, at three, six, and 12 months, and yearly thereafter, with similar radiological surveillance. Forty-nine consecutive series shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24–87 months). Median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90º to 140º). Four patients died, but no others were lost to follow-up. Apart from one infection at 18 months postoperatively and one minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency or posterior re-subluxations. Radiographs showed good incorporation of the wedge augment with correction of glenoid retroversion from median 22º (13º to 46º) to 4º. All but four glenoids were corrected to within the target range (less than 10º retroversion). The porous metal wedge-shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure.
Cryocompression therapy is a non-invasive and non-pharmacological modality used in managing acute post-operative inflammation and pain. A prospective, randomised controlled trial (RCT) was undertaken to evaluate the effectiveness of a post-operative cryocompression protocol using the Game Ready™ (GR) device versus usual care on recovery following total knee arthroplasty (TKA). A single centre RCT was conducted with 70 TKAs (68 patients) randomised to a 2-week intervention period consisting of treatment with GR cryocompression (n=33, 33.3% males) or a usual care protocol of ice with static compression using tubigrip (n=35, 54.3% males). Knee range of movement (ROM) (flexion and extension), a visual analogue pain score (VAS) and limb circumference were documented at day 1, 2 and 14, as well as 6 and 12 weeks post-surgery. ROM was also recorded at day 90, while medication use and length of hospital stay were documented. Patient reported outcome measures (PROMs) including the KOOS and patient satisfaction questionnaire were employed. The GR group demonstrated 2.3° more (p=0.05) knee extension ROM overall, as well as 2. 8° more at day 1 (p=0.048), 3.8° at day 14 (p=0.007) and 5.4° at 3 months (p=0.017). There were no group differences (p>0.05) observed in pain (VAS), flexion ROM, limb circumference, opioid use or other PROMs. Across the full cohort, higher pain levels resulted in increased opioid intake (p=0.002), older patients used significantly less opioids (p<0.001) and males reported significantly less pain (VAS) than females (p=0.048). Using GR following TKA is a safe, non-invasive tool that can be used to aid in the post-operative recovery period. Patients using the GR cryocompression device gained significantly more extension ROM compared to the conventional ice with compression group, despite no other group differences.
The risk of AVN is high in Unstable Slipped Capital Femoral Epiphysis (SCFE) and the optimal surgical treatment remains controversial. Our AVN rates in severe, unstable SCFE remained unchanged following the introduction of the Modified Dunn Procedure (MDP) and as a result, our practice evolved towards performing an Anterior Open Reduction and Decompression (AOR) in an attempt to potentially reduce the “second hit” phenomenon that may contribute. The aim of this study was to determine the early surgical outcomes in Unstable SCFE following AOR compared to the MDP. All moderate to severe, Loder unstable SCFEs between 2008 and 2022 undergoing either an AOR or MDP were included. AVN was defined as a non-viable post-operative SPECT-CT scan. Eighteen patients who underwent AOR and 100 who underwent MPD were included. There was no significant difference in severity (mean PSA 64 vs 66 degrees, p = 0.641), or delay to surgery (p = 0.973) between each group. There was no significant difference in the AVN rate at 27.8% compared to 24% in the AOR and MDP groups respectively (p = 0.732). The mean operative time in the AOR group was 24 minutes less, however this was not statistically significant (p = 0.084). The post-reduction PSA was 26 degrees (range, 13–39) in the AOR group and 9 degrees (range, -7 to 29) in the MDP group (p<0.001). Intra-operative femoral head monitoring had a lower positive predictive value in the AOR group (71% compared to 90%). Preliminary results suggest the AVN rate is not significantly different following AOR. There is less of an associated learning curve with the AOR, but as anticipated, a less anatomical reduction was achieved in this group. We still feel that there is a role for the MDP in unstable slips with a larger remodelling component.
Numerous prediction tools are available for estimating postoperative risk following spine surgery. External validation studies have shown mixed results. We present the development, validation, and comparative evaluation of novel tool (NZSpine) for modelling risk of complications within 30 days of spine surgery. Data was gathered retrospectively from medical records of patients who underwent spine surgery at Waikato Hospital between January 2019 and December 2020 ( Overall complication rate was 34%. In the multivariate model, higher age, increased surgical invasiveness and the presence of preoperative anemia were most strongly predictive of any postoperative complication (OR = 1.03, 1.09, 2.1 respectively, Internal validation using the bootstrapped models showed the model was robust, with an AUC of 0.73. Using sensitivity analysis, 80% of the model's predictions were correct. By comparison SpineSage had an AUC of 0.71, and in decision curve analysis the novel model showed greater expected benefit at all thresholds of risk. NZSpine is a novel risk assessment tool for patients undergoing acute and elective spine surgery and may help inform clinicians and patients of their prognosis. Use of an objective tool may help to provide uniformity between DHBs when completing the “clinician assessment of risk” section of the national prioritization tool.
This technique is a novel superior based muscle sparing approach. Acetabular reaming in all hip approaches requires femoral retraction. This technique is performed through a hole in the lateral femoral cortex without the need to retract the femur. A 5 mm hole is drilled in the lateral femur using a jig attached to the broach handle, similar to a femoral nail. Specialised instruments have been developed, including a broach with a hole going through it at the angle of the neck of the prosthesis, to allow the rotation of the reaming rod whilst protecting the femur. A special C-arm is used to push on the reaming basket. The angle of the acetabulum is directly related to the position of the broach inside the femoral canal and the position of the leg. A specialised instrument allows changing of offset and length without dislocating the hip during trialling. Some instrumentation has been used in surgery but ongoing cadaver work is being performed for proof of concept. The ability to ream through the femur has been proven during surgery. The potential risk to the bone has been assessed using finite analysis as minimal. The stress levels for any diameter maintained within a safety factor >4 compared to the ultimate tensile strength of cortical bone. The described technique allows for transfemoral acetabular reaming without retraction of the femur. It is minimally invasive and simple, requiring minimal assistance. We are incorporating use with a universal robot system as well as developing an electromagnetic navigation system. Assessment of the accuracy of these significantly cheaper systems is ongoing but promising. This approach is as minimally invasive as is possible, safe, requires minimal assistance and has a number of other potential advantages with addition of other new navigation and simple robotic attachments.
Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated. Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07). HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments.
Instability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability. This is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; SERF, DÉCINES-CHARPIEU, FRANCE) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation. With a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients. The use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years. That's why we also recommend DM cup for all high risk of dislocation situations.
Due to shorter hospital stays and faster patient rehabilitation Unicompartmental Knee Replacements (UKR) are now considered more cost effective than Total Knee Joint Replacements (TKJR). Obesity however, has long been thought of as a relative contraindication to UKR due to an unproven theoretical concern of early loosening. This study is a retrospective review of patient reported outcome scores and revision rates of all UKR with recorded BMI performed by the Canterbury District Health Board (CDHB) from January 2011 and September 2021. Patient reported outcome scores were taken preoperatively, at 6 months, 1 year, 5 years and 10 years post operatively. These included WOMAC, Oxford, HAAS, UCLA, WHOQOL, normality, pain and patient satisfaction. 873 patients had functional scores recorded at 5 years and 164 patients had scores recorded at 10 years. Further sub-group analysis was performed based on patient BMI of <25, 25–30, 30–35 and >35. Revision data was available for 2377 UKRs performed in Christchurch during this period. Both obese (BMI >30) and non-obese (BMI <30) patients had significantly improved post-operative scores compared to preoperative. Pre-operatively obese patients had significantly lower functional scores except for pain and UCLA. All functional scores were lower in obese patients at 5 years but this did not meet minimum clinical difference. At 10 years, there was significantly lower HAAS, satisfaction and WOMAC scores for obese patients but no difference in Oxford, normality, WHOQOL, UCLA and pain scores. There was no significant difference in the improvement from pre-operative scores between obese and non-obese patients. All cause revision rate for obese patients at 10 years was 0.69 per 100 observed component years compared to 0.76 in non-obese. This was not statistically significant. Our study proves that UKR is an excellent option in obese patients with post-operative improvement in functional scores and 10 year survivorship equivalent to non-obese patients.
PVNS or TGCT (Pigmented Villonodular Synovitis, or Tenosynovial Giant Cell tumour) is a benign tumour affecting the synovial lining of joints and tendon sheaths, historically treated with surgical excision or debridement. We have shown previously this management is fraught with high recurrence rates, especially in its diffuse form. We present the encouraging early results of medical management for this condition with use of a CSF1 inhibitor, in comparison to a cohort of 137 cases previously treated at our institution.
Meniscal repairs are commonly performed during anterior cruciate ligament (ACL) reconstruction. This study aimed to identify the risk factors for meniscal repair failure following concurrent primary ACL reconstruction. Primary ACL reconstructions with a concurrent repair of a meniscal tear recorded in the New Zealand ACL Registry between April 2014 and December 2018 were analyzed. Meniscal repair failure was defined as a patient who underwent subsequent meniscectomy, and was identified after cross-referencing data from the ACL Registry with the national database of the Accident Compensation Corporation (ACC). Multivariate Cox regression was performed to produce hazard ratios (HR) with 95% confidence intervals (CI) to identify the patient and surgical risk factors for meniscal repair failure. 2041 meniscal repairs were analyzed (medial = 1235 and lateral = 806). The overall failure rate was 9.4% (n = 192). Failure occurred in 11.1% of medial (137/1235) and 6.8% of lateral (55/806) meniscal repairs. The risk of medial failure was higher with hamstring tendon autografts (adjusted HR = 2.00, 95% CI 1.23 – 3.26, p = 0.006) and in patients with cartilage injury in the medial compartment (adjusted HR = 1.56, 95% CI 1.09 – 2.23, p = 0.015). The risk of lateral failure was higher when the procedure was performed by a surgeon with an annual case volume of less than 30 ACL reconstructions (adjusted HR = 1.92, 95% CI 1.10 – 3.33, p = 0.021). Age, gender, time from injury-to-surgery and femoral tunnel drilling technique did not influence the risk of meniscal repair failure. When repairing a meniscal tear during ACL reconstruction, the use of a hamstring tendon autograft or the presence of cartilage injury in the medial compartment increases the risk of medial meniscal repair failure. Lower surgeon case volume increases the risk of lateral meniscal repair failure.
Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori. A retrospective cohort study from January 1st, 2015, to December 31st 2020 inclusive. Eligible patients were 16–65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriate No statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004) Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori. The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area.
It is undetermined which factors predict return to work following arthroscopic rotator cuff repair. We aimed to identify which factors predicted return to work at any level, and return to pre-injury levels of work 6 months post-arthroscopic rotator cuff repair. Multiple logistic regression analysis of prospectively collected demographic, pre-injury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work, and return to pre-injury levels of work respectively, 6 months post-surgery. Six months post-rotator cuff repair, 76% of patients returned to work (RTW), and 40% returned to pre-injury levels of work (Full-RTW). RTW at 6 months was likely if patients were still working after their injuries, but prior to surgery (Wald statistic [W]=55, p<0.0001), were stronger in internal rotation preoperatively (W=8, p=0.004), had full-thickness tears (W=9, p=0.002), and were female (W=5, p=0.030). Patients who achieved Full-RTW were likely to have worked less strenuously pre-injury (W=173, p<0.0001), worked more strenuously post-injury but pre-surgery (W=22, p<0.0001), had greater behind-the-back lift-off strength preoperatively (W=8, p=0.004), and had less passive external rotation range of motion preoperatively (W=5, p=0.034). Patients who were still working post-injury, but pre-surgery were 1.6-times more likely to RTW than patients who were not (p<0.0001). Patients who nominated their pre-injury level of work as “light” were 11-times more likely to achieve Full-RTW than those who nominated “strenuous” (p<0.0001). Six months post-rotator cuff repair, a higher patient-rated post-injury, but pre-surgery level of work was the strongest predictor of RTW. A lower patient-rated pre-injury level of work was the strongest predictor of Full-RTW. Greater preoperative subscapularis strength independently predicted both RTW, and Full-RTW.
The Coronal Plane Alignment of the Knee (CPAK) is a recent method for classifying knees using the hip-knee-ankle angle and joint line obliquity to assist surgeons in selection of an optimal alignment philosophy in total knee arthroplasty (TKA)1. It is unclear, however, how CPAK classification impacts pre-operative joint balance. Our objective was to characterise joint balance differences between CPAK categories. A retrospective review of TKA's using the OMNIBotics platform and BalanceBot (Corin, UK) using a tibia first workflow was performed. Lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were landmarked intra-operatively and corrected for wear. Joint gaps were measured under a load of 70–90N after the tibial resection. Resection thicknesses were validated to recreate the pre-tibial resection joint balance. Knees were subdivided into 9 categories as described by MacDessi et al.1 Differences in balance at 10°, 40° and 90° were determined using a one-way 2-tailed ANOVA test with a critical p-value of 0.05. 1124 knees satisfied inclusion criteria. The highest proportion of knees (60.7%) are CPAK I with a varus aHKA and Distal Apex JLO, 79.8% report a Distal Apex JLO and 69.3% report a varus aHKA. Greater medial gaps are observed in varus (I, IV, VII) compared to neutral (II, V, VIII) and valgus knees (III, VI, IX) (p<0.05 in all cases) as well as in the Distal Apex (I, II, III) compared to Neutral groups (IV, V, VI) (p<0.05 in all cases). Comparisons could not be made with the Proximal Apex groups due to low frequency (≤2.5%). Significant differences in joint balance were observed between and within CPAK groups. Although both hip-knee-ankle angle and joint line orientation are associated with joint balance, boney anatomy alone is not sufficient to fully characterize the knee.
Prosthetic joint infections (PJI) are one of the most devastating complications of joint replacement surgery. They are associated with significant patient morbidity and carry a significant economic cost to treat. The management of PJI varies from antibiotic suppression, debridement, antibiotics, and implant retention (DAIR) procedures through to single/multiple stage revision procedures. Concerns have been raised recently in relation to the rising number of revision arthroplasty procedures that are being undertaken in relation to infection. This database aims to collect data on all PJIs that have been managed in the Australian Capital Territory (ACT) region. This will allow us to investigate the microbial trends, outcomes of surgical intervention and patient outcomes within our local population. This database will incorporate diagnostic, demographic, microbiological and treatment information in relation to local PJI cases. The data will be collated from the local infectious diseases database, hospital medical records, and where available the Australian Orthopaedic Association National Joint Replacement Registry Data. The first 100 cases of PJI were assessed. 76% were defined as being acute. 56% of the patients received antibiotics prior to their diagnosis however only 3% were culture negative. 89% were monomicrobial and 11% polymicrobial. The intended management strategy was a DAIR in 38% of patients and a 2-stage revision in 12% of cases. The intended management strategy was successful in 46% of the patients. The ACT is uniquely placed to analyze and create a local PJI database. This will allow us to guide further treatment and local guidelines in terms of management of these complex patients.
We hypothesised that diet-induced obesity (DIO) would result in inferior enthesis healing in a rat model of rotator cuff (RC) repair and that dietary intervention in the peri-operative period would improve enthesis healing. A total of 78 male Sprague-Dawley rats were divided into three weight-matched groups from weaning and fed either: control diet (CD), high-fat diet (HFD), or HFD until surgery, then CD thereafter (HF-CD). After 12 weeks, the left supraspinatus tendon was detached, followed by immediate surgical repair. At 2 and 12 weeks post-surgery, animals were culled, and RCs harvested for biomechanical and histological evaluation. Body composition and metabolic markers were assessed via DEXA and plasma analyses, respectively. DIO was established in the HFD and HF-CD groups before surgery and subsequently reversed in the HF-CD group after surgery. Histologically, the appearance of the repaired entheses was poorer in both the HFD and HF-CD groups compared with the CD group at 12 weeks after surgery, with semiquantitative scores of 6.2 (P<0.01), 4.98 (P<0.01), and 8.7 of 15, respectively. The repaired entheses in the HF-CD group had a significantly lower load to failure (P=0.03) at 12 weeks after surgery compared with the CD group, while the load to failure in the HFD group was low but not significantly different (P=0.10). Plasma leptin were negatively correlated with histology scores and load to failure at 12 weeks after surgery. DIO impaired enthesis healing in this rat RC repair model, with inferior biomechanical and histological outcomes. Restoring normal weight with dietary change after surgery did not improve healing outcomes. Circulating levels of leptin significantly correlated with poor healing outcomes. This pre-clinical rodent model demonstrates that obesity is a potentially modifiable factor that impairs RC healing and increases the risk of failure after RC surgery.
The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation. Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12-month period in a single-centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores. A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading. This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritise improving documentation of informed consent for orthopaedic trauma patients to ensure a patient-centred approach to healthcare.
In Australia nearly two-thirds of arthroplasty procedures are performed in the private setting, which is disproportionate to the dimensioning 43.5% of the population with private health cover. The rapid growth of shoulder arthroplasty surgery will be absorbed by both private and public sectors. This study aimed to assess the influence of healthcare setting on elective shoulder arthroplasty outcomes, defined by revision rate, and functional measures. Data was collected on all primary procedures performed from 2004 – 2019 within a regional area of Victoria, Australia. Patients were categorised into private or public settings. Trauma cases for acute proximal humerus fractures were excluded. The primary outcome of revision surgery was recorded as a cumulative percentage, and survival analysis conducted to calculate a hazard ratio (HR). Functional outcomes were measured through range-of-motion (ROM) and multiple validated patient-reported-outcome-measures (PROMs). 458 patients were identified in the study: 290 private and 168 public. There was no difference in the revision rate (3.8% private, 4.8% public), with an adjusted HR of 1.25 (p=0.66) for public compared to private. Baseline and post-operative functional measures were significantly greater in the private setting for ROMs and PROMs analysis, in particular post-operative QuickDASH (15.9±14.7 to 32.7±23.5; p<0.001) and Oxford Shoulder Score (42.6±6.3 to 35.7±11.2; p<0.001). However, there was no significant difference for any of the functional measures in the amount of change from baseline to 12-months between settings. Although healthcare setting does not appear to influence revision rate for shoulder arthroplasty, clear differences were demonstrated for functional measures both pre and post operatively. This may be attributed to factors such as access to perioperative rehabilitation and should be an area to target future investigations.
This study investigated concurrent talar dome injuries associated with tibial pilon fractures, mapping their distribution across the proximal talar dome articular surface. It compared the two main mechanisms of injury (MOI), falling from a height and motor vehicle accident (MVA), and whether the fractures were open or closed. From a previously compiled database of acute distal tibial pilon fractures (AO/OTA 43B/C) in adults of 105 cases, 53 cases were identified with a concurrent injury to the talar dome with a known mechanism of injury and in 44 it was known if the fracture was open or closed. Case specific 2D injury maps were created using a 1x1mm grid, which were overlayed in an Excel document to allow for comparative analyses. A two-way ANOVA was conducted that examined the effect of both MOI and if the fracture was open or closed on what percentage of the talar dome surface was injured. There was a statistically-significant difference between the average percentage of injured squares on the talar dome by both whether the fracture was open or closed (f(1)=5.27, p= .027) and the mechanism of injury (f(1)=8.08, p= .007), though the interaction between these was not significant (p= .156). Open injuries and injuries that occurred during an MVA were more likely to increase the surface area of the talar dome injuries. We have identified both MOI and if the fracture was either open or closed impacts the size of the injury present on the talar dome. Future research will investigate the aetiology of the differences noted, highlighting the clinical implications. Surgeons treating tibial pilon fractures caused by either a MVA or an open fracture, should be aware of an increased risk of large injuries to the surface of the talar dome.
Neer Type-IIB lateral clavicle fractures are inherently unstable fractures with associated disruption of the coracoclavicular (CC) ligaments. A novel plating technique using a superior lateral locking plate with antero-posterior (AP) locking screws, resulting in orthogonal fixation in the lateral fragment has been designed to enhance stability. The purpose of this study was to biomechanically compare three different clavicle plating constructs. 24 fresh-frozen cadaveric shoulders were randomised into three groups (n=8 specimens). Group 1: lateral locking plate only (Medartis Aptus Superior Lateral Plate); Group 2: lateral locking plate with CC stabilisation (Nr. 2 FiberWire); and Group 3: lateral locking plate with two AP locking screws stabilising the lateral fragment. Data was analysed for gap formation after cyclic loading, construct stiffness and ultimate load to failure, defined by a marked decrease in the load displacement curve. After 500 cycles, there was no statistically significant difference between the three groups in gap-formation (p = 0.179). Ultimate load to failure was significantly higher in Group 3 compared to Group 1 (286N vs. 167N; p = 0.022), but not to Group 2 (286N vs. 246N; p = 0.604). There were no statistically significant differences in stiffness (Group 1: 504N/mm; Group 2: 564N/mm; Group 3: 512N/mm; p = 0.712). Peri-implant fracture was the primary mode of failure for all three groups, with Group 3 demonstrating the lowest rate of peri-implant fractures (Group 1: 6/8; Group 2: 7/8, Group 3: 4/8; p = 0.243). The lateral locking plate with orthogonal AP locking screw fixation in the lateral fragment demonstrated the greatest ultimate failure load, followed by the lateral locking plate with CC stabilization. The use of orthogonal screw fixation in the distal fragment may negate against the need for CC stabilization in these types of fractures, thus minimizing surgical dissection around the coracoid and potential complications.
Polyetheretherketone (PEEK) interbody fusion cages combined with autologous bone graft is the current clinical gold standard treatment for spinal fusion, however, bone graft harvest increases surgical time, risk of infection and chronic pain. We describe novel low-stiffness 3D Printed titanium interbody cages without autologous bone graft and assessed their biological performance in a pre-clinical in vivo interbody fusion model in comparison to the gold standard, PEEK with graft. Titanium interbody spacers were 3D Printed with a microporous (Ti1: <1000μm) and macroporous (Ti2: >1000μm) design. Both Ti1 and Ti2 had an identical elastic modulus (stiffness), and were similar to the elastic modulus of PEEK. Interbody fusion was performed on L2-L3 and L4-L5 vertebral levels in 24 skeletally mature sheep using Ti1 or Ti2 spacers, or a PEEK spacer filled with iliac crest autograft, and assessed at 8 and 16 weeks. We quantitatively assessed bone fusion, bone area, mineral apposition rate and bone formation rate. Functional spinal units were biomechanically tested to analyse range of motion, neutral zone, and stiffness. Results: Bone formation in macroporous Ti2 was significantly greater than microporous Ti1 treatments (p=.006). Fusion scores for Ti2 and PEEK demonstrated greater rates of bone formation from 8 to 16 weeks, with bridging rates of 100% for Ti2 at 16 weeks compared to just 88% for PEEK and 50% for Ti1. Biomechanical outcomes significantly improved at 16 versus 8 weeks, with no significant differences between Ti and PEEK with graft. This study demonstrated that macroporous 3D Printed Ti spacers are able to achieve fixation and arthrodesis with complete bone fusion by 16 weeks without the need for bone graft. These significant data indicate that low-modulus 3D Printed titanium interbody cages have similar performance to autograft-filled PEEK, and could be reliably used in spinal fusion avoiding the complications of bone graft harvesting.
We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%). Cemented THA with the Exeter Contemporary Flanged cup and the Exeter stem is a durable combination with results that can be replicated outside of the design centre. The Exeter Contemporary Flanged cup has excellent survivorship at 15 years when used with the Exeter stem. Cemented THA with well-proven components should be considered the benchmark against which newer designs and materials should be compared.
This study aimed to evaluate the month-to-month prevalence of antibiotic dispensation in the 12 months before and after total knee arthroplasty (TKA) and total hip arthroplasty (THA) and to identify factors associated with antibiotic dispensation in the month immediately following the surgical procedure. In total, 4,115 THAs and TKAs performed between April 2013 and June 2019 from a state-wide arthroplasty referral centre were analysed. A cross-sectional study used data from an institutional arthroplasty registry, which was linked probabilistically to administrative dispensing data from the Australian Pharmaceutical Benefits Scheme. Multivariable logistic regression was carried out to identify patient and surgical risk factors for oral antibiotic dispensation. Oral antibiotics were dispensed in 18.3% of patients following primary TKA and 12.0% of patients following THA in the 30 days following discharge. During the year after discharge, 66.7% of TKA patients and 58.2% of THA patients were dispensed an antibiotic at some point. Patients with poor preoperative health status were more likely to have antibiotics dispensed in the month following THA or TKA. Older age, undergoing TKA rather than THA, obesity, inflammatory arthritis, and experiencing an in-hospital wound-related or other infectious complications were associated with increased antibiotic dispensation in the 30 days following discharge. A high rate of antibiotic dispensation in the 30 days following THA and TKA has been observed. Although resource constraints may limit routine wound review for all patients by a surgeon, a select cohort may benefit from timely specialist review postoperatively. Several risk factors identified in this study may aid in identifying appropriate candidates for such changes to follow-up care.
Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants.Aims
Methods
There is growing interest in the peri-operative management of patients with indications for hip and knee arthroplasty in the setting of modifiable risk factors such as morbid obesity, type 2 diabetes mellitus, and smoking. A recent survey of the American Association of Hip and Knee Surgeons (AAHKS) found that 95% of respondents address modifiable risk factors prior to surgery. The aim of this study was to poll Australian arthroplasty surgeons regarding their approach to patients with modifiable risk factors. The survey tool used in the AAHKS study was adapted for use in the Australian context and distributed to the membership of the Arthroplasty Society of Australia via Survey Monkey. Seventy-seven survey responses were received, representing a response rate of 64%. The majority of respondents were experienced, high volume arthroplasty surgeons. Overall, 91% of respondents restricted access to arthroplasty for patients with modifiable risk factors. Seventy-two percent of surgeons restricted access for excessive body mass index, 85% for poor diabetic control, and 46% for smoking. Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Despite differences in healthcare systems, our findings were similar to those of the AAHKS survey, although their responses were more restrictive in all domains. Differences were noted in responses concerning financial considerations for potentially underprivileged populations. The survey is currently being administered by arthroplasty societies in six other countries, allowing comparison of orthopaedic practice across different healthcare systems around the world. In conclusion, over 90% of Australian arthroplasty surgeons who responded to the survey address modifiable risk factors prior to surgery.
The New Zealand Joint Registry (NZJR) was established in 1999. However, ethnicity data was not recorded by prioritisation in line with Ministry of Health (MoH) recommendations. Recently, cross-referencing with MoH updated ethnicity data for all 326,150 entries in the NZJR database. The objective of this national level, population study was to identify any ethnic disparities in access and outcome for Māori for primary total hip (THA) and knee arthroplasty (TKA) for Osteoarthritis. The utilisation rate for THA and TKAs were calculated for the Māori and NZ European population from all data in the NZJR and Census data in 2001, 2006, 2013 and 2018. Utilisation rate was reported separately for four age groups (<55, 55-64, 65-74, >75) over four time periods (1999-2004, 2005-2009, 2010-2014, 2015-2020). Revision rate, 6 months and 5-year Oxford scores were adjusted for age, sex and BMI, then compared between groups. In every age group and at all but one time point, significant under-utilisation of TKA was observed in Māori. For THAs, Māori had similar utilisation rates in the <55 and 55-64 age groups, but significantly lower utilisation rates in all other age groups. When adjusted for age, sex and BMI, no significant differences in revision rates were observed between Māori and NZ Europeans for THAs (HR 0.939, P 0.417) or TKAs (HR 1.129, P 0.149). Adjusted 6 months and 5-year Oxford scores were significantly higher in NZ Europeans, however, the maximum difference was less than 3 points and is unlikely to be clinically significant. Despite the same risk of being diagnosed with osteoarthritis, Māori are less likely to undergo THA and TKA. There are no clinically significant differences in outcomes post arthroplasty between Māori and NZ Europeans. Further research is required to investigate causes for lower utilisation in Māori.
3D printing and Bioprinting technologies are becoming increasingly popular in surgery to provide a solution for the regeneration of healthy tissues. The aim of our project is the regeneration of articular cartilage via bioprinting means, to manage isolated chondral defects. Chrondrogenic hydrogel (chondrogel: GelMa + TGF-b3 and BMP6) was prepared and sterilised in our lab following our standard protocols. Human adipose-derived mesenchymal stem cells were harvested from the infrapatellar fat pad of patients undergoing total knee joint replacements and incorporated in the hydrogel according to our published protocols. The chondrogenic properties of the chondrogel have been tested (histology, immunohistochemistry, PCR, immunofluorescence, gene analysis and 2nd harmonic generation microscopy) in vitro and in an ex-vivo model of human articular defect and compared with standard culture systems where the growth factors are added to the media at repeated intervals. The in-vitro analysis showed that the formation of hyaline cartilage pellet was comparable between the two strategies, with a similar metabolic activity of the cells. These results have been confirmed in the ex-vivo model: hyaline-like cartilage was observed within the chondral defect in both the chondrogel group and the control group after 28 days in culture. The use of bioprinting techniques in vivo requires the ability of stem cells to access growth factors directly in the environment they are in, as opposed to in vitro techniques where these factors are provided externally at recurrent intervals. This study showed the successful strategy of incorporating chondrogenic growth factors for the formation of hyaline-like cartilage in vitro and in an ex-vivo model of chondral loss. The incorporation of chondrogenic growth factors in a hydrogel is a possible strategy for articular cartilage regeneration.
Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired. We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility. This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile.
The purpose of this study is to assess the long term results of combined ACL reconstruction and unicompartmental knee replacements (UKR). These patients have been selected for this combined operation due to their combination of instability symptoms from an absent ACL and unicompartmental arthritis. Retrospective review of 44 combined UKR and ACL reconstruction by a single surgeon. Surgeries included both medial and lateral UKR combined with either revision ACL reconstruction or primary ACL reconstruction. Patient reported outcomes were obtained preoperatively, at one year, 5 years and 10 years. Revision rate was followed up over 13 years for a mean of 7.4 years post-surgery. The average Oxford score at one year was 43 with an average increase from pre-operation to 1 year post operation of 15. For the 7 patients with 10 year follow up average oxford score was 42 at 1 year, 43 at 5 years and 45 at 10 years. There were 5 reoperations. 2 for revision to total knee arthroplasty and 1 for an exchange of bearing due to wear. The other 2 were the addition of another UKR. For those requiring reoperation the average time was 8 years. Younger more active patients presenting with ACL deficiency causing instability and unicompartmental arthritis are a difficult group to manage. Combining UKR and ACL reconstruction has scant evidence in regard to long term follow up but is a viable option for this select group. This paper has one of the largest cohorts with a reasonable follow up averaging 7.4 years and a revision rate of 11 percent. Combined unilateral knee replacements and ACL reconstruction can be a successful operation for patients with ACL rupture causing instability and unicompartmental arthritis.
In the Unites States, approximately 24% of people undergoing primary total knee or total hip arthroplasty (TKA, THA) are chronic opioid users pre-operatively. Few studies have examined the incidence of opioid use prior to TKA/THA and whether it predicts outcomes post-surgery in the Australian context. The aim was to determine: (i) the proportion of TKA and THA patients who use opioids regularly (daily) pre-surgery; (ii) if opioid use pre-surgery predicts (a) complication and readmission rates to 6-months post-surgery, (b) patient-reported outcomes to 6-months post-surgery. A retrospective cohort study was undertaken utilising linked individual patient-level data from two independent databases comprising approximately 3500 people. Patients had surgery between January 2013 and June 2018, inclusive at Fairfield and Bowral Hospitals. Following data linkage, analysis was completed on 1185 study participants (64% female, 69% TKA, mean age 67 (9.9)). 30% were using regular opioids pre-operatively. Unadjusted analyses resulted in the following rates in those who Adjusted regression analyses controlling for multiple co-variates indicated no significant association between pre-op opioid use and adverse events/patient-reported outcomes. Pre-operative opioid use was high amongst this Australian arthroplasty cohort and was not associated with increased risk of adverse events post-operatively. Further research is needed in assessing the relationship between the amount of pre-op opioid use and the risk of post-operative adverse events.
Obesity is associated with worse outcomes following total knee/hip arthroplasty (TKA/TKA). This study aimed to determine the feasibility of a dietitian-led low-inflammatory weight-loss program for people with obesity awaiting arthroplasty. Quasi-experimental pilot study enrolled people with obesity waitlisted for primary TKA/THA into ‘usual care’ (UC) or weight-loss (low-inflammatory diet) program (Diet). Recruitment occurred between July 2019 and February 2020 at Fairfield and Campbelltown Hospitals. Assessments at baseline, pre-surgery, time of surgery and 90-days following surgery included anthropometric measurements, patient-reported outcomes, serum biomarkers and 90-day postoperative complication rate. 97 people consented to the study (UC, n=47, mean age 67, BMI 37, TKA 79%; Diet, n=50, mean age 66, BMI 36, TKA 72%). Baseline characteristics indicated gross joint impairments and poor compliance with a low-inflammatory diet. Study feasibility criteria included recruitment rate (52%), proportion of diet patients that improved compliance to low-inflammatory diet by ≥10% (57%) and had ≥60% attendance of dietitian consultations (72%), proportion of patients who undertook serum biomarkers (55%). By presurgery assessments, the diet group had more patients who cancelled their surgery due to symptom improvement (4 vs 0), reduced waist-circumference measurements, increased compliance with the Low-Inflammatory diet and preservation of physical activity parameters. More usual care participants experienced at least one postoperative complication to 90-days (59% vs 47%) and were discharged to inpatient rehabilitation (21% vs 11%). There was no difference in weight change, physical function, and patient-reported outcome measures from pre-surgery to 90-days post-surgery, and length of hospital stay. Using pre-determined feasibility criteria, conducting a definitive trial is not feasible. However, intervention audit demonstrated high intervention fidelity. Pilot data suggest our program may promote weight loss but the clinical effects for most are modest. Further research utilising a stronger intervention may be required to assess the effectiveness of a pre-arthroplasty weight-loss intervention.
The triangular fibrocartilage complex (TFCC) is a known stabiliser of the distal radioulnar joint (DRUJ). An injury to these structures can result in significant disability including pain, weakness and joint stiffness. The contribution each of its components makes to the stability of the TFCC is not well understood. This study was undertaken to investigate the role of the individual ligaments of the TFCC and their contribution to joint stability. The study was undertaken in two parts. 30 cadaveric forearms were studied in each group. The ligaments of the TFCC were progressively sectioned and the resulting effect on the stability of the DRUJ was measured. A custom jig was created to apply a 20N force through the distal radius, with the ulna fixed. Experiment one measured the effect on DRUJ translation after TFCC sectioning. Experiment two added the measurement of rotational instability. Part one of the study showed that complete sectioning of the TFCC caused a mean increase in translation of 6.09(±3) mm. Sectioning the palmar radioulnar ligament of the TFCC caused the most translation. Part two demonstrated a change in rotation with a mean of 18 (± 6) degrees following sectioning of the TFCC. There was a progressive increase in rotational instability until the palmar radioulnar ligament was also sectioned. Linear translation consistently increased after sectioning all of the TFCC ligaments, confirming its importance for DRUJ stability. Sectioning of the palmar radioulnar ligament most commonly caused the greatest degree of translation. This suggests injury to this ligament would more likely result in a greater degree of translational instability. The increase in rotation also suggests that this type of instability would be symptomatic in a TFCC injury.
The role of dual consultant operating (DCO) in general orthopaedics has not been researched; where it has shown benefit in other specialties, there is a lack of information on how DCO affects the surgeons themselves. We wanted to explore the potential effects of DCO on stress, as a foundation for further research to guide support for our surgeons. We conducted a survey among orthopaedic consultants around New Zealand, containing questions pertaining to the demographics of respondents, their experience with DCO, what the expected risks and benefits of DCO would be, and provided two high-stress exemplar clinical scenarios where respondents were asked to rate their expected stress level at baseline, with a more junior consultant present, and with a more senior consultant present. We found 99% of respondents had been involved in DCO at some point in their careers, yet only 38% were involved in DCO on at least a monthly basis. Perceived benefits greatly outweighed potential risks: 95% felt DCO would decrease their stress, 91% felt it improved intraoperative decision making, and 89% felt it provided more enjoyment at work and enhanced collegiality. A decrease in perceived stress was seen from baseline with a more junior consultant available and a greater decrease in stress seen with a more senior consultant, particularly in a complex elective setting. All respondents felt there is benefit in DCO and the vast majority feel it has positive effects on stress levels. In a time where burnout is more prevalent, using tools such as DCO could be an effective way to decrease stress, enhance enjoyment and collegiality — challenging some key contributors to burnout — and support mentorship with further skill acquisition. This research provides a good base to pursue further qualitative and quantitative research into the area, with a view to addressing barriers to provision of regular DCO.
A larger radial tuberosity, and therefore a smaller radioulnar space, may cause mechanical impingement of the DBT predisposing to tear. We sought to investigate anatomic factors associated with partial DBT tears by retrospectively reviewing 3-T MRI scans of elbows with partial DBT tears and a normal elbow comparison group 3-T MRI scans of elbows with partial DBT tears and elbows with no known pathology were reviewed retrospectively by two independent observers. Basic demographic data were collected and measurements of radial tuberosity length, radial tuberosity thickness, radio-ulnar space, and radial tuberosity-ulnar space were made using simultaneous tracker lines and a standardised technique. The presence or absence of enthesophytes and the presence of a single or double DBT were noted. 26 3-T MRI scans of 26 elbows with partial DBT tears and 30 3-T MRI scans of 30 elbows without pathology were included. Basic demographic data was comparable between the two groups. The tear group showed statistically significant larger mean measurements for radial tuberosity length (24.3mm vs 21.3mm, p=0.002), and radial tuberosity thickness (5.5mm vs 3.7mm, p=<0.0001. The tear group also showed statistically significant smaller measurements for radio-ulnar space (8.2mm vs 10.0mm, p=0.010), and radial tuberosity-ulnar space (7.2mm vs 9.1mm, p=0.013). There was a statistically significant positive correlation between partial DBT tears and presence of enthesophytes (p=0.007) as well as between partial DBT tears and having two discrete DBTs rather than a single or interdigitating tendon (p=<0.0001). Larger radial tuberosities, and smaller radio-ulnar and radial tuberosity-ulnar spaces are associated with partial DBT tears. This may be due to chronic impingement, tendon delamination and consequent weakness which ultimately leads to tears. Enthesophytes may be associated with tears for the same reason. Having two discrete DBTs that do not interdigitate prior to insertion is also associated with partial tears.
Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures.
The aim of this study was to investigate surgeons’ reported change of treatment preference in response to the results and conclusion from a randomized controlled trial (RCT) and to study patterns of change between subspecialties and nationalities. Two questionnaires were developed through the Delphi process for this cross-sectional survey of surgical preference. The first questionnaire was sent out before the publication of a RCT and the second questionnaire was sent out after publication. The RCT investigated repair or non-repair of the pronator quadratus (PQ) muscle during volar locked plating of distal radial fractures (DRFs). Overall, 380 orthopaedic surgeons were invited to participate in the first questionnaire, of whom 115 replied. One hundred surgeons were invited to participate in the second questionnaire. The primary outcome was the proportion of surgeons for whom a treatment change was warranted, who then reported a change of treatment preference following the RCT. Secondary outcomes included the reasons for repair or non-repair, reasons for and against following the RCT results, and difference of preferred treatment of the PQ muscle between surgeons of different nationalities, qualifications, years of training, and number of procedures performed per year. Of the 100 surgeons invited for the second questionnaire, 74 replied. For the primary outcome, 6 of 32 surgeons (19%), who usually repaired the PQ muscle and therefore a change of treatment preference was warranted, reported a change of treatment preference based on the RCT publication. Of the secondary outcomes, restoring anatomy was the most common response for repairing the PQ muscle. The majority of the orthopaedic surgeons, where a change of treatment preference was warranted based on the results and conclusion of a RCT, did not report willingness to change their treatment preference.
Local antimicrobial therapy is an integral aspect of treating orthopaedic device related infection (ODRI), which is conventionally administered via polymethylmethacrylate (PMMA) bone cement. PMMA, however, is limited by a suboptimal antibiotic release profile and a lack of biodegradability. In this study, we compare the efficacy of PMMA versus an antibioticloaded hydrogel in a single- stage revision for chronic methicillin-resistant sheep. Antibiofilm activity of the antibiotic combination (gentamicin and vancomycin) was determined There was a nonsignificant reduction in biofilm with an increasing antibiotic concentration in vitro (p = 0.12), confirming the antibiotic tolerance of the MRSA biofilm. In the in vivo study, four out of five sheep from each treatment group were culture negative. Antibiotic delivery via hydrogel resulted in 10–100 times greater local concentrations for the first 2–3 days compared with PMMA and were comparable thereafter. Systemic concentrations of gentamicin were minimal or undetectable in both groups, while renal and liver function tests were within normal limits. This study shows that a single-stage revision with hydrogel or PMMA is equally effective, although the hydrogel offers certain practical benefits over PMMA, which make it an attractive proposition for clinical use.
The prevalence of gluteal tendinopathy (GT) associated with osteoarthritis of the hip is difficult to determine as it is frequently undiagnosed or misdiagnosed as trochanteric bursitis. Its relationship to total hip arthroplasty (THA) outcomes is currently unknown. The aim of this study was to determine the incidence of GT at the time of hip arthroplasty and examine the relationship between GT and patient reported outcomes (PROMS) before and after THA. Patients undergoing THA for primary osteoarthritis between August 2017 and August 2020 were recruited. Tendinopathy was assessed and graded at time of surgery. PROMS included the Oxford Hip Score (OHS), HOOS JR, EQ-5D, and were collected preoperatively and at one year after THA. Satisfaction with surgery was also assessed at 1 year. 797 patients met eligibility criteria and were graded as Grade 1: normal tendons (n =496, 62%), Grade 2: gluteal tendinopathy but no tear (n=222, 28%), Grade 3: partial/full thickness tears or bare trochanter (n=79, 10%). Patients with abnormal gluteal tendons were older (p=0.001), had a higher mean BMI (p=0.01), and were predominately female (p=0.001). Patients with higher grade tendinopathy had statistically significant inferior PROMS at one year, OHS score (44.1 v 42.9 v 41.3, p 0.001) HOOS JR (89.3 V 86.3 V 85.6 p 0.005). Increasing gluteal tendon grade was associated with a greater incidence of problems with mobility (p=0.001), usual activities (p=0.001) and pain (p=0.021) on EQ5D. There was a 3 times relative risk of overall dissatisfaction with THA in the presence of gluteal tears. This study demonstrated that gluteal tendinopathy was commonly observed and associated with inferior 1-year PROMS in patients undergoing THA for OA. Increasing degree of tendinopathy was a negative prognostic factor for worse functional outcomes and patient satisfaction.
Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery. Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery. Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41) Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings.
Proximal femoral focal deficiency is a congenital disorder of malformation of the proximal femur and/or the acetabulum. Patients present with limb length discrepancy and clinical features along a spectrum of severity. As these patients progress through to skeletal maturity and on to adulthood, altered biomechanical demands lead to progression of arthropathy in any joint within the lower limb. Abnormal anatomy presents a challenge to surgeons and conventional approaches and implants may not necessarily be applicable. We present a case of a 62-year-old lady with unilateral proximal femoral focal deficiency (suspected Aitken Class A) who ambulated with an equinus prosthesis for her entire life. She presented with ipsilateral knee pain and instability due to knee arthritis but could not tolerate a total knee arthroplasty due to poor quadriceps control. A custom osteointegration prosthesis was inserted with a view to converting to the proximal segment to a total hip replacement if required. The patient went on to develop ipsilateral symptomatic hip arthritis but altered acetabular anatomy required a custom tri-flange component (Ossis, Christchurch, New Zealand) and a custom proximal femoral component to link with the existing osseointegration component (Osseointegration Group of Australia, Sydney, Australia) were designed and implanted. The 18 month follow up of the custom hip components showed that the patient had Oxford hip scores that were markedly improved from pre-operatively. Knee joint heights were successfully restored to equal when the patient's prosthesis was attached. The patient describes feeling like “a normal person”, walks unaided for short distances and can ambulate longer distances with crutches. Advances in design and manufacture of implants have empowered surgeons to offer life improving treatments to patients with challenging anatomy. Using a custom acetabular tri-flange and osseointegration components is one possible solution to address symptomatic ipsilateral hip and knee arthropathy in the context of PFFD in adulthood.