Aims. The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula. Methods. We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification. Results. The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05). Conclusion. Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence. Cite this article: Bone Joint J 2023;105-B(12):1314–1320

Aims. In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility. Methods. Patients with PJI of the knee and subsequent KA or AKA between June 2011 and May 2021 were included. Demographic data, comorbidities, and patient history were analyzed. Functional outcomes and QoL were prospectively assessed in both groups with additional treatment-specific scores after AKA. Outcomes, complications, and mortality were evaluated. Results. A total of 98 patients were included, 52 treated with arthrodesis and 47 with AKA. The mean number of revision surgeries between primary arthroplasty and arthrodesis or AKA was 7.85 (SD 5.39). Mean follow-up was 77.7 months (SD 30.9), with a minimum follow-up of two years. Complications requiring further revision surgery occurred in 11.5% of patients after arthrodesis and in 37.0% of AKA patients. Positive intraoperative tissue cultures obtained during AKA was significantly associated with the risk of further surgical revision. Two-year mortality rate of arthrodesis was significantly lower compared to AKA (3.8% vs 28.3%), with age as an independent risk factor in the AKA group. Functional outcomes and QoL were better after arthrodesis compared to AKA. Neuropathic pain was reported by 19 patients after AKA, and only 45.7% of patients were fitted or were intended to be fitted with a prosthesis. One-year infection-free survival after arthrodesis was 88.5%, compared to 78.5% after AKA. Conclusion. Above-knee amputation in PJI results in high complication and mortality rates and poorer functional outcome compared to arthrodesis. Mortality rates after AKA depend on patient age and mobility, with most patients not able to be fitted with a prosthesis. Therefore, arthrodesis should be preferred whenever possible if salvage procedures are indicated. Cite this article: Bone Joint J 2024;106-B(7):669–679

Aims. This prospective cohort study aims to determine if the size of the tendon gap following acute rupture of the Achilles tendon shows an association with the functional outcome following non-operative treatment. . Patients and Methods. All patients presenting within two weeks of an acute unilateral rupture of the Achilles tendon between July 2012 and July 2015 were considered for the study. In total, 38 patients (nine female, 29 male, mean age 52 years; 29 to 78) completed the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon Total Rupture score (ATRS) six months after the completion of a rehabilitation programme. Results. Patients with a gap ≥ 10 mm with the ankle in the neutral position had significantly greater peak torque deficit than those with gaps < 10 mm (mean 23.3%; 7% to 52% vs 14.3%; 0% to 47%, p = 0.023). However, there was no difference in ATRS between the two groups (mean score 87.2; 74 to 100 vs 87.4; 68 to 97, p = 0.467). There was no significant correlation between gap size and torque deficit (τ = 0.103), suggesting a non-linear relationship. There was also no significant correlation between ATRS and peak torque deficit (τ = -0.305). . Conclusion . This is the first study to identify an association between tendon gap and functional outcome in acute rupture of the Achilles tendon. We have identified 10 mm as a gap size at which deficits in plantarflexion strength become significantly greater, however, the precise relationship between gap size and plantarflexion strength remains unclear. Large, multicentre studies will be needed to clarify this relationship and identify population subgroups in whom deficits in peak torque are reflected in patient-reported outcome measures. . Cite this article: Bone Joint J 2017;99-B:87–93

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling. Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results. Cite this article: Bone Joint J 2016;98-B:690–5

Aims. The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan. Methods. We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results. Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, no further progression has been noted, resulting in an overall 91.9% success rate (34 of 37) at a mean follow-up period of 47.5 months (24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up (p < 0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% (55.2% to 96.1%) at the medial malleolus, 65.1% (27.6% to 97.1%) at the tibia, and 81.2% (42.8% to 98.7%) at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation (p = 0.001). Conclusion. Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting. Cite this article: Bone Joint J 2024;106-B(5):475–481

Aims. Ilium is the most common site of pelvic Ewing’s sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients’ outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft. Methods. Medical files of 43 patients with ilium and iliosacral ES who underwent surgical resection and reconstruction with a tibial strut allograft between January 2010 and October 2021 were reviewed. The lesions were classified into four resection zones: I. 1. , I. 2. , I. 3. , and I. 4. , based on the extent of resection. Functional outcomes, oncological outcomes, and surgical complications for each resection zone were of interest. Functional outcomes were assessed using a Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score (TESS). Results. The mean age of the patients was 17 years (SD 9.1). At a mean follow-up of 70.8 months (SD 50), the mean functional outcomes were 24.2 points (SD 6.3) for MSTS and 81 points (SD 11) for TESS. The mean MSTS and TESS scores were associated with the iliac resection zone (< 0.001). Nine patients (20.9%) had local recurrence. The recurrence was not associated with the zone of iliac resection (p = 0.324). The two-year disease-free survival of the patients was 69.4%. The mean time to graft union was longer in patients with the I. 4. resection zone (p < 0.001). The complication rate was 34.9%, and nerve palsy (11.6%) was the most common. The rate of surgical complications was not associated with the resection zone. Conclusion. Reconstruction using tibial strut allograft is an efficient procedure after the resection of the ilium and iliosacral ES. Functional outcomes and complications of iliac ES depend on the resection zone, and inferior outcomes could be generally expected when more segments of the pelvic ring are resected, even if it is reconstructed. Cite this article: Bone Jt Open 2024;5(5):385–393

Aims. Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. Methods. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included. Results. Of 5,941 studies, 19 were included after full-text screening. A total of 15 surgical techniques were described. All studies described an improvement in active external rotation (range 12° to 128°). A decrease in range of motion and Mallet score after long-term (five to 30 years) follow-up compared to short-term follow-up was seen in most studies. Conclusion. The literature reveals that functional outcome increases after different secondary procedures, even in the long term. Due to the poor methodological quality of the included studies and the variations in indication for surgery and surgical techniques described, a consensus on the long-term functional outcome after secondary surgical procedures in BPBP patients cannot be made. Cite this article: Bone Joint J 2023;105-B(4):455–464

Aims. Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure. Methods. Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years’ follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m. 2. (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter. Complications and revisions were evaluated at the last follow-up. Functional outcomes were assessed using the Knee Society Score (KSS) and range of motion. Results. The mean follow-up was 51 months (SD 26; 24 to 121). Bony union was confirmed in 95% of patients (128/135) at a mean of 3.4 months (SD 2.7). The complication rate was 15% (20/135), consisting of nine tibial tubercle fracture displacements (6.7%), seven nonunions (5%), two delayed unions, one tibial fracture, and one wound dehiscence. Seven patients (5%) required eight revision procedures (6%): three bone grafts, three osteosyntheses, one extensor mechanism allograft, and one wound revision. The functional scores and flexion were significantly improved after surgery: mean KSS knee, 48.8 (SD 17) vs 79.6 (SD 20; p < 0.001); mean KSS function, 37.6 (SD 21) vs 70.2 (SD 30; p < 0.001); mean flexion, 81.5° (SD 33°) vs 93° (SD 29°; p = 0.004). Overall, 98% of patients (n = 132) had no extension deficit. The use of hinge implants was a significant risk factor for tibial tubercle fracture (p = 0.011). Conclusion. TTO during rTKA was an efficient procedure to improve knee exposure with a high union rate, but had significant specific complications. Functional outcomes were improved at mid term. Cite this article: Bone Joint J 2023;105-B(10):1078–1085

Background. Neglected clubfoot in this series is defined as untreated equino-cavo-adducto-varus in older children, or adults. Relapsed clubfoot is the residual deformity that remains after single or multiple surgical interventions. Severe neglected clubfoot rarely exists today in developed countries, except in some emigrants from low- and middle-income countries. Acute surgical management with corrective mid-foot osteotomy and elongation of the Achilles tendon has excellent functional outcome. Objective. To assess the functional outcome of acute correction of neglected Talipes-quino-varus deformity in adults. Methods. This is cross sectional, hospital–based study that took place in Khartoum, Sudan. Forty patients were included in this study. Midfoot osteotomy and elongation of the Achilles tendon were performed to all patients. Data was collected using a questionnaire and the functional outcome has been assessed using the American Orthopaedic Foot and Ankle Society Score (AOFAS). This score was measured before surgery and one years after surgery. Results. The mean age was 19.9±4.7 years. Males were 25 (62.5%) and females were 15 (37.5%). The mean preoperative AOFAS score was 37.7±7.1 (poor). This score improved to 80.7±13.7 (good to excellent), two years after surgery. However, this indicates significant change in the functional outcome after the operation (P value < 0.05). Excellent post-operative functional outcome was found among patients aged 18 – 23 years 18 (50%) P. value: 0.021. The majority of patients 36(90%) were fully satisfied with the operation, 2(5%) partially satisfied and 2(5%) were unsatisfied. Conclusion. Acute correction of neglected and relapsed TEV with elongation of the Achilles tendon and single midfoot osteotomy has excellent functional outcome as assessed by AOFAS Score. The satisfaction with this procedure is impressive. The younger age population showed better outcomes with this procedure

Aims. Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods. This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination. This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(5):411–418

Aims. Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations. Methods. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Medline, Embase, Cinahl, and Cochrane reviews were searched for relevant papers. Papers analyzing surgical treatment for failed ankle arthroplasties were included. All papers were reviewed by two authors. Overall, 34 papers met the inclusion criteria. A meta-analysis of proportions was performed. Results. Six papers analyzed all-cause reoperations of revision ankle arthroplasties, and 14 papers analyzed failures of conversion of a TAA to fusion. It was found that 26.9% (95% confidence interval (CI) 15.4% to 40.1%) of revision ankle arthroplasties required further surgical intervention and 13.0% (95% CI 4.9% to 23.4%) of conversion to fusions; 14.4% (95% CI 8.4% to 21.4%) of revision ankle arthroplasties failed and 8% (95% CI 4% to 13%) of conversion to fusions failed. Conclusion. Revision of primary TAA can be an effective procedure with improved functional outcomes, but has considerable risks of failure and reoperation, especially in those with periprosthetic joint infection. In those who undergo conversion of TAA to fusion, there are high rates of nonunion. Further comparative studies are required to compare both operative techniques. Cite this article: Bone Jt Open 2022;3(7):596–606

Aims. Robotic-assisted unicompartmental knee arthroplasty (R-UKA) has been proposed as an approach to improve the results of the conventional manual UKA (C-UKA). The aim of this meta-analysis was to analyze the studies comparing R-UKA and C-UKA in terms of clinical outcomes, radiological results, operating time, complications, and revisions. Methods. The literature search was conducted on three databases (PubMed, Cochrane, and Web of Science) on 20 February 2024 according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Inclusion criteria were comparative studies, written in the English language, with no time limitations, on the comparison of R-UKA and C-UKA. The quality of each article was assessed using the Downs and Black Checklist for Measuring Quality. Results. Among the 3,669 articles retrieved, 21 studies on 19 series of patients were included. A total of 3,074 patients (59.5% female and 40.5% male; mean age 65.2 years (SD 3.9); mean BMI 27.4 kg/m. 2. (SD 2.2)) were analyzed. R-UKA obtained a superior Knee Society Score improvement compared to C-UKA (mean difference (MD) 4.9; p < 0.001) and better Forgotten Joint Score postoperative values (MD 5.5; p = 0.032). The analysis of radiological outcomes did not find a statistically significant difference between the two approaches. R-UKA showed longer operating time (MD 15.6; p < 0.001), but reduced complication and revision rates compared to C-UKA (5.2% vs 10.1% and 4.1% vs 7.2%, respectively). Conclusion. This meta-analysis showed that the robotic approach for UKA provided a significant improvement in functional outcomes compared to the conventional manual technique. R-UKA showed similar radiological results and longer operating time, but reduced complication and revision rates compared to C-UKA. Overall, R-UKA seems to provide relevant benefits over C-UKA in the management of patients undergoing UKA. Cite this article: Bone Jt Open 2024;5(5):374–384

Aims. The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods. All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results. The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion. This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963

Abstract. Background. The primary objective of the study is to determine the function outcome and survivorship of patellofemoral replacement. The secondary aim is to find the determinants of successful/poor outcome. Methods. This retrospective study involved 45 patients who underwent AVON patellofemoral replacement between January 2015 to December 2020 with the minimal follow-up off for 12 months. The functional outcome was measured using Oxford Knee score (OKS), EuroQol five dimension (EQ-5D). IWANO and Kellgren-Lawrence classification was used to analyse radiographs. To identify determinants of outcome, the following subgroups the presence or absence of normal alignment, tibiofemoral arthritis, trochlear dysplasia and previous surgery. Complications and revision rates were also recorded. Results. The mean follow-up period was 41.7 +/− 8.3 months with no patients lost in follow-up. Patellofemoral replacement significantly improved the Oxford Knee score (OKS), EuroQol five dimension (EQ-5D) (p<0.001). Four out of 45(8.9%) patients underwent revision surgery. Patients with normal alignment preoperatively did worse than those with abnormal alignment with patellar instability. Patients with grade two tibiofemoral arthritis, history of previous surgery did significantly worse with poorer functional outcome. Conclusion. Patellofemoral arthroplasty is reliable treatment option which improves patient function and quality of life with good survivorship in isolated patellofemoral arthritis in mid-term follow-up

Abstract. Objectives. This study aims to evaluate the functional outcomes of early weight-bearing in a functional orthosis for conservatively managed, complete AT ruptures. Also we tried to evaluate the patient reported outcome with this form of treatment. Design. In this prospective study, we have analysed data from 41 patients with ultrasound diagnosed compete AT ruptures, with a gap of less than 5 cm. Every patient was treated in a functional weight-bearing orthosis (VACOped®) for 8 weeks with early weight-bearing following a specific treatment protocol, followed by rehabilitation with a trained physiotherapist. Methods. Patients were followed up with foot and ankle trained physiotherapist for at least 1 year post-injury. At final follow up, the followings were measured: calf girth, single-leg heel raise height and repetitions. Furthermore, ATRS score and a patient feedback were taken on this final visit. Result. The mean ATRS score was 82.1, with a re-rupture rate of only 2% as compared to 5% in normal orthosis. The average calf bulk difference was 1.6 cm, the average heel raise height difference was 1.8cm and a heel raise repetition difference of 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p=0.02). However, there was no significant correlation between ATRS and heel raise height or heel raise repetitions. Conclusion. Early weight-bearing in a functional orthosis provides excellent functional outcomes for conservatively managed, complete AT ruptures, and is associated with very low re-rupture rates. A multidisciplinary approach with a guided rehabilitation programme is essential for optimising functional outcome

Aims. The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. Methods. Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). Results. There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). Conclusion. ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709–1716

Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

Aims. We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. Methods. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. Results. Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a cost savings of over £13,500 per year with the new self-care model compared to the traditional model. Conclusion. Our study supports a VFC self-care pathway for patients with minimally displaced distal radius fractures. The pathway provides a good level of patient satisfaction and function. To improve the service, we will make minor amendments to our patient information sheet. Cite this article: Bone Jt Open 2022;3(9):726–732

Aims. The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed. Methods. A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19). Results. Overall, 27 patients (45%) were reconstructed, while 33 (55%) had no formal reconstruction. There was no difference in the use of chemotherapy (p = 1.000) or radiotherapy (p = 0.292) between the groups. Patients with no reconstruction had a mean larger tumour (11 cm (SD 5) vs 8 cm (SD 4); p = 0.014), mean shorter operating times (664 mins (SD 195) vs 1,324 mins (SD 381); p = 0.012), and required fewer blood units (8 (SD 7) vs 14 (SD 11); p = 0.012). Patients undergoing a reconstruction were more likely to have a deep infection (48% vs 12%; p = 0.003). Nine reconstructed patients had a hardware failure, with five requiring revision. Postoperatively 55 (92%) patients were ambulatory, with no difference in the proportion of ambulatory patients (89% vs 94%; p = 0.649) or mean Musculoskeletal Tumor Society Score (59% vs 65%; p = 0.349) score between patients who did or did not have a reconstruction. The ten-year disease-specific survival was 69%, with no difference between patients who were reconstructed and those who were not (78% vs 45%; p = 0.316). There was no difference in the rate of metastasis between the two groups (hazard ratio (HR) 2.78; p = 0.102). Conclusion. Our results demonstrate that SIJ reconstruction is associated with longer operating times, greater need for blood transfusion, and more postoperative infections, without any improvement in functional outcomes when compared to patients who did not have formal SIJ reconstruction. Cite this article: Bone Joint J 2024;106-B(1):93–98

Abstract. Purpose. Since arthroscopic reconstruction of the anterior cruciate ligament (ACL) started, the use of peroneus longus grafts for primary ACL reconstruction (ACLR) was never thought of as there is very scant literature on it. So, our study aims to compare the functional outcome and complications in patients with ACL injury managed by ACLR with peroneus longus tendon (PLT) and hamstring tendons (HT) respectively. Materials and Methods. Patients with 16–50 years of either gender presenting with symptomatic ACL deficiency were admitted for arthroscopic single bundle ACLR and allocated into two groups (PLT and HT) operated and observed. Functional scores (IKDC and Lysholm score), clinical knee evaluation, donor site morbidity (AOFAS score) and thigh circumference were recorded preoperatively and at six months, one year post-operatively. The same post-op rehabilitation protocol was followed in both groups. Results. 194 patients (hamstring n=96, peroneus n=98) met the inclusion criteria. There were no significant differences between the pre-op, six months post-op and one-year postoperative score between the hamstring and peroneus longus groups in the IKDC (p=0.356) and Lysholm knee score (p=0.289). The mean for the AOFAS was 99.05±3.56 and 99.80±0.70 in the PLT and HT group respectively showing no statistical difference, with a significant improvement in thigh muscle wasting among the PLT group at final follow-up (p<0.001). Conclusion. We observed similar knee stability, functional outcome and no obvious donor site morbidity among both groups and recommend that a PL graft may be a safe, effective, and viable option for arthroscopic single bundle ACL reconstruction

Aims. To compare the functional outcome, health-related quality of life (HRQoL), and satisfaction of patients who underwent primary total hip arthroplasty (THA) and a single debridement, antibiotics and implant retention (DAIR) procedure for deep infection, using either the transgluteal or the posterior surgical approach for both procedures. Methods. The study was registered at clinicaltrials.gov (ID: NCT03161990) on 15 May 2017. Patients treated with a single DAIR procedure for deep infection through the same operative approach as their primary THA (either the transgluteal or the posterior approach) were identified in the Norwegian Arthroplasty Register and given a questionnaire. Median follow-up after DAIR by questionnaire was 5.5 years in the transgluteal group (n = 87) and 2.5 years in the posterior approach group (n = 102). Results. Patients in the posterior approach group were less likely to limp after the DAIR procedure (17% vs 36% limped all the time; p = 0.005), had a higher mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (80 vs 71; p = 0.013), and were more likely to achieve a patient acceptable symptom state for the WOMAC function score (76% vs 55%; p = 0.002). In a multivariable analysis, the point estimate for the increase in WOMAC function score using the posterior approach was 10.2 (95% CI 3.1 to 17.2; p = 0.005), which is above the minimal clinically important improvement. The patients in the posterior approach group also reported better mean HRQoL scores and were more likely to be satisfied with their hip arthroplasty (77% vs 55%; p = 0.001). Conclusion. In patients treated with a single, successful DAIR procedure for deep infection of a primary THA, the use of the posterior approach in both primary surgery and DAIR was associated with less limping, better functional outcome, better HRQoL, and higher patient satisfaction compared with cases where both were performed using the transgluteal approach. The observed differences in functional outcome and patient satisfaction were clinically relevant. Cite this article: Bone Joint J 2020;102-B(12):1662–1669

Aims. The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness. Methods. A group of 130 patients who had received an AP tibial component were matched for demographic factors of age, BMI, American Society of Anesthesiologists (ASA) grade, sex, and preoperative Knee Society Score (KSS) to create a comparison group of 130 patients who received a MB tibial component. Functional outcome was assessed prospectively by KSS, quality of life by 12-Item Short-Form Health Survey questionnaire (SF-12), and range of motion (ROM), and implant survivorships were compared. The SF six-dimension (6D) was used to calculate the incremental cost effectiveness ratio (ICER) for AP compared to MB tibial components using quality-adjusted life year methodology. Results. The AP group had a mean KSS-Knee of 83.4 (standard deviation (SD) 19.2) and the MB group a mean of 84.9 (SD 18.2; p = 0.631), while mean KSS-Function was 75.4 (SD 15.3) and 73.2 (SD 16.2 p = 0.472), respectively. The mental (44.3 vs 45.1; p = 0.464) and physical (44.8 vs 44.9; p = 0.893) dimensions of the SF-12 and ROM (97.9° vs 99.7°; p = 0.444) were not different between the groups. Implant survivorship at five years were 99.2% and 97.7% (p = 0.321). The AP group had a greater SF-6D gain of 0.145 compared to the MB group, with an associated cost saving of £406, which resulted in a negative ICER of -£406/0.145 = -£2,800. Therefore, the AP tibial component was dominant, being a more effective and less expensive intervention. Conclusion. There were no differences in functional outcomes or survivorship at five years between AP and MB tibial components in patients aged 70 years and older, however the AP component was shown to be more cost-effective. In the UK, only 1.4% of all total knee arthroplasties use an AP component; even a modest increase in usage nationally could lead to significant financial savings. Cite this article: Bone Jt Open 2022;3(12):969–976

Background. Patients who undergo either primary or revision total ankle replacement (TAR) expect improvements in pain, function and quality of life. The goal of this study was to measure the functional outcome improvements and the difference in patient-reported outcomes in patients undergoing primary total ankle replacements compared to revision TAR. Methods. A single-center prospective cohort study was undertaken between 2016 and 2022. All patients were followed up for a minimum of 6 months. Patients undertook the Manchester Oxford Foot Questionnaire (MoxFQ) and EQ-5D health quality questionnaires pre-operatively, at 6 months and yearly for life. The Mann Whitney test was undertaken for statistical analysis. Results. A total of 165 primary and 71 revision ankle replacements were performed between 2016 and 2022. The mean age was 71 years for primary replacements and 69 years for revisions. The INFINITY was utilized in the majority of primary total ankle replacements. Revision replacements were either the INBONE II or INVISION and they were most often revising the MOBILITY implant. The main indication for revision was aseptic loosening (83%). Other causes included infection, malalignment and insert wear. The overall MoxFQ improved by a mean of 46.5 for primaries and 40.2 for revisions. The EQ-5D score also showed overall improvements with the mean difference in mobility increasing by 1.6. Conclusion. Both primary and revision ankle replacements result in improved functional scores at 6 months, 1 year and 2 years. In this cohort with the implants used, both primary and revision ankle replacements demonstrate similar improvements in functional scores

Aims. To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). Methods. All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up. Results. All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016). Conclusion. Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246–253

Aims. Nearly 99,000 total knee arthroplasties (TKAs) are performed in UK annually. Despite plenty of research, the satisfaction rate of this surgery is around 80%. One of the important intraoperative factors affecting the outcome is alignment. The relationship between joint obliquity and functional outcomes is not well understood. Therefore, a study is required to investigate and compare the effects of two types of alignment (mechanical and kinematic) on functional outcomes and range of motion. Methods. The aim of the study is to compare navigated kinematically aligned TKAs (KA TKAs) with navigated mechanically aligned TKA (MA TKA) in terms of function and ROM. We aim to recruit a total of 96 patients in the trial. The patients will be recruited from clinics of various consultants working in the trust after screening them for eligibility criteria and obtaining their informed consent to participate in this study. Randomization will be done prior to surgery by a software. The primary outcome measure will be the Knee injury and Osteoarthritis Outcome Score The secondary outcome measures include Oxford Knee Score, ROM, EuroQol five-dimension questionnaire, EuroQol visual analogue scale, 12-Item Short-Form Health Survey (SF-12), and Forgotten Joint Score. The scores will be calculated preoperatively and then at six weeks, six months, and one year after surgery. The scores will undergo a statistical analysis. Discussion. There is no clear evidence on the best alignment for a knee arthroplasty. This randomized controlled trial will test the null hypothesis that navigated KA TKAs do not perform better than navigated MA TKAs. Cite this article: Bone Jt Open 2021;2(11):945–950

Aims. The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee. Patients and Methods. All adult patients (18 to 75 years) undergoing IR after fracture fixation below the level of the knee between November 2014 and September 2016 were included as part of the WIFI (Wound Infections Following Implant Removal Below the Knee) trial, performed in 17 teaching hospitals and two university hospitals in The Netherlands. In this multicentre prospective cohort, the primary outcome was the difference in functional status before and after IR, measured by the Lower Extremity Functional Scale (LEFS), with a minimal clinically important difference of nine points. Results. A total of 179 patients were included with a median age of 50 years (interquartile range (IQR) 37 to 60), of whom 71 patients (39.7%) were male. With a median score of 60 before IR (IQR 45 to 72) and 66 after IR (IQR 51 to 76) on the LEFS, there was a statistically significant improvement in functional outcome (p < 0 .001). A total of 31 surgical site infections (17.3%) occurred. Conclusion. Although IR led to a statistically significant improvement of functional outcome, the minimal clinically important difference was not reached. In conclusion, this study shows that IR does not result in a clinically relevant improvement in functional outcome. These results, in combination with the high complication rate, highlight the importance of carefully reviewing the indication for IR. Cite this article: Bone Joint J 2019;101-B:447–453

Aims. The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture. Methods. We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671). Results. The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients’ demography or functional outcomes between operative and nonoperative treatments. Conclusion. Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J 2021;103-B(5):951–957

Aims. To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach. Methods. Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded. Results. The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient. Conclusion. Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J 2021;103-B(7):1309–1316

Aims. The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time. Methods. A study of 2,393 TKAs was performed in 2,393 patients. Patient demographics, comorbidities, OKS, EuroQol five-dimension score (EQ-5D), and Forgotten Joint Score (FJS) were collected preoperatively and one year postoperatively. Overall patient satisfaction with their TKA was assessed at one year. Patients with VTE within six months of surgery were identified retrospectively and compared with those without. Results. A total of 37 patients (1.5%) suffered a VTE and were significantly more likely to have associated comorbidities of stroke (p = 0.026), vascular disease (p = 0.026), and kidney disease (p = 0.026), but less likely to have diabetes (p = 0.046). In an unadjusted analysis, patients suffering a VTE had a significantly worse postoperative OKS (difference in mean (DIM) 4.8 (95% confidence interval (CI) 1.6 to 8.0); p = 0.004) and EQ-5D (DIM 0.146 (95% CI 0.059 to 0.233); p = 0.001) compared with patients without a VTE. After adjusting for confounding variables VTE remained a significant independent predictor associated with a worse postoperative OKS (DIM -5.4 (95% CI -8.4 to -2.4); p < 0.001), and EQ-5D score (DIM-0.169 (95% CI -0.251 to -0.087); p < 0.001). VTE was not independently associated with overall satisfaction after TKA (odds ratio 0.89 (95% CI 0.35 to 2.07); p = 0.717). Conclusion. Patients who had a VTE within six months of their TKA had clinically significantly worse knee-specific outcome (OKS) and general health (EQ-5D) scores one year postoperatively, but the overall satisfaction with their TKA was similar to those patients who did not have a VTE. Cite this article: Bone Joint J 2021;103-B(7):1254–1260

Aims. The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations. Patients and Methods. A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25 a combination technique. Injuries were assessed preoperatively according to the Myerson classification system. The outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ) functional tool, and the radiological Wilppula classification of anatomical reduction. Results. Significantly better functional outcomes were seen in the bridge plate group. These patients had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3 for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and 45.5 in the combination group (p < 0.001). Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was noted which indicated that plate fixation is associated with a better anatomical reduction (p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome, suggesting that total incongruity in either a homolateral or divergent pattern leads to worse outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001). Conclusion. Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. Cite this article: Bone Joint J 2018;100-B:468–74

Aims. MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. Methods. A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing. Results. Two-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score. Conclusion. The two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed. Cite this article: Bone Jt Open 2021;2(8):569–575

The first three months following Total Knee Arthroplasty (TKA) provide an early window into a patient's functional outcomes, with the change of function in this time yielding valuable insight. 20 patients due to undergo primary TKA were recruited to the study. Data were recorded at three time points; pre-assessment clinic (PAC) before the operation, 6-weeks-post-operation (6WKs), at 12-weeks-post-operation (12WKs). Functional activity levels were monitored during early post-operative recovery for changes in early functional outcome, and allowed a comparison of metrics at each time point. This included direct functional testing of power output, timed functional performance in clinic, patient reported outcome measures, and multiday activity monitoring devices. Maximal power output symmetry (Power) was similar at 6WKs vs PAC (p = 0.37). At 12WKs, it had increased (p < 0.05). Timed functional performance (Performance) remained similar across all three time points (p = 0.27). Patient reported activities of daily living (ADL) performance significantly increased at 6WKs vs PAC (p < 0.05). At 12WKs, it remained similar (p = 0.10). Patient daily step count significantly decreased at 6WKs vs PAC (p < 0.05). By 12WKs, this had increased to similar levels to PAC (p = 0.30). Within the functional outcome measures, strong post-operative correlations were observed between Power and Performance (r = 0.62), Power and ADL (r = 0.49), and Performance and ADL (r = 0.61). Despite reduced measured step count and similar functional performance, patients report improved ADL at 6WKs. When symmetrical power output and measured step count have improved at 12WKs, patients report similar ADL to that at 6WKs. Multiple measures are required to get a full picture, however this highlights the different aspects measured by different tools

Aims. The primary aim was to assess the patient-perceived effect of restrictions imposed due to COVID-19 on rehabilitation following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Secondary aims were to assess perceived restrictions, influence on mental health, and functional outcome compared to patients undergoing surgery without restriction. Methods. During February and March 2020, 105 patients underwent THA (n = 48) or TKA (n = 57) and completed preoperative and six-month postoperative assessments. A cohort of 415 patients undergoing surgery in 2019 were used as the control. Patient demographic data, BMI, comorbidities, Oxford Hip Score (OHS) or Knee Score (OKS), and EuroQoL five-domain (EQ-5D) score were collected preoperatively and at six months postoperatively. At six months postoperatively, the 2020 patients were also asked to complete a questionnaire relating to the effect of the social restrictions on their outcome and their mental health. Results. Nearly half of the patients (47.6%, n = 50/105) felt that the restrictions imposed by COVID-19 had limited their rehabilitation and were associated with a significantly worse postoperative OKS (p < 0.001), EQ-5D score (p < 0.001), and lower satisfaction rate (p = 0.019). The reasons for the perceived limited rehabilitation were: being unable to exercise (n = 32, 64%), limited access to physiotherapy (n = 30, 60%), and no face-to-face follow-up (n = 30, 60%). A quarter (n = 26) felt that their mental health had deteriorated postoperatively; 17.1% (n = 18) felt depressed and 26.7% (n = 28) felt anxious. Joint-specific scores and satisfaction for the 2020 group were no different to the 2019 group, however patients undergoing THA in 2020 had a significantly worse postoperative EQ-5D compared to the 2019 cohort (difference 0.106; p = 0.001) which was not observed in patients undergoing TKA. Conclusion. Half of the 2020 cohort felt that their rehabilitation had been limited and was associated with worse postoperative Oxford and EQ-5D scores, and lower rates of patient satisfaction, but relative to the 2019 cohort their overall outcomes were no different, with the exception of THA patients who had a worse general health score. Level of evidence: Prospective study, Level 2. Cite this article: Bone Jt Open 2021;2(6):380–387

Aims. Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. Methods. In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). Results. The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. Conclusion. THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. Level of evidence IV. Femoral shortening useful in conditions other than DDH and septic sequelae. Restoration of hip centre combined with offset to be planned and ensured

Aims. The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare length of hospital stay, general health improvement, and satisfaction between rUKA and mTKA. Methods. A powered (1:3 ratio) cohort study was performed. A total of 30 patients undergoing rUKA were propensity score matched to 90 patients undergoing mTKA for isolated medial compartment arthritis. Patients were matched for age, sex, body mass index (BMI), and preoperative function. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were collected preoperatively and six months postoperatively. The Forgotten Joint Score (FJS) and patient satisfaction were collected six months postoperatively. Length of hospital stay was also recorded. Results. There were no significant differences in the preoperative demographics (p ⩾ 0.150) or function (p ⩾ 0.230) between the groups. The six-month OKS was significantly greater in the rUKA group when compared with the mTKA group (difference 7.7, p < 0.001). There was also a greater six-month postoperative EQ-5D (difference 0.148, p = 0.002) and FJS (difference 24.2, p < 0.001) for the rUKA when compared to the mTKA. No patient was dissatisfied in the rUKA group and five (6%) were dissatisfied in the mTKA, but this was not significant (p = 0.210). Length of stay was significantly (p < 0.001) shorter in the rUKA group (median two days, interquartile range (IQR) 1 to 3) compared to the mTKA (median four days, IQR 3 to 5). Conclusion. Patients with isolated medial compartment arthritis had a greater knee-specific functional outcome and generic health with a shorter length of hospital stay after rUKA when compared to mTKA. Cite this article: Bone Joint Res 2019;9(1):15–22

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation. Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions. Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient. The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort

The aim of this study was to define the long-term outcome following adolescent clavicle fracture. We retrospectively reviewed all adolescent fractures presenting to our region (13–17years) over a 10-year period. Patient reported outcomes were undertaken at a minimum of 4 years post-injury (QuickDASH and EQ-5D) in completely displaced midshaft fractures (Edinburgh 2B, >2cm displacement, n=50) and angulated midshaft fractures (Edinburgh 2A2, >30 degrees angulation, n=32). 677 clavicle fractures were analysed. The median age was 14.8 (IQR 14.0–15.7) and 89% were male. The majority were midshaft (n=606, 89.5%) with either angulation (39.8%) or simple fully displaced (39.1%). Only 3% of midshaft fractures underwent acute fixation (n=18/606), all of which were fully displaced. The incidence of refracture following non-operative management of midshaft fractures was 3.2% (n=19/588), all united with non-operative management. Fracture type, severity of angulation or displacement was not associated with risk of refracture. There was one case of non-union encountered following non-operative management of all displaced midshaft fractures (0.4%, n=1/245). At a mean of 7.6 years following injury, non-operative management of both displaced and angulated fractures had a median QuickDASH was 0.0 (IQR 0.0–2.3), EQ-5D was 1.0 (IQR 1.0–1.0). 97% of angulated fractures and 94% of displaced fractures were satisfied with their final shoulder function. We conclude that Non-operative management of adolescent midshaft clavicle fractures result in excellent functional outcomes with a low rate of complications at long-term follow up. The relative indications for surgical intervention for clavicle fractures in adults do not appear to be applicable to adolescents

Aims. We conducted a study to determine whether radiological parameters correlate with patient reported functional outcome, health-related quality of life and physical measures of function in patients with a fracture of the distal radius. Patients and Methods. The post-operative palmar tilt and ulnar variance at six weeks and 12 months were correlated with the Patient Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand, and EuroQol scores, grip strength, pinch strength and range of movement at three, six and 12 months for 50 patients (mean age 57 years; 26 to 85) having surgical fixation, with either percutaneous pinning or reconstruction with a volar plate, for a fracture of the distal radius. Results. Radiological parameters were found to correlate poorly with the patient reported outcomes (r = 0.00 to 0.47) and physical measures of function (r = 0.01 to 0.51) at all intervals. Conclusion. This study raises concerns about the use of radiological parameters to determine management, and to act as a surrogates for successful treatment, in patients with a fracture of the distal radius. Restoration of ‘normal’ radiographic parameters may not be necessary to achieve a satisfactory functional outcome for the patient. Cite this article: Bone Joint J 2017;99-B:376–82

Aims. The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years. Methods. This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed. Results. Mean follow-up was 8.4 years (5 to 11). There were no significant differences in mean absolute (p = 0.125) or adjusted (p = 0.569) Constant, UCLA (p = 0.088), QuickDASH (p = 0.135), VAS-pain (p = 0.062), or range of movement at the final follow-up. However, patient satisfaction was significantly lower in the fracture group (p = 0.002). The complication rate was 1.5% (one patient) versus 9.3% (six patients), and the revision rate was 1.5% (one patient) versus 7.8% (five patients) in the fracture and arthropathy groups, respectively. The ten-year arthroplasty survival was not significantly different (p = 0.221). Conclusion. RSA may be used not only for patients with irreparable rotator cuff deficiencies, but also for those with acute complex proximal humeral fractures. We found that RSA provided similar functional outcomes and a low revision rate for both indications at long-term. However, satisfaction is lower in patients with an acute fracture. Cite this article: Bone Joint J 2020;102-B(11):1555–1559

Aims. This study assessed the association of classes of body mass index in kg/m. 2. (classified as normal weight 18.5 kg/m. 2 . to 24.9 kg/m. 2. , overweight 25.0 kg/m. 2 . to 29.9 kg/m. 2. , and obese ≥ 30.0 kg/m. 2. ) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures. Patients and Methods. We performed a historical cohort study with chart review of 1011 patients who were treated for ankle fractures by open reduction and internal fixation in two hospitals, with a follow-up postal survey of 959 of the patients using three functional outcome scores. Results. Obese patients had more severe overall complications and higher odds of any complication than the normal weight group, with adjusted odds ratio 1.67 (95% confidence interval (CI) 1.08 to 2.59; p = 0.021) and 1.71 (95% CI 1.10 to 2.65; p = 0.016), respectively. In total 479 patients (54.6%) responded to the questionnaire. Obese patients had worse scores on the Olerud and Molander Ankle Score (p < 0.001), Self-Reported Foot and Ankle Questionnaire (p = 0.003) and Lower Extremity Functional Scale (p = 0.01) than those with normal weight. In contrast, overweight patients did not have worse functional scores than those with normal weight. Conclusion. Obese patients had more complications, more severe complications, and worse functional outcomes three to six years after ankle surgery compared with those with normal weight. Cite this article: Bone Joint J 2017;99-B:1389–98

Fracture of the femoral head usually results from high-energy trauma, particularly motor vehicle accidents. These fractures are often associated with poor functional outcomes. SF-36 and MFA scores were obtained for twenty-five femoral head fractures. The mean SF-36 scores was 57.2 (22.6 to 82) and the mean MFA score was 37.6 (10–72). As expected the scores were negatively correlated (−0.587, p=0.005). The presence of an ipsilateral posterior acetabluar wall fracture negatively affected functional outcome. Fragment excision was associated with a higher functional outcome when compared to internal fixation. Posterior surgical approach resulted in higher scores than patients who underwent an anterior procedure. Fracture of the femoral head is a rare but severe injury. The purpose of this study is to determine the functional outcome of and prognostic factors associated with femoral head fractures. Acetabular wall fracture, surgical approach, and method of surgical treatment are prognostic factors of functional outcome as measured by the SF-36 and the MFA. There is currently no consensus on the management of femoral head fractures and treatment practices have evolved on the basis of a limited series of studies. Functional outcome following femoral head fracture has been evaluated using Epstein’s criteria in several studies, however, only one study has been conducted using a validated outcome measure. Twenty-five femoral head fractures in twenty-four patients were identified from the trauma and orthopaedic databases of two major trauma centres. The patient with bilateral femoral head fractures was not included in the analysis. After obtaining informed consent, the patients’ medical records were reviewed. Functional outcome was assessed using two validated, patient-based outcome measures, the Short Form (SF)-36 and the Musculoskeletal Functional Assessment instrument (MFA). The average age of the patients was 36.8 (std. dev. 11.1) and the mean length of follow-up was 41.4 months (minimum twelve months). Three factors were identified using non-parametric analysis that significantly affected the functional outcome scores:. The presence of an ipsilateral posterior acetabluar wall fracture negatively affected functional outcome (p=0.08). Fragment excision resulted in significantly higher scores when compared with the patients treated by internal fixation (p=0.067). A posterior surgical approach resulted in a better functional outcome than the anterior approach (p=0.013)

Aim: To investigate factors that influence outcomes one year after distal radial fractures To investigate how deformity (radiologically), functional outcome and patient satisfaction affect one another. Background: Identifying the factors that influence outcome in DRF is important in anticipating and treating patients with potentially correctable factors that may affect recovery. Previous studies have looked at different sub-sets of the DRF group most often with patient reported outcomes. We have reviewed a large consecutive group of DRF looking at which factors influenced the outcomes. Methods: Data on 640 distal radial fractures was prospectively recorded over a 24 month period. The database was reviewed and validated. Mechanism of injury, hand dominance and occupation were noted. Initial, post reduction, one week, 6 week and one year x-rays were taken. The volar and dorsal shortening, tilt and angulation were recorded. Any operative intervention or complication was noted. At one year follow up functional testing was performed including range of movement. This tested for grip strength, multiple postional strengths and a functional score looking at activities of daily living. Results: Prediction of functional outcome was significantly associated with age, volar communition, dorsal angulation and pain. The grip strength after a distal radial fracture is significantly stronger in dominant side fractures compared with non dominant, in younger patients and those without dorsal communition. We also showed that fractures that are most likely to malunite show a significantly poorer functional outcome and weaker grip strength. Conclusion: This study identifies factors that predict the functional outcome in Distal Radial fractures. Although many assumptions are made that certain fractures lead to poorer results this has rarely been shown in such a large, diverse group of DRFs. In an age where patients and practitioners strive to ever increasing levels of knowledge this study allows us to counsel patients in their likely functional outcomes more accurately

Objectives. Preservation of posterior condylar offset (PCO) has been shown to correlate with improved functional results after primary total knee arthroplasty (TKA). Whether this is also the case for revision TKA, remains unknown. The aim of this study was to assess the independent effect of PCO on early functional outcome after revision TKA. Methods. A total of 107 consecutive aseptic revision TKAs were performed by a single surgeon during an eight-year period. The mean age was 69.4 years (39 to 85) and there were 59 female patients and 48 male patients. The Oxford Knee Score (OKS) and Short-form (SF)-12 score were assessed pre-operatively and one year post-operatively. Patient satisfaction was also assessed at one year. Joint line and PCO were assessed radiographically at one year. Results. There was a significant improvement in the OKS (10.6 points, 95% confidence interval (CI) 8.8 to 12.3) and the SF-12 physical component score (5.9, 95% CI 4.1 to 7.8). PCO directly correlated with change in OKS (p < 0.001). Linear regression analysis confirmed the independent effect of PCO on the OKS (p < 0.001) and the SF-12 physical score (p = 0.02). The overall rate of satisfaction was 85% and on logistic regression analysis improvement in the OKS (p = 0.002) was a significant predictor of patient satisfaction, which is related to PCO; although this was not independently associated with satisfaction. Conclusion. Preservation of PCO should be a major consideration when undertaking revision TKA. The option of increasing PCO to balance the flexion gap while maintaining the joint line should be assessed intra-operatively. Cite this article: N. D. Clement, D. J. MacDonald, D. F. Hamilton, R. Burnett. Posterior condylar offset is an independent predictor of functional outcome after revision total knee arthroplasty. Bone Joint Res 2017;6:172–178. DOI: 10.1302/2046-3758.63.BJR-2015-0021.R1

Aims. While patients with psychological distress have poorer short-term outcomes after total knee arthroplasty (TKA), their longer-term function is unknown. We aimed to 1) assess the influence of preoperative mental health status on long-term functional outcomes, quality of life, and patient satisfaction; and 2) analyze the change in mental health after TKA, in a cohort of patients with no history of mental health disorder, with a minimum of ten years’ follow-up. Methods. Prospectively collected data of 122 patients undergoing primary unilateral TKA in 2006 were reviewed. Patients were assessed pre- and postoperatively at two and ten years using the Knee Society Knee Score (KSKS) and Function Score (KSFS); Oxford Knee Score (OKS); and the Mental (MCS) and Physical Component Summary (PCS) which were derived from the 36-Item Short-Form Health Survey questionnaire (SF-36). Patients were stratified into those with psychological distress (MCS < 50, n = 51) and those without (MCS ≥ 50, n = 71). Multiple regression was used to control for age, sex, BMI, Charlson Comorbidity Index (CCI), and baseline scores. The rate of expectation fulfilment and satisfaction was compared between patients with low and high MCS. Results. There was no difference in the mean KSKS, KSFS, OKS, and SF-36 PCS at two years or ten years after TKA. Equal proportions of patients in each group attained the minimal clinically important difference for each score. Psychologically distressed patients had a comparable rate of satisfaction (91.8% (47/51) vs 97.1% (69/71); p = 0.193) and fulfilment of expectations (89.8% vs 97.1%; p = 0.094). The proportion of distressed patients declined from 41.8% preoperatively to 29.8% at final follow-up (p = 0.021), and their mean SF-36 MCS improved by 10.4 points (p < 0.001). Conclusion. Patients with poor mental health undergoing TKA may experience long-term improvements in function and quality of life that are comparable to those experienced by their non-distressed counterparts. These patients also achieved a similar rate of satisfaction and expectation fulfilment. Undergoing TKA was associated with improvements in mental health in distressed patients, although this effect may be due to residual confounding. Cite this article: Bone Joint J 2020;102-B(7):845–851

Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. However, patients often report functional limitations even years after the injury. This study investigates the influence of the surgical approach (transpatellar vs. parapatellar) on gait performance and patient reported outcome six months after surgery.

Twenty-two patients with tibial shaft fractures treated by intramedullary nailing through a transpatellar approach (TP: n=15, age 41±15, BMI 24±3) or a parapatellar approach (PP: n=7, age 34±15, BMI 23±2) and healthy, matched controls (n=22, age 39±13, BMI 24±2) were assessed by instrumented motion analysis six months after intramedullary nailing. Short musculoskeletal function assessment questionnaire (SMFA) as well as kinematic and kinetic gait data were collected during level walking. Comparisons among approach methods and control group were performed by analysis of variance and Mann-Whitney test.

Six months after surgery, knee kinetics in both groups differed significantly compared to controls (p <.04). The approach method affected gait speed (TP: p = .002; PP: p = .08) and knee kinematics in the early stance phase (TP: p = .011; PP: p = .082), with the parapatellar approach showing a more favorable outcome. However, the difference between patient groups was not significant for any of the assessed gait parameters (p > .2). Also, no differences could be found in the bother index (BI) or function index (FI) of SMFA between surgical approach methods (BI: TP: Mdn = 7.2, PP: Mdn = 9.4; FI: TP: Mdn = 10.3, PP: Mdn = 9.2, p > .7).

Our study demonstrates, that six months after surgery for tibial shaft fractures functional limitations remain. These limitations appear not to be different for either a trans- or a parapatellar approach for the insertion of the intramedullary nail. The findings of this study are limited by the relatively short follow up time period and small number of patients. Future studies should investigate the source of the functional limitation after intramedullary nailing of tibial shaft fractures.

Currently long term survivorship is highly predictable for total knee replacements. However, they still do not have the functional outcome of a normal knee, particularly in younger people. Using our results published in 1999 we compared the functional outcomes with a modern design implant. 415 patients having an LPS Flex Mobile implant were performed by one surgeon and were assessed using the SF36 functional outcome questionnaire. Patients were looked at pre-operatively, three months post-operatively and 12 months post-operatively. The results were compared with the previously reported study and there were shown to be some exciting changes in respect to functional outcome, particularly in the younger age group, and at the same time not incurring any increased complications. Comparing the 2 studies in 1999 and this study and using the ABS survey where population norms were calculated we showed that the results in the older patients were maintained with no additional compllcations. In 1999 the younger patients performed poorly however in this new study the younger patients returned to the age matched expected norms for the broader community. Total knee replacements still do not provide normal function in a knee, however, recent changes to design concepts have permitted improved functional outcome for patients particularly in the younger age group

Aims

The primary aim of our study was to assess the influence of age on hip-specific outcome following total hip arthroplasty (THA). Secondary aims were to assess health-related quality of life (HRQoL) and level of activity according to age.

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

To evaluate if young patients have a poorer functional outcome following Total Knee Arthroplasty surgery. Database of 700 consecutive Total Knee Arthroplasty patients from Scotland, UK was collected with Oxford Knee scores and American Knee Society Scores both pre-operatively and at sequential follow up reviews (PFC database, DePuy). Complication data was also collated. Patients were then age stratified into below 55, 56–64, 65–74 and over 75 groups. Analysis was performed using General Linear Model ANOVA (Minitab v10) comparing functional score change between pre operative and 2 year score data. No statistical difference was identified between the patient age groups and change in functional outcome scores (AKSS p=0.994; OKS p=0.368). All groups showed an improvement in functional scores over the 2 year period using both patients assessed (OKU) and physician scored outcomes (AKSS). There was no statistical difference in revision or infection rates. Recent data has suggested higher revision and infection rates in young patients undergoing Total Knee Arthroplasty (Scottish Arthroplasty Report 2012). The data from the PFC database does not show any change in infection or revision rates within this sample population and the data does also not support any variance in change in functional outcome with all groups showing improvement following TKA. The findings may be limited due to sample size of 700 patients

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Purpose: Fractures of the femoral head are relatively uncommon injuries and usually occur following a traumatic dislocation of the hip joint. The purpose of this study was to evaluate self-reported functional outcome of patients who have sustained a femoral head fracture. Methods: A search of the trauma database at a Level I trauma center between the years 1987–2003 was conducted. Sixty two patients, sustaining 63 femoral head fractures were identified. Two patient-based outcome measures, the Short Form-36 (SF-36) and Short Musculoskeletal Functional Assessment (SMFA) were used to evaluate functional outcome. Forty patients were lost to follow-up including three deaths. Results: To date twenty-three subjects (13 male, mean age 37.3 +/− 15.6), with 24 femoral head fractures have complete functional outcome data. Ten hips (42%) were classified as Pipkin type I, 12 (50%) type II, 1 (4%) type III, and 1 (4%) type IV. The mean follow-up was 10.3 +/− 5.4 yrs. Mechanism of injury included motor vehicle collisions (18/24), and falls from height (6/24). The mean ISS was 11.3 +/− 5.3. Fifteen subjects were treated operatively (13 internal fixation, 1 excision, 1 open reduction only). Four hips failed initial treatment and required delayed total hip arthroplasty (THA). Subjects (n=20) not having a THA functioned below the Canadian normal population for SF-36 physical component score (mean 44.5 +/− 11.0, p < 0.03). Conclusions: This is the first report of patient-based functional outcome following treatment of femoral head fractures. Physical function was significantly lower when compared to Canadian population norms

Aim. This study was conducted to investigate the clinical outcome, functional outcome, and quality of life of patients treated for post traumatic osteomyelitis (PTO) of femur and tibia from July 2007 to June 2014. Method. Forty seven patients consented and participated in this study. The median age of participants was 44 years old, and ranges from 16 to 80 years old. There were 26 tibia and 21 femur osteomyelitis evaluated in this study. Thirty-eight participants (80.9%) had implants inserted. The PTO patients were classified according to Cierny-Mader (CM) classification: 2 CM-I; 8 CM-II; 18 CM III; 19 CM IV and 25 CM-A and 19 CM-B. The participants were follow up for a mean duration of 4.6 years (range 2.3–9.5 years). Interviews were then conducted and clinical assessments were performed to evaluate the clinical outcome. Their functional outcome was evaluated using the Lower Extremity Functional Score (LEFS) and the quality of life was evaluated using the validated SF-36v2 and the results were compared to the general population (GP). Results. Forty four (93.6%) of participants had achieved union without recurrence of infection. Others who had failure of treatment were CM-IIIA, CM-IVA, and CM-IVB. Concurrent medical problem and CM-B (Systemic) hosts significantly contributed to poorer functional outcome, and lower quality of life score especially the Physical Component domain. Conclusions. Most patients with post traumatic osteomyelitis had successful treatment. However their quality of life was poorer in comparison to the general population. Concurrent medical problem and CM-B (Systemic) hosts had significantly poorer functional outcome and quality of life than the general population

Recovery after femur fractures is slow, despite rapid bone union. Causes of disability require investigation. Forty patients with isolated, diaphyseal femur fractures treated with antegrade locked intramedullary nailing were prospectively studied. Functional outcome was measured using the Western Ontario – McMaster University Osteoarthritis Index (WOMAC) and Short Musculoskeletal Functional Assessment (SMFA). Pain scores from the groin, buttock, thigh, and knee six months following the injury were correlated with functional outcome. Severity of pain was highest at the knee. Both knee and thigh pain had strong correlations with functional outcome measures following diaphyseal femur fractures. Further investigation into post-traumatic pain is warranted. This study was performed to compare pain at the knee, thigh, buttock and groin with functional outcome scores 6 months following femur fractures. Pain at the knee and thigh correlated with functional outcome measures. Many patients with femoral fractures have prolonged disability. Knee pain is common, severe, and correlates with functional outcome. Forty skeletally-mature patients with diaphyseal femoral fractures treated with locked antegrade intramedullary nails were prospectively enrolled. Exclusion criteria included polytrauma, ipsilateral injuries, metaphyseal extension, and pathologic fractures. Functional outcomes were assessed using the Western Ontario-McMaster University Osteoarthritis Index (WOMAC) and the Short Musculoskeletal Function Assessment (SMFA). Patients were instructed to record pain in the groin, buttock, thigh or knee of the fractured extremity on a 10-point visual analog scale. Patients reported more pain at the knee (3.7 ± 3.1), compared to the thigh (2.5 ± 2.7), buttock (1.7 ± 2.7), and groin (1.0 ± 1.7) (p=0.003). Pain and functional outcomes were plotted on scatter graphs and correlations performed using the Spearman rank test. Strongest correlations were noted between knee pain and WOMAC pain (ρ=0.748, p< 0.001), function (ρ=0.701, p< 0.001), and SMFA (ρ=0.733, p< 0.001); and between thigh pain and WOMAC pain (ρ=0.705, p< 0.001), stiffness (ρ=0.707, p< 0.001), function (ρ=0.731, p< 0.001), and SMFA (ρ=0.723, p< 0.001). Weaker correlations were noted between groin and buttock pain and functional outcomes. Knee pain is common and severe after femur fractures. Knee and thigh pain correlate with functional outcomes. Further investigation should be directed to this common problem. Funding: Funding from Synthes Canada, Smith and Nephew Richards Canada, and the Lawson Health Research Institute was received in support of this study

Introduction. Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications. Results. 142 patients with 143 fractures were identified, 40 (28%) were open, 94 (66%) were intra-articular, 85 (59%) were tertiary referrals. 32% were type 1, 28%, type 2 and 40% type 3 AO/OTA severity. 139 (97%) of the fractures united (2 non-unions, 1 amputation and 2 delayed unions who remain in frames), at a median of 165 days (range 104 to 429, IQR 136 to 201). 62% united by 6 months, 87% by 9 months and 94% by 1 year. Both non-unions have united with further treatment. Closed fractures united more rapidly than open (median 157 vs 185 days; p=0.003) and true Pilon (43C3) fractures took longer to unite other fractures (median 156 vs 190 days; p<0.001). 34% of patients encountered a problem, 12% an obstacle and 10% a complication. Of the complications, 6 (4%) were minor, 5 (3.5%) major not interfering with the goals of treatment and 4 (3%) major interfering with treatment goals (including the 2 patients with non-union and 1 who underwent amputation as well as 1 significant mal-union). This will increase to 4% if the 2 delayed unions fail to unite. Overall 56% reported good or excellent ankle scores at last report, 28% fair and 16% poor. Closed, extra-articular and non-43C3 fractures had better functional outcome scores than open, intra-articular and 43C3 fractures respectively. Conclusions. This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries. *Judged best paper*

Radiographic follow-up of traumatic spondylolisthesis of the axis is well documented in the literature. However, there is a paucity of studies regarding the long-term functional outcome of this type of injury. To study the population, treatment and outcome following traumatic spondylolisthesis of the axis, we reviewed 36 consecutive patients presenting to our institution, a tertiary referral spinal trauma centre, over a 6-year period. We assessed: (a) the mechanism of injury, (b) the mode of treatment, (c) the radiographic classification using the Levine and Edwards system and (d) functional outcome using the Cervical Spine Outcomes Questionnaire (CSOQ) by BenDebba. Of the 36 patients presenting there were 24 males and 12 females with a mean age of 46 (range18-82) years. The commonest mechanism of injury was road traffic accidents. There were 14 Type-I, 11 Type-II and 1 Type-IIA fractures. Twenty-seven patients were treated with halo vest immobilisation and nine were immobilised in a Minerva jacket. Four patients were converted from halo to Minerva because of pin failure. The mean duration of hospital stay was 10 (range 3-30) days. All fractures demonstrated radiographic union at a mean of 12 (range 10-16) weeks. There were no neurological complications. Upon review, all patients, whether Type-I or Type-II demonstrated low CSOQ scores approaching their pre-morbid status. However, Type-II fractures scored higher in 3 functional outcome categories when compared to Type-I fractures. This unique study of an uncommon fracture shows for the first time a difference in the functional outcome scores of Type-II fractures of the axis when compared to Type-I fractures at a mean follow-up of 3 years and 10 months

Aims. Advocates of debridement, antibiotics and implant retention (DAIR) in hip periprosthetic joint infection (PJI) argue that a procedure not disturbing a sound prosthesis-bone interface is likely to lead to better survival and functional outcome compared with revision. This case-control study aims were to compare outcome of DAIRs for infected primary total hip arthroplasty (THA) with outcomes following primary THA and two-stage revision of infected primary THAs. Patients and Methods. We retrospectively reviewed all DAIRs, performed for confirmed infected primary hip arthropasty (n = 82) at out institution, between 1997 and 2013. Data recorded included full patient information and type of surgery. Outcome measures included complications, mortality, implant survivorship and functional outcome. Outcome was compared with two control groups matched for gender and age; a cohort of primary THAs (n = 120) and a cohort of two-stage revisions for infection (n = 66). Results. Mean age at DAIR was 69 years (33 to 87) and mean follow-up was eight years (2 to 17; standard deviation (. sd). 5). A total of 52 (63%) of DAIRs were for early PJI (less than six weeks). Greater success in the eradication of infection with DAIR was identified with early PJI, comprising an interval less than a week between onset of symptoms and exchange of modular components with the DAIR procedure. Eradication of infection, complications and re-operation rates were similar in the DAIR and two-stage revision groups. For hips with successful eradication of infection with DAIR, the five-year survival (98%; 95% confidence interval (CI) 94 to 100) was similar to the primary THA group (98%; 95% CI 95 to 100) (n = 43; p = 0.3). The DAIR group had inferior mean Oxford Hip Scores (OHS) (38; 12 to 48) compared with the primary THA group (42; 15 to 48) (p = 0.02) but a significantly better mean OHS compared with the two-stage revision group (31; 0 to 48) (p = 0.008). Patients who required only one DAIR for eradication of infection had a similar mean OHS (41; 20 to 48) to the primary THA group (p = 0.2). Conclusion. The DAIR procedure is associated with a similar complication rate and ability to eradicate infection as two-stage revision. This study emphasises the need for exchange of modular components for improved chances of eradication of infection. This is the first study showing that DAIR is better than a two-stage revision regarding functional outcome. Cite this article: Bone Joint J 2017;99-B:614–22

Aims

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes.

Background. Cheilectomy and arthrodesis are accepted procedures for symptomatic hallux rigidus. Although good functional outcomes have been reported, there is little data available on post-operative sporting ability for these patients. Aims. We investigated sporting ability and functional outcomes of two cohorts of patients, the first underwent dorsal cheilectomy and the second arthrodesis. Methods. Physical and sporting ability was assessed using the Foot & Ankle Ability Measure (FAAM) sports questionnaire. Functional outcomes were assessed using MOXFQ. Radiological assessment was done according to Hattrup and Johnson classification. (HJ). Results. Group A (cheilectomy) consisted of 38 feet (35 patients) with a mean age of 57.2 (31–84) and mean follow-up 21.4 months (6–43). 21.6% were HJ1, 43.2% HJ2 and 35.1% HJ3. Group B (arthrodesis) consisted of 49 feet (47 patients) with a mean age of 64.1 (41–81) and mean follow-up 18.5 months (5–41). 6.8% were HJ1, 40.9% HJ2 and 52.3% HJ3. Mean FAAM score for group A was 78.89% (28.1%–100%). Mean FAAM score for group B was 81.55% (28.1%-100%). Mean MOXFQ score for group A was 14.89/64 (0–41). Mean MOXFQ score for group B was 10.43/64 (0–50). Pain, walking/standing and social domains were 29.74 (0–70), 21.8 (0–96.4) and 17.76 (0–68.8) in group A respectively. In group B, it was 14.79 (0–75), 16.54 (0–78.6), and 17.76 (0–100) respectively. FAAM was higher for group B in comparison to group A, but not statistically significant (P=0.425). Mean MOXFQ score was better in group B compared to group A (P< 0.05). Pain domain in particular was better in group B (P< 0.05). Conclusion. Our results suggest that both cheilectomy and arthrodesis for hallux rigidus result in similar post-operative sporting ability. Arthrodesis is superior to cheilectomy in overall functional outcomes, particularly in the pain domain

Purpose. Investigate the functional outcome of medial patellofemoral ligament (MPFL) surgery for patella instability. Compare functional outcome of direct MPFL repair and reconstruction using hamstring graft. Methods. All patients that underwent MPFL surgery for patella instability between 2007-2010 were retrospectively identified from operative records. Patients were divided based on whether they underwent direct repair of MPFL, or reconstruction using hamstring graft. The Kujala scoring questionnaire for patellofemoral disorders (max score 100) was used to assess their functional outcome following surgery. Results. 33 patients were identified, 11 were not suitable for inclusion in the study. The remaining 22 patients had a total of 25 operations for patella stabilisation (3 bilateral). Average age of patient at time of surgery was 21 (15-33), 15 male and 7 female. 17 had direct repair of MPFL, 8 had reconstruction using hamstring graft. Of the 8 reconstructions 6 were primary procedures and 2 were for failed direct repair due to further traumatic injury. Mean follow-up period was 17 months (6-43). Mean Kujala score overall 91.6, mean score for reconstruction group 93.2, direct repair score 90.7. Total number of further patella dislocations in the repair group was 1/17 (5.9%). No patients in the reconstruction group reported any further patella dislocations following their surgery. Conclusion. Both direct repair and reconstruction of MPFL for patella instability demonstrate high functional outcome at short/mid-term follow up. Our high success rate in direct MPFL repair, good functional outcome and low re-dislocation rate is better than that quoted in the current literature

Introduction. We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome. Methods. All patients undergoing open reduction internal fixation of the ankle between November 2006 and November 2007 at one centre, and January to December 2009 at the other were included. Adequacy of reduction was assessed on the initial post-operative radiographs using Pettrone's criterion. The post-operative functional outcome was recorded using the Lower Extremity Functional Scale (LEFS), completed by postal or telephone follow-up at 64 months post injury (60–74 months). Results. There were 261 patients in the cohort, with a mean age of 47 years (17–91). Weber B fractures were sustained in 193 patients compared to 68 Weber C fractures. The medial malleolus was fractured in 43 cases, and a large posterior malleolar fragment (>20%) was found in 13 cases. Malreduction of the Weber B cohort was identified in 61 ankles (31%): Malreduction of the Weber C cohort was identified in 25 cases (37%): At time of follow-up 26 patients were not traceable or had died. Of the surviving 235 patients, 139 responded to the LEFS questionnaire (60%). The mean LEFS was 58 (out of 80) in the Weber B cohort and 61 in the Weber C cohort. Significantly lower LEFS were found in patients who had a malreduction in 2 or more criteria. Conclusion. Our study shows that there is high incidence of malreduction in the operative treatment of ankle fractures which leads to a significantly poorer functional outcome. We strongly recommend that adequate care and supervision are used in theatre together with post-operative independent review of intra-operative fluoroscopy images

Aims. The aim of this study was to investigate the difference in functional outcome after repair and non-repair of the pronator quadratus muscle in patients undergoing surgical treatment for a distal radial fracture with volar plating. Patients and Methods. A total of 72 patients with a distal radial fracture were included in this randomized clinical trial. They were allocated to have the pronator quadratus muscle repaired or not, after volar locked plating of a distal radial fracture. The patients, the assessor, the primary investigator, and the statistician were blinded to the allocation. Randomization was irreversibly performed using a web application that guaranteed a secure and tamper-free assignment. The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) after 12 months. Secondary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) score, pronation strength, grip strength, the range of pronation and supination, complications, and the operating time. Results. Of the 72 patients, 63 (87.5%) completed follow-up for the primary outcome measure: 31 (86.1%) from the non-repair group and 32 (88.9%) from the repair group. At the 12-month follow-up, the mean difference in PRWE of 5.47 (95% confidence interval (CI) -4.02 to 14.96) between the repair (mean 18.38 (95% CI 10.34 to 26.41)) and non-repair group (mean 12.90 (95% CI 7.55 to 18.25)) was not statistically significant (p = 0.253). There was a statistically significant difference between pronation strength, favouring non-repair. We found no difference in the other secondary outcomes. Conclusion. We found that repairing pronator quadratus made no difference to the clinical outcome, 12 months after volar plating of a distal radial fracture. We conclude that there is no functional advantage in repairing this muscle under these circumstances and advise against it. Cite this article: Bone Joint J 2019;101-B:1498–1505

Aims

Ganz’s studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes’ disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach.

Aims. This prospective cohort study aimed to determine if the size of the tendon gap following acute tendo Achillis rupture influences the functional outcome following non-operative treatment. Patients and methods. All patients presenting with acute unilateral tendo Achillis rupture were considered for the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon rupture score (ATRS) six months after the completion of a rehabilitation programme. Results. 38 patients (mean age 52 years, range 29–78 years) completed the study. Patients with a gap ≥10mm with the ankle in the neutral position had significantly greater peak torque deficit than those with gaps < 10mm (mean 23.3% vs 14.3%, P=0.023). However, there was no overall correlation between gap size and torque deficit (τ=0.103), suggesting a non-linear relationship. There was also weak correlation between ATRS and peak torque deficit (τ=−0.305), with no difference in ATRS between the two groups (mean score 87.2 vs 87.4, P=0.467). Conclusion. This is the first study to identify tendon gap size as a predictor of functional outcome in acute tendo Achillis rupture, although the precise relationship between gap size and plantarflexion strength remains unclear. Large, multi-centre studies will be needed to clarify this relationship and identify population subgroups in whom deficits in peak torque are reflected in patient-reported outcome measures

To analyse and compare long-term functional outcome of combined spino-pelvic injuries to an isolated pelvis and spinal fractures, the outcome of matched 30 patients with combined pelvic and spinal fractures was compared with 32 patients with isolated pelvic fractures and 30 patients with isolated spinal fractures. Functional outcome was measured using the self-report questionnaire EuroQol EQ-5D, a generic outcome tool. The functional outcome was compared with the average UK population scores. The mean age, median ISS and demographic profile were similar in all 3 groups. Neurological injuries were seen in 10 patients in the combined injury group, 5 patients in the pelvic injury group and 3 patients in the spinal fracture group. 1 patient had sexual dysfunction in the combined injury group. The EuroQol EQ-5D descriptive scores for the combined group were 0.67±0.11 (0.71±0.12 for spine fracture, 0.61±0.18 for pelvic fracture) and Valuation scores for the combined injury were 69.6±11.4 (65.1±19.4 for spine fracture, 61.5±21.9 for pelvic fracture), which are p=0.004 and p=0.003 for the combined injury compared to the average UK population. Duration of hospital stay was a mean of 13 days in spine injury group compared to 49 days in the combined injury group. 70% of patients with spinal injuries returned to the same level of employment in a mean duration of 5.3 months with only 10% retired due to injury; compared to 56.6% returned to work in the combined injury group after a mean duration of 12.8 months with 23.3% retired due to injury. Long-term functional outcome is significantly better with isolated spinal injuries compared to pelvic injury or combined injury. There is no significant long-term difference between the combined spino-pelvic group and the isolated pelvic injury group. We feel that the spinal injuries in a patient with coexisting pelvic fracture do not contribute towards the overall functional outcome in those patients

Aims: Our objectives is to evaluate the functional outcome of tibial nailing in 29 patients operated at the South Birmingham Trauma unit in the period between 1992–1996. Methods: This is a retrospective study; all patients included had a tibial nail inserted for two or more years. Assessment was made by reviewing the notes, interviewing and examining the patients. A pro-forma was for each patient was collected covering various activities and outcomes. Results: The results showed that the majority of patients demonstrated a compromised activity level, both in their leisure activity and occupation. No statistical difference was observed between reamed and unreamed nails in their functional outcome measurements. Conclusions: Our conclusion that the functional outcome of tibial nailing is not as good as the anatomical restoration would predicts

We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114º versus 127º; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01). Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease. Cite this article: Bone Joint J 2014; 96-B:1111–18

Patellofemoral problems are probably the most common type of knee complaint in adolescents and adults. Our aim is to evaluate the mid- and long-term functional outcome, as well as to detect factors affecting it in patients who underwent a modified Elmslie-Trillat procedure. Forty-two patients (49 procedures) were included in this study. Nine were male and the 33 female, with a mean age of 31,3 years (range: 19 to 56). The reason for operation was patellar instability (recurrent subluxation or dislocation) in 13 cases (26,5%), anterior knee pain with malalignment of the extensor mechanism in 17 cases (34,7%) and a combination of both in the remaining 19 cases (38,8%). Patients were followed for a minimum of 18 months and an average of 38,6 months (range: 18 to 130 months). The functional outcome according to Cox’s criteria was excellent in 14 cases (28,6%), good in 20 cases (40,8%), fair in 9 cases (18,4%) and poor in the remaining 6 cases (12,2%). Patients scored an average of 3,57 (range: 2–8) in their Tegner Activity Scale, while their score in Activities of Daily Living Scale of the Knee Outcome Survey ranged from 43 to 98 (average: 75,8). Result analysis revealed that the functional outcome was better in the subgroup that had the procedure due to patellar instability. Furthermore, the outcome was significantly better in the absence of grade 3 or 4 chondral changes in the patellofemoral joint at the time of operation (t-test: p=0,0362). Elmslie-Trillat procedure satisfactorily restores patellofemoral stability and offers a very good functional outcome, especially in the absence of significant chondral changes in the patellofemoral joint at the time of operation

The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. One hundred and fifteen patients were identified. 63% were male; mean age was thirty-seven years; mean ISS was thirty. Three patients died from their injuries. At a mean follow-up of 3.5 years, patients exhibited profound functional deficits compared to the normal population. Those with an acetabular fracture involving the posterior wall or an associated lower extremity injury have a particularly poor prognosis. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. To evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. These results will allow us to further investigate which injury is dictating prognosis in the combined injury – the pelvic or the acetabular fracture. One-hundred and fifteen patients with combined pelvic and acetabular injuries were identified at a level One trauma centre. 63% were male; mean age was thirty-seven years (13–88); mean ISS was thirty (16–75). Three patients died from their injuries. 16% involved bilateral pelvic fractures; 7% bilateral acetabular fractures; and for 2%, both were bilateral. 64% were Tile B and 34% were Tile C. Most acetabular fractures involved the anterior column or both column. Only 18% were treated with ORIF for both injuries. 25% had ORIF of their acetabulum and 14% had ORIF on their pelvis. Sixty-five patients completed validated functional outcome questionnaires at a mean follow-up of 3.5 (one to eleven) years. Patient function was significantly compromised with a mean MFA score of 33.8 (SD 21.8). Function was worse for all 8 SF-36 domains and the two component scores compared to the health status of the Canadian normal population (p< 0.001). Those individuals with an acetabular fracture involving the posterior wall or an associated lower extremity injury have a particularly poor prognosis. There was no relationship found between treatment or the pre-defined stability groups and functional outcome. Funding: Grant funded from AO/ASIF

Purpose: Identifying optimal treatment strategies in patients with traumatic foot and ankle injuries has been hampered by the variety of different measurement tools and lack of validation of generic and foot-specific functional measures. It remains plausible that the choice of functional outcome measure may influence our ability to accurately measure treatment effects. This prospective observational study aims to correlate the scores across six functional outcome measures in patients with traumatic foot and ankle injuries and to examine agreement of scores and patients’ subjective health status. Method: Patients with traumatic foot or ankle injuries completed two generic, the SF-12 Health Survey and the Short Musculoskeletal Functional Assessment (SMFA), and four specific health outcome measures, the Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopedic Surgeons (AAOS) Foot and Ankle Questionnaire and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, at a single follow-up visit. Raw scores were calculated and used to assign patients to a categorical functional level (excellent, very good, good, fair or poor). Agreement between the assignments was assessed and Pearson correlation co-efficients were calculated for each pair of outcome scores. Statistical significance was determined using an α of 0.05. Results: 52 patients (mean age 43.3 ± 16.8 years) were enrolled at a mean follow-up of 15.5 months. All correlations except for that between the AOFAS ankle-hindfoot scale and the mental component of the SF-12 were statistically significant. The strongest correlations were found between the SMFA, FFI, AAOS Foot and Ankle Questionnaire and the FAAM. Despite significant correlation between scores and patients’ subjective functional outcome, there was minimal agreement between assigned categorical functional levels. Conclusion: The high correlations between scores on the generic and foot-specific functional measures suggest that it is likely unnecessary to use more than one instrument when examining functional outcome in patients with traumatic foot and ankle injuries. Generic tools also appear to function as well as specific scores in this population. However, assignment of patients to a categorical functional level based on raw outcome scores must be performed with caution as the results obtained may not accurately reflect functional outcome

The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. One hundred and fifteen patients were identified. 63% were male; mean age was thirty-seven years; mean ISS was thirty. Four died from their injuries. Five patients had open injuries. Only 18% were treated with ORIF for both injuries. At a mean follow-up of 3.5 years, patients with combined pelvic and acetabular fractures exhibit profound functional deficits compared to the normal population. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. Those individuals with an acetabular fracture involving the posterior wall and an associated lower extremity injury have a particularly poor prognosis. Individuals who have sustained high energy combined injuries exhibit profound functional impairments compared to the general normal population even in the long term. One hundred and fifteen patients with combined pelvic and acetabular injuries were identified using a trauma database at a level one trauma centre. 63% were male; mean age was thirty-seven years (13–8); mean ISS was thirty (9–5). 16% involved bilateral pelvic fractures; 7% bilateral acetabular fractures; and for 2%, both were bilateral. 64% were Tile B and 34% were Tile C. Most acetabular fractures were anterior column (31%) or both column fractures (26%). Only 18% were treated with ORIF for both injuries. 25% had ORIF of their acetabulum and 14% had ORIF on their pelvis. Sixty-five patients completed functional outcome questionnaires at a mean follow-up of 3.5 years (1–21). Function was significantly compromised with a mean MFA score of 33.8±21.8. Function was worse for all eight SF-36 domains and the two component scores compared to the Canadian normal population (p< 0.001). There was no relationship found between severity of pelvic or acetabular injury and patient function nor between treatment and functional outcome. Funding: Grant funded from AO/ASIF

56 patients who had undergone lower limb lengthening in accordance with Ilizarov principles in 61 bone segments were retrospectively studied and functional outcomes were evaluated by 5 different assessment systems. There were 17 cases of congenial bone deficiencies, 11 post poliomyelitis, 11 post traumatic, 8 post infection, and 9 miscellaneous cases. The average lengthening was 7.6 centimeters (3–14). Among the 46 patients who had reached skeletal maturity at the time of study,79% had reached their lengthening goal. 10 patients had still open physes and would require further equalization procedures. There were 40 side effects (complications and obstacles) and 37 problems. 27 cases required additional surgery to treat the complications. Major complications were most commonly seen in congenital femoral lengthening cases. The functional outcome as evaluated by the five different assessment systems revealed improvement in almost all aspects. The improvement in esthetic appearance of the limb and shoe -wear, walking, sporting activities, and limp were the most common reasons for satisfaction as observed in 89% of the cases

Introduction: Life expectancy is increasing, this leads to a major number of hip fracture and its subsequent complications and costs. Proximal femur fracture is not only a medical problem but also a social handicap. Our objective is to see, by means of a prospective observational study, how the function varies after hip fracture and which are the most influencing factors in order to get maximum benefits of resources for this patology. Materials and Methods: 262 patients had been hospitalized suffering hip fracture in our centre between june 2006 and December 2007.107 of them were included in the study, the others were excluded for different reasons: cognitive impairment (based on Folstein test), previous hip fracture or pathologic fractures. 86 female and 21 male. Mean age 74 years (65–93).44 suffering subcapital fracture and 63 pertrochanteric fracture. 76 patients underwent gamma nail or canulated screws and 31 hemi or total hip replacement. Mean surgery delay 3 days (1–14) At the moment of hospital registration we also determined marital status, familiar support, living at home or institution, morbidity pre- fracture (according to Charlson index), level of dependence (Barthel index), mental status (Folstein Mini Mental State Examination)quality of life perceived (short form 36 (SF-36)) and depression symptoms (Geriatric Depression Scale 15 (GDS 15)). At three months post discharge we determined again all the test mentioned before and also recorded the functional level (Harris test), which haven’t been passed preoperatively because it includes a part of physical evaluation, not possible to do in a fractured leg. Statistics: Analysis of Variance for repeated measures, Spearman correlation coefficient, level significance 0.05. Results: Most part of patients came from their own houses (87,6%), where only returned 23% of them at hospital discharge. In the control visit al 3 months most of them had returned at home (79%). There were no significant differences between functional outcome al three months and delay of the surgery (p 0.76) or the type of surgery (artroplasty vs osteosintesis) (p0.308). There was a negative correlation (rho-spearman −0.656)between depression and functional outcome, the more depressed a patient is the worse functional outcome he has (p 0.002). There was a positive correlation (rho-spearman 0.605) between function (Harris test) and dependency (Barthel index).Patients less independent pre fracture are the ones with low function at three months. (p 0.000). Discussion: There are a lot of patients needing nursing or social facilities at hospital discharge with the high costs that this supposes. We have seen that depressed people at hospital income are going functionally worse than non depressed and consequently are more dependent persons. Maybe early diagnosis ant treatment of depression will help to get maximum results of rehabilitation procedure

Twenty-three patients with scapular chondrosarcomas presented to our institution between 1989 and 2003. Twenty-two were treated surgically while one presented with metastases and was treated palliatively. Fourteen patients underwent partial scapulectomy and eight had a Tikhoff-Linberg procedure. There were no local recurrences and only two patients have suffered a systemic recurrence at mean follow-up of fifty-two months. Mean functional scores were: TESS – 88, MSTS 1987 – 27 and MSTS 1993 – 84. Overall, the oncologic and functional outcome for these patients was excellent. To examine the oncologic and functional outcome of patients treated for chondrosarcoma of the scapula. Rates of local recurrence and metastasis for adequately treated chondrosarcomas of the scapula were very low and patient function was quite good. Unlike previous reports in the literature, we found that scapular chondrosarcomas are highly amenable to limb salvage surgery and the oncologic and functional outcomes are excellent. Retrospective review of our prospectively collected database for all patients treated surgically at our institution for scapular chondrosarcoma between 1989 and 2003. Twenty-three patients presented with scapular chondrosarcoma, but one had spine metastases and was treated palliatively. Thus twenty-two patients were treated with limb salvage surgery. There were fourteen males and eight females. One patient presented as a local recurrence. Four tumors were grade one, sixteen grade two and two grade three. Eight were secondary to a primary benign primary tumor of bone. There were fourteen partial scapulectomies and eight Tikhoff-Linberg procedures. Surgical margins were positive in three cases. two patients received post-operative radiation and no patients received adjuvant chemotherapy. At last follow-up, twenty patients were alive with no evidence of disease (90.9%), one was alive with disease and one was dead of disease. There were two systemic recurrences and no local recurrences at an average follow-up of fifty-two months (range 12–113). Mean functional scores were: TESS – 88, MSTS – 1987 27 and MSTS 1993 – 84

This is a retrospective study of fifty nine hips in fourty nine patients with a previous total hip replacement for developmental dysplasia of the hip who underwent a revision arthroplasty of the hip. Fifty three patients were available for follow up. Radiographs and charts were reviewed and functional outcome scores were obtained in order to determine if a correlation existed between cup position and functional outcome and survivorship. Cup height was found to be a statistically significant predictor for functional outcome and cup survivorship. To determine if cup height, lateralization or angle are correlated with functional outcome or survivorship in revision total hip replacement (THR) in patients with a previous THR for developmental dysplasia of the hip (DDH). There is a paucity of literature correlating functional outcome with cup position in revision THR. Cup height was found to have a statistically significant (p< 0.05) correlation with Harris Hip, SF36, and WOMAC functional scores. High hip centers correlated with worse scores. In addition, patients with hip centers less than 3.5 cm above the radiographic tear drop had a statistically significant improvement in cup survivorship compared to those with higher hip centers. A retrospective investigation of forty-nine sequential patients (fifty-nine hips) previously diagnosed with DDH who underwent revision THR at our center between 1984 and 2000 was performed. Forty-three patients (fifty-three hips) were available for survivorship analysis and thirty-five patients (forty-five hips) were available for functional analysis. The mean follow up was one hundred and eighteen months (range 36–230). Three independent variables identified apriori as possible correlates were cup height, lateralization and angle as measured on the AP radiographs. Functional outcome measurement consisted of the Harris Hip, SF36 and WOMAC questionnaires. Linear regression analysis and Kaplan-Meier curves were used to determine if any of the variables correlated with functional outcome or survivorship. Restoration of hip center height to as close to the radiographic tear drop as possible improves functional outcome. Placement of the cup to within 3.5 cm of the tear drop improves cup survivorship

Aim. To assess the influence of route of antibiotic administration on patient-reported outcome measures (PROMS) of individuals treated for hip and knee infections in the OVIVA multi-centre randomised controlled trial. Method. This study was designed to determine whether oral antibiotic therapy is non-inferior to intravenous (IV) therapy when given for the first six weeks of treatment for bone and joint infections. Of the 1054 participants recruited from 26 centres, 462 were treated for periprosthetic or native joint infections of the hip or knee. There were 243 participants in the IV antibiotic cohort and 219 in the oral cohort. Functional outcome was determined at baseline through to one year using the Oxford Hip/Knee Score (OHS/OKS) as joint-specific measures (0 the worse and 48 the best). An adjusted quantile regression model was used to compare functional outcome scores. Results. Of the 214 participants in the hip sub-group, 110 were randomized to IV antibiotics and 104 to oral. Of the 248 participants in the knee cohort, 133 were treated with IV antibiotics and 115 with oral. The OHS/OKS questionnaire response rate was 68%. Baseline median OHS of the hip sub-group was 14 (Interquartile range [IQR]:8–22) for the IV cohort and 12 (IQR:7–22) for the oral cohort. The one-year median OHS was 35 (IQR: 23–44) for the IV cohort and 27 (IQR:16–40) for the oral cohort with no significant difference between cohorts (p=0.181). The baseline median OKS of the knee sub-group, was 14 (IQR:8–23) for the IV cohort and 12 (IQR:8–21) for the oral cohort. The one-year median OKS was 24 (IQR: 15–35) for the IV cohort and 27 (IQR:17–38) for the oral cohort with a statistically significant difference in favour of oral therapy (p=0.036). Conclusions. At one year, there was improvement in functional outcome of patients treated with either IV or oral antibiotics in this RCT. It suggests that joint function generally improved progressively following the start of treatment irrespective of the route of antibiotic therapy. Functional outcome of patients with hip infections was similar irrespective of the route of antibiotic therapy, whereas there was statistically greater improvement in functional outcome of patients with knee infections treated with oral antibiotics. The PROMS findings of this trial support the clinical findings (i.e. infection eradication rates) and suggest that there is no advantage of using prolonged intravenous therapy as compared to oral therapy in the early treatment of infections around the hip and knee joint

Background. Adhesive capsulitis (frozen shoulder) is a debilitating condition affecting 2–5% of the adult population. Its aetiology is still unclear and there is no consensus on the most effective treatment. The aim of this retrospective study was to investigate the mid-term functional outcome of one specific treatment protocol. Methods. Patients with a diagnosis of idiopathic adhesive capsulitis treated by one orthopaedic surgeon between 2004 and 2008 were identified from outpatient clinic letters. All patients had initially received conservative treatment, consisting of physiotherapy with capsular stretches and subacromial injections. Patients in whom conservative treatment failed underwent an arthroscopic capsular release. At a minimum of two years following diagnosis patients were sent the Oxford Shoulder Score (OSS [0 to 48]), Western Ontario Rotator Cuff Index (WORC [0 to 2100]) and a satisfaction questionnaire by post. In addition case notes were reviewed and type of treatment and range of movement (ROM) recorded. Results. 60 patients with the diagnosis of idiopathic adhesive capsulitis were identified. 42 patients (70%) returned the completed questionnaires. Range of movement data was available from 43 patients (72%). Mean OSS was 41 (SD 10.7) and mean WORC 307 (SD 437.1). Analysis showed that patients in whom conservative treatment was successful had significantly better functional outcome scores in OSS and WORC and better ROM than patients who underwent surgery. Overall 33 patients (79%) were satisfied or very satisfied with the outcome of their treatment. Conclusion. This study shows that patients who respond to conservative treatment have a better functional outcome than patients who undergo surgery following failed conservative treatment. Further studies are needed to directly compare the two types of treatment

Introduction. Fracture around the knee can lead to posttraumatic osteoarthritis (PTOA) of the knee. Malunion, malalignment, intra-articular osseous defects, retained internal fixation devices, and compromised soft tissues may affect the outcome of total knee replacement (TKR). On average, the posttraumatic patient subsets were 10.4 years younger than those for primary knee OA. Recently, there were several studies reporting the outcome of THA for posttraumatic OA hip. However, no current literature defines the comparative functional outcome between PTOA and primary OA knee. The purpose of our study was to compare the midterm outcomes of patients undergoing TKR following periarticular knee fractures/ligamentous injuries versus primary osteoarthritis (PO) of the knee. Materials and methods. Retrospective chart reviews of patients underwent TKR between 2008 and 2013 were identified. 136 patients underwent open reduction and internal fixation with plate and screws or ligament reconstruction while 716 patients were primary OA. Mean follow up time was comparable in both groups. Demographic data, medical comorbidities, WOMAC, visual analogue scale, and complications were recorded. Results. There were significantly different in age (56.5 vs 63.8 years, p<0.0001), gender (48.5% vs 63.1% of female, p=0.0014), and obese (62.3% vs 76.0%, p=0.025) between PTOA and PO groups, respectively. The PO group had higher comorbidities than PTOA group including anticoagulant usage (51% vs 30.9%, p=0.0002), number of disease ≥ 4 (69.6% vs 45.3%, p<0.0001), ASA class ≥3 (38.8% vs 21.6%, p<0.0001), and Charlson Comorbidity Index (3.6 vs 2.8, p<0.0001). The PTOA group had longer operative time (110.9 vs 100.1 minutes, p<0.0001) than PO group. Preoperatively anatomical axis of the knee was approximately valgus in PTOA but varus alignment in PO group (p<0.0001). However, postoperatively anatomical and mechanical axis was comparable in both groups. Postoperative VAS (1.8 vs 1.2, p=0.002) at 1 year follow up and pain component of WOMAC (77.8 vs 85.7, p=0.013) in PTOA group was worse than PO group, respectively. On the contrary, there was no difference in postoperative complication and readmission rate between groups. Conclusion. Total knee replacement for Post-traumatic OA was associated with poorer functional outcome compared to those for primary osteoarthritis in midterm follow up

Aim. Data of optimal management of infections after internal fixation (IIF) is scarce and long-term follow-up results often lack. We analyzed characteristics of infections after intramedullary (IIIF) and extramedullary long bone fixation (IEIF) and evaluated their infection and functional outcome. Method. Consecutive patients with IIF diagnosed at our institution from 01/2010-10/2017 were retrospectively included. Infection was defined as visible purulence, sinus tract, microbial growth in ≥2 independent samples or positive histopathology. The outcome was compared before and after implementation of a comprehensive surgical and antimicrobial treatment algorithm in 04/2013. Results. Of 127 patients, infection involved lower extremity in 111 patients (87%). Median age was 53 years (range, 19–89 years), 70% were men. Fixation was performed with intramedullary nail in 47 (37%) and with extramedullary osteosynthesis (plates, screws, pins) in 80 patients (63%). At infection diagnosis, the implant was in situ in 96 patients (76%), whereas 31 patients (24%) had residual osteomyelitis after implant removal. The time from bone fixation to infection was longer in IIIF than IEIF (25 vs. 7 months, p=0.027). Pain was reported in 55 patients (43%) and local infection signs in 96 patients (75%), including sinus tract in 46 patients, more commonly reported after IIIF than IEIF (49% vs. 29%, p=0.035). Infections were monomicrobial in 85 (67%), polymicrobial in 18 (14%) and culture-negative in 23 patients (18%). Most common pathogens were S. aureus (43%), coagulase-negative staphylococci (28%) and gram-negative rods (22%). Débridement (with device retention, if present) was performed in 40, device removal in 43, one-stage exchange in 16 and two-stage exchange in 20 patients. One patient had no surgery and 7 patients underwent limb amputation. 43 patients (34%) were treated before implementation of the interdisciplinary treatment concept and 84 patients (66%) afterwards. Among 111 patients with available follow-up (median, 5.2 months; range, 0.2–86 months), in 78 cases (70%) infection eradication was achieved (similar in IIIF and IEIF). However, overall infection and functional outcome was only 48% (53 patients). After implementation of the treatment algorithm, the infection outcome improved from 56% to 79% (p=0.03) and the overall success from 33% to 56% (p=0.016). Conclusions. Approximately half of infections after IIF failed in terms of infection eradication or restoration of function. After implementation of standardized surgical and antibiotic treatment concept, infection and functional outcome improved significantly. No significant differences between IIIF and IEIF was observed in terms of infection and functional success

Introduction: The severity of symptoms, rate and completeness of recovery after closed treatment of the fractured clavicle has not been fully explored. Materials and Methods: The severity and duration of pain, analgesic requirements, ability to perform acts of daily living, return to work, driving and sport were recorded along with appearance of the shoulder in 58 patients between one to two years after fracture was recorded. Radiographs were assessed by Robinson’s classification8 supplemented by fracture displacement. Results: The majority of patients experienced severe pain that required codeine, paracetamol and ibuprofen. 13/58 patients (22%) ceased to experience pain by one month, 35/58 (60%) by three and 48/58 (83%) by six. There was no improvement in the remaining ten patients after six months. 21 patients described difficulty reaching and lifting (36%), 11/36 (31%) digging the garden, 13/58 (22%) were unable to reach between their shoulder blades. Over 90% had no difficulty with feeding (55/58), dressing (50/58), personal toilet (56/58), brushing hair (41/46), hanging up clothes (52/56) or ironing (37/41) but overall 23/58 patients (40%) had some functional restriction 1–2 years after injury. 18/48 patients (38%) returned to work within one month, 39 (81%) by three, and all by six. 28/30 (93%) clerical workers had returned within three months compared with 11/18 (61%) of manual (p < 0.05) 36/42 (86%) sportsmen returned. High impact sportsmen were less likely to resume than low impact or overhead. 38/46 (83%) of drivers returned by three months and all by six. 40/58 (69%) patients noted cosmetic deformity the severity of which was associated with worse functional outcome (p = 0.002). The degree of displacement of the fracture was associated with cosmetic deformity (p = 0.015) and functional outcome (p = 0.025), but the Robinson classification8 alone was not. Conclusion: The majority of patients with a fractured clavicle perceive a cosmetic deformity and a substantial minority impaired function. There is potential to improve outcome and deformity by reduction and fixation in those with displacement of two or more cortical diameters

Introduction and Aims: The combination of ipsilateral intertrochanteric and femoral shaft fractures is an uncommon pattern associated with high-energy trauma. This retrospective study used self-report measures to evaluate functional outcome of patients sustaining this fracture pattern and compared two common treatment methods. Method: Three patient-based outcome measures, the Short Form-36 (SF-36), Short Musculoskeletal Functional Assessment (SMFA), and Lower Extremity Functional Scale (LEFS) were used to evaluate the functional outcome of twenty-one patients (13 male, mean 46.7 +/− 16.5 years) treated with a reconstruction nail (n=11) or with a sliding hip screw and retrograde nail (n=10). Results: Mechanisms of injury included motor vehicle accidents (66.7%) and falls from height (14.3%). SF-36 physical and mental component scores were less than Canadian norms, with mean values of 35.9 (p=0.0001) and 43.7 (p=0.02), respectively. There was a trend towards better functional outcome in the group treated with the sliding hip screw with retrograde nail despite this group sustaining more severe injuries as measured by ISS (p=0.004), number of days in hospital (p=0.027), and number of days in ICU (p=0.009). Conclusion: Functional outcome following treatment of ipsilateral intertrochanteric and femoral shaft fractures was reduced compared to Canadian norms. Despite having sustained more severe injuries, the sliding hip screw with retrograde nail group showed a trend towards better outcome as compared to the group treated with the reconstruction nail

Introduction. Bilateral total knee replacement can either be simultaneous, in which both knees are operated in the same sitting, in one day, or staged, in which both knees are operated but not on the same day. With appropriate patient selection, the potential benefits of conducting this procedure in a simultaneous fashion outweigh the possible risks of the procedure. Very few studies have evaluated the results of bilateral knee replacement in a single sitting in Indian population. Objectives. To determine the functional outcome after simultaneous knee replacement and assessment of the peri and post operative complications. Methods. Patients undergoing bilateral total knee arthroplasty in a single sitting by a single surgeon using standard technique and posterior stabilized cruciate substituting prosthesis. Evaluation was done using Hospital for Special Surgery Knee and Function scores. Results. The mean knee score improved to 85.81 from 67.83 and the mean function score improved to 83.15 from 69.14. Post operative complications included two cases of acute coronary syndrome, one case of psychosis and another of opiod withdrawal. Conclusions. Simultaneous bilateral total knee replacement remains an appropriate option in select patients

Purpose. Limited information is available regarding the functional outcomes of radial head fractures managed with open reduction and internal fixation (ORIF). The purpose of this study was to determine the functional outcomes of radial head fractures treated with ORIF. Method. Fifty-two patients, with a mean age of 4412 years, who were treated with radial head ORIF were evaluated at a mean of 4.42.4 years. Thirty were isolated radial head fractures (Group A), 13 (Group B) were associated with a complex fracture-dislocation (terrible triad variants), and 5 (Group C) were associated with a proximal ulnar fracture (Monteggia/trans-olecranon variants). Fourty-four were partial articular fractures and 8 were complete articular fractures. Outcomes were assessed with physical and radiographic examination, and validated self-reported questionnaires. Results. The average PREE score (Patient Rated Elbow Evaluation) for Groups A, B, and C were 7.613.1, 12.313.4, and 108.5, respectively. The average MEPI (Mayo Elbow Performance Score) for Groups A, B, and C were 8913, 8511, and 918, respectively. For Groups A, B, and C respectively, the prevalence of radiographic radiocapitellar arthritis was 30%, 46%, and 20%. The average flexion/extension arc for Groups A, B, and C were 7 to 132, 6 to 134, and 10 to 132 respectively. Secondary surgery was performed in 17% of cases, most commonly for decreased motion. Three comminuted fractures failed ORIF and required conversion to radial head arthroplasty. Conclusion. Patients with radial head fractures, including those associated with complex fracture-dislocations, can achieve excellent functional outcomes with low self reported pain and disability when treated with ORIF, despite radiographic evidence of mild post-traumatic arthritis

Aims. The aim of this study was to compare early functional and health related quality of life outcomes (HRQoL) in patients who have undergone total hip arthroplasty (THA) using a bone conserving short stem femoral component and those in whom a conventional length uncemented component was used. Outcome was assessed using a validated performance based outcome instrument as well as patient reported outcome measures (PROMs). Patients and Methods. We prospectively analysed 33 patients whose THA involved a contemporary proximally porous coated tapered short stem femoral component and 53 patients with a standard conventional femoral component, at a minimum follow-up of two years. The mean follow-up was 31.4 months (24 to 39). Patients with poor proximal femoral bone quality were excluded. The mean age of the patients was 66.6 years (59 to 77) and the mean body mass index was 30.2 kg/m. 2. (24.1 to 41.0). Outcome was assessed using the Oxford Hip Score (OHS) and the University College Hospital (UCH) hip score which is a validated performance based instrument. HRQoL was assessed using the EuroQol 5D (EQ-5D). Results. There were no major peri-operative complications. There was no difference in the mean post-operative OHS, EQ-5D or function subscale of the UCH hip scores between the two groups. The mean pre-operative OHS and EQ-5D scores improved significantly (all p <  0.001). The mean functional component of the UCH hip score at final follow-up was 42.5 and 40.6 in the short stem and conventional stem groups, respectively. There was no statistically significant difference between the groups (p = 0.42). A total of seven patients (21.2%) in the short stem group and nine (16.98%) in the conventional group achieved a ceiling effect using the OHS; none did using the function subscale of the UCH hip score. Conclusion. The proximally porous coated tapered short stem femoral component achieves comparable short-term functional outcomes when compared with a conventional longer stem uncemented femoral component when THA is undertaken in patients with good bone quality. Cite this article: Bone Joint J 2017;99-B(4 Supple B):49–55

Management of pseudotumours associated with MoM THA can be difficult and complications are frequent. The functional outcome of patients after revision surgery may be suboptimal. The objective of this study was to assess our experience with revisions of failed MoM THA due to pseudotumours. 78 hips were diagnosed with pseudotumours in 70 patients following metal-on-metal hip replacements. Of these, 68 MoM THA were revised in 62 patients. Pre operative symptoms, radiographic analysis, metal ion levels, MRI results, intra-operative findings, WOMAC scores, the satisfaction level and the complication rate were recorded. Five patients had a resurfacing arthroplasty as their primary implants while the remaining 63 hips in 57 patients had MoM THA of different brands. The average time between the primary and revision surgery was 69 months (range 15–120). The average age at revision was 59 years (43–87). The mean follow-up was 24 months (range 2–73). 36 patients had minimal one year follow-up. Most lesions consisted of cystic changes and solid lesions were observed in 19 patients. In 57 hips, the pseudotumours were located posteriorly or postero-laterally around the greater trochanter. Intra operatively, muscle necrosis was observed in 15(22%) patients. Most THA cases demonstrated wear and corrosion at the head neck junction of the femoral implants. Thirty-five patients (44.9%) had greater than 50 degrees of cup abduction, including 10 patients (12.8%) with an abduction angle greater than 60 degrees. The average pre operative and postoperative Co ion levels were 27.46 ug/L (range 0.36–145.6) and 2.46 (range 0.4–12.48), respectively. Post revision, a total of 10 hips (14.7%) sustained a dislocation, with seven (10.3%) of them experiencing recurrent dislocations. In 8/10 hips, the femoral head size was 36mm or greater. Revision for dislocation occurred in seven(10.3%) patients. Three(4.4%) deep and one(1.47%) superficial infections occurred and deep infections were re-operated. One(1.47%) fracture of the greater trochanter and one (1.47%) psoas tendinitis did not need revision. Therefore, a total of 10 patients (14.7%) were reoperated. 6 revisions for instability were performed in the first 34 patients, while 1 were done in the last 34 patients. At one year post revision surgery, the mean WOMAC score was 19.68 (range 0–48). In comparison, the mean WOMAC score of the same patients one year after their primary surgery was 8.1 (0–63). Patient satisfaction level of patients one year post revision surgery was 7.61 (range 5–10) compared to 4.15 (range 0–7) pre-revision one. The complication rate after revision of pseudotumours is high. Most re revisions occurred secondary to instability despite the use of larger femoral heads. The functional outcome at one year post revision seems to be lower than that seen after primary THA but similar to other revisions in the literature. Experience in the management of these patients may reduce the complication rate

Introduction. Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device. Materials and Methods. Prospectively collected clinical data was reviewed of all consecutive patients who underwent repair of the ruptured Achilles tendon using the Achillon device. Patients were contacted using a postal questionnaire for assessment of their functional status using the validated Achilles Tendon Total Rupture Score (ATRS) and compared with their uninjured side. The outcomes were compared to the published results. Results. We present patient demographics; and clinical and functional outcomes of 140 consecutive patients who underwent repair of ruptured Achilles tendon using the minimally invasive technique between June 2007 to August 2010. Our complication rate was of two-three percent each of proximal DVT, scar sensitivity, superficial wound infection and no re-rupture after a minimum of 6 months. There was no case of nerve injury leading to permanent neurological deficit. Discussion. This study demonstrates good clinical and functional outcomes from using the Achillon device in repair of ruptured Achilles tendon with a low complication rate comparable to other published series. We recommend Achillon device as a safe minimally invasive technique for repair of the ruptured Achilles tendon

Introduction. Metal on metal hip resurfacing (MMHR) has been advocated for the younger patient for several reasons including for the preservation of bone stock and ease of revision to total hip replacement (THR), thus ‘buying an additional operation’ for the patient. This rationale however assumes a good functional outcome after the revision to a THR and that the results of the ‘revision primary’ will not be compromised by the resurfacing which preceded it. We present our data on a consecutive series of 68 revised MMHRs. Methods. Between September 1997 and September 2009, 927 consecutive patients underwent a hip resurfacing procedure performed by one of three senior surgeons at our institution. The Cormet resurfacing system was used for all patients. Sixty-eight of these patients had their resurfacing revised. Oxford hip score (OHS) obtained at a minimum of 12 months follow-up was used as the primary outcome measure. Results. Average age at time of index procedure was 51.9 (24 to 68) years. The MMHRs were revised an average of 49 (1 to 121) months after index procedure. At time of writing OHS post revision was 21.4 (range 12 to 48) at an average of 42 months post revision (range 16 to 111 months). Patients with a primary diagnosis of dysplasia were at an increased risk of revision RR 3.7 (1.9–7.1, p < 0.05).). No other primary diagnosis significantly increased risk of revision. Five patients underwent a second revision procedure. Discussion. We present the fuctional outcome scores of a large series of revised MMHRs. Despite MMHRs offering the advantage of preservation of bone stock we have found revision of MMHRs to THRs technically difficult. Our functional outcome scores in patients post revision were disappointing. We cannot support the concept that MMHR “buys patients another operation”

Computer assisted total knee arthroplasty helps in accurate and reproducible implant positioning, bony alignment, and soft-tissue balancing which are important for the success of the procedure. In TKR, there are two surgical techniques one is measured resection in which bony landmarks are used to guide the bone cuts and the other is gap balancing which equal collateral ligament tension in flexion and extension is done before and as a guide to final bone cuts. Both these procedures have their own advantages and disadvantages. We retrospectively collected the data of 128 consecutive patients who underwent computer-assisted primary TKA using either a gap-balancing technique or measured resection technique. All the operations were performed by a single surgeon using computer navigation system available during a period between June 2016 to October 2016. Inclusion criteria were all patients requiring a primary TKA, male or female patients, and who have given informed consent for participation in the study. All patients requiring revision surgery of a previous implanted TKA or affected by active infection or malignancy, who presented hip ankylosis or arthrodesis, neurological deficit or bone loss or necessity of more constrained implants were excluded from the study. Two groups measured resection and gap balancing was randomly selected. At 1-year follow-up, patients were assessed by a single orthopaedic registrar blinded to the type of surgery using the Knee Society score (KSS) and functional Knee Society score (FKSS). Outcomes of the 2 groups were compared using the paired t test. All the obtained data were analysed. Statistical analysis was performed using SPSS 11.5 statistical software (SPSS Inc. Chicago). Inter-class correlation coefficient (ICC) and paired t-test were used and statistical significance was set at P = 0.05. In the measured resection group, the mean FKSS increased from 48.8769 (SD, 2.3576), to 88.5692 (SD, 2.7178) respectively. In the gap balancing group, the respective scores increased from 48.9333 (SD, 3.6577) to 89.2133(SD, 7.377). Preoperative and Postoperative increases in the respective scores were slightly better with the gap balancing technique; the respective p values were 0.8493 and 0.1045. The primary goal of TKA is restoration of mechanical axis and soft-tissue balance. Improper restoration leads to poor functional outcome and premature prosthesis loosening. Computer navigation enables precise femoral and tibial cuts and controlled soft-tissue release. Well balanced and well aligned knee is important for good results. Mechanical alignment and soft-tissue balance are interlinked and corrected by soft tissue releases and precise proximal tibial and distal femoral cuts. The 2 common techniques used are measured resection and gap balancing techniques. In our study, knee scores of the 2 groups at 1-year follow-up were compared, as most of the improvement occurs within one year, with very little subsequent improvement. Some surgeons favour gap balancing technique, as it provides more consistent soft-tissue tension in TKA

Background: Revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip (DDH) can be a challenging and technically demanding procedure. Two of the major concerns are deficient acetabular bone stock and the position of the acetabular implant, particularly if the hip centre was not restored during the primary procedure. The purpose of this study was to determine if cup height, lateralization or abduction angle are correlated with functional outcome or survivorship in revision total hip replacement (THR) in patients with a previous diagnosis of DDH. Methods: A retrospective investigation of 51 sequential patients (63 hips) previously diagnosed with DDH who underwent revision THR at our center between 1984 and 2000 was performed. The mean duration of follow up was 119 months (range 36 to 238 months). Forty-one patients (52 hips) were available for functional outcome and survivorship analysis. The remaining ten patients (11 hips) were available only for survivorship analysis. Three independent variables identified apriori as possible correlates were cup height, lateralization and angle as measured on the AP radiographs. Functional outcome measurement consisted of the Harris Hip, SF36 and WOMAC questionnaires. Linear regression analysis and Kaplan-Meier curves were used to determine if any of the variables correlated with functional outcome or survivorship. Results: Cup height was found to have a statistically significant (p< 0.05) correlation with Harris Hip, SF36, and WOMAC functional scores. High hip centers correlated with worse scores. In addition, patients with hip centers less than 3.5 cm above the radiographic tear drop had a statistically significant improvement in cup survivorship compared to those with higher hip centers. Conclusion: Restoration of hip center height to as close to the radiographic teardrop as possible improves functional outcome and cup survivorship

Aim. Advocates of Debridement-Antibiotics-and-Implant-Retention (DAIR) in hip peri-prosthetic joint infection (PJI) argue that a procedure not disturbing a sound prosthesis-bone interface is likely to lead to better survival and functional outcome compared to revision. However, no evidence supports this. This case-control study's aims were to compare outcome of DAIRs for infected 1° total hip arthroplasty (THA) with outcomes following 1° THA and 2-stage revisions of infected 1° THAs. Method. We retrospectively reviewed all DAIRs, performed for confirmed infected 1° THR (DAIR-Group, n=80), in our unit between 1997–2013. Data recorded included patient demographics, medical history, type of surgery and organism identified. Outcome measures included complications, mortality, implant survivorship and functional outcome using the Oxford Hip Score (OHS). Outcome was compared with 2 control groups matched for gender and age; a cohort of 1° THA (1°-THA-Group, n=120) and a cohort of 2-stage revisions for infection (2-Stage-Revision-Group, n=66). Results. The mean age at DAIR was 69 years and mean follow-up was 8 years (SD:5). 60% of DAIRs were for early PJI (< six weeks). Greater infection eradication with DAIR was detected with early-PJI, interval less than a week between onset of symptoms and exchange of modular components with the DAIR procedure. Infection eradication, complications and re-operation rates were similar in the DAIR- and 2-stage-revision Groups (p>0.05). For hips with successful infection eradication with DAIR, the 5-yr survival (98%) was similar to the 1°THA-Group (98%) (p=0.3). The DAIR-Group had inferior OHS (38) compared to the 1°THA-Group (42) (p=0.02) but significantly better OHS compared to the 2-stage-revision-Group (31) (p=0.008). Patients that required only one DAIR for infection eradication had similar OHS (41) to the 1° THA-Group (p=0.2). Conclusions. DAIRs are associated with similar complication and infection eradication to 2-stage revisions. Exchange of modular components is advised for improved chances of infection eradication. Functional outcome following DAIRs was better than a 2-stage revision and as good as that of a 1° THA if a single DAIR was necessary for infection eradication

Purpose. Although classic teaching holds that the least amount of constraint should be implanted, there is very little in the literature to substantiate this. This study attempts to quantify the influence of constraint and various indications upon functional outcome following aseptic first time revision knee arthroplasty. The null hypothesis was that the level of constraint and indication for surgery would not influence the functional outcome following revision knee replacement. Methods. A single centre prospective study was performed to examine the outcome for 175 consecutive total revision knee replacements performed between 2003 and 2008 with a minimum follow-up of two years. Patient reported outcome data was used to determine the influence of final level of component constraint and its relationship with primary indication for surgery. Results. All patients were found to have a significant improvement for WOMAC pain, function and stiffness score (p< 0.001) and physical functioning, role physical, bodily pain and social functioning components of SF-36 score (p< 0.05). 69% were satisfied with the overall procedure. WOMAC function, pain and stiffness score was significantly worse for patients revised for instability (27%) compared to that for aseptic loosening (46%). A significantly higher proportion of patients were satisfied with the procedure (p< 0.001), had a better quality of life (p=0.004) and would have the surgery (p=0.005) again in the aseptic loosening group as compared to the instability group. Revision to a higher level of constraint did not improve knee function irrespective of the primary indication for surgery. Conclusion. Revision for an instability pattern irrespective of choice of new device was met with significantly poorer functional outcome

Background:. Modified posterior approach and its effect on stability and functional outcome in total hip arthroplasty. Material & Methods:. A retrospective comparative evaluation was done to assess the functional outcome and rate of dislocation in 233 hips (Group A) operated before 2007 by convention posterior approach and 567 hips (Group B) were operated by modified posterior approach.(2007–2011) In this modified posterior approach technique, 2–3 stay sutures (non-absorbale Nylon) are applied in the piriformis tendon, short external rotator and proximal part of Quadratous muscle. Then a conjoint- myocapsular sleeve is raised by starting cutting (with cautery) linearly over the capsule with adherent fibers of gluteus minimus to piriformis tendon, short rotators and part of quadratus to expose and dislocate the head. After inserting the definite prosthesis, upper part of sleeve (capsule, piriformis tendon) is sutured with same nonabsorbable Nylon at the lower part of tip of greater trochanter by passing through the bone with needle or by drilling the bone; lower part of the sleeve is tied with lateral trochanteric bone. Additional stability to repair was given by closing the tendinous part of the gluteus maximus by horizontal cross mattress sutures up its attachment to the proximal femoral shaft. Results:. All patients underwent cementless total hip arthroplasty; average Harris hip score at minimum 3.1 yr follow was 88.7 in Group B & 85.2 in Group B. Group B had only one dislocation while Group A had 12 dislocations (5%). Conclusion:. This technique provide enhanced stability and improve functional outcome

The purpose of this study was to evaluate functional outcome following supracondylar femur fractures using patient-based outcome measures. Patients having sustained supracondylar femur fractures between 1990 and 2004 were identified from the fracture databases of two level-one trauma centres. Three patient-based outcome measures, the Short Form-36 (SF-36) Version two, the Short Musculoskeletal Functional Scale (SMFA), and the Lower Extremity Functional Scale (LEFS) were used to evaluate functional outcome. Each patient’s medical record was also reviewed to obtain information regarding potential predictors of outcome, including age, gender, fracture type (AO classification), presence of comorbidities, smoking status, open vs. closed fracture, and occurrence of complications. Univariate and multivariate models were then used to identify significant predictors of outcome, as reflected in the SMFA bother and dysfunction scores. Sixty-one patients (thirty-five males and twenty-six females) with an average age (at time of injury) of 53 ± 18 years consented to participate. The average length of follow-up was 64 ± 34 months from the time of injury. Mean SF-36 V2 scores were lower than Canadian population norms indicating decreased function or greater pain, while mean SMFA scores were higher than published population norms indicating greater impairment and bother. The mean LEFS score was 40.78 ± 15.90 out of a maximum score of eighty. At the univariate level, the presence of complications was a significant predictor of both the SMFA bother (p=0.002) and dysfunction scores (p=0.015), while positive smoking status was a significant predictor of the bother score (p=0.002). Based on a multivariate linear regression model, the presence of complications (p=0.013) and positive smoking status (p=0.011) were both significant predictors of a higher SMFA bother score. In the multivariate model for SMFA dysfunction score, the presence of complications (p=0.014) and the presence of comorbidities (p=0.017) were significant predictors of a higher score. Comparing SF-36 and SMFA scores with published population norms, supracondylar femur fractures were associated with residual impact. Based on our analysis, smoking, the presence of medical comorbidities at the time of fracture, and the occurrence of complications following fracture repair were the main predictors of poorer patient outcomes following supracondylar femur fracture

Purpose: Patello-femoral arthritis presents a considerable challenge to the orthopaedic surgeon. Traditionally, surgical options have produced unsatifactory results. Arthroscopic debridement, patellectomy, isolated patellar resurfacing and grafting have a poor long term clinical outcome. Patello-femoral arthroplasty is an alternative to total knee arthroplasty and patellectomy for anterior compartment osteoarthritis. Patello-femoral arthroplasty provides a more conservative approach in younger and more active patients especially. Advances in component design and biomechanics have led to many new generation replacements. The aim of this study was to look at the long term functional outcome of patello-femoral arthroplasty. Methods: From a prospective database 36 patients were identified having a patello-femoral arthroplasty between 1990 – 2000. Four patients were lost to followup. Eighteen patients (56%) underwent an additional procedure for patella re-alignment (patella tendon transfer or lateral release) at the time of the patello-femoral arthroplasty. Mean followup was 72 months (range 24 – 149 mo). Clinical data was collected from a personal questionnaire and physical examination. All data was processed and all patients were evaluated using the Hungerford-Kenna score and the modified Lysholm score. Radiographs were assessed pre-operatively and at the most recent follow up. Peri-operative documentation was evaluated for etiology, pre-operative functional and subjective impairment, intra-operative technical difficulties or complications, early and late post-operative complications and post-operative functional outcomes. Results: At the time of the most recent follow up, 22 knees had good or excellent result, 4 had fair result and 4 had a poor result. The remaining 2 knees were revised to a total knee arthrplasty due to progression of osteoarthritis. No loosening of the components was observed. The mean Lysholm knee score improved from 35.4 (range 9–68) pre-operatively to 76.1(range 37–100) post-operatively and the mean Hungerford-Kenna knee score improved from 29.6(range 10–65) pre-operatively to 78.1(range 45–100) post-operatively. Conclusion: With proper patient selection, patello-femoral arthroplasty is a reliable procedure for the treatment of the patello-femoral arthritis. This procedure delays the need for further surgical procedures such as total knee arthroplasty with good results

Aims

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

Purpose. Identifying optimal treatment strategies for inpatients with traumatic foot and ankle injuries has been hampered by a wide variety of outcome measures with unproven reliability and validity. It remains plausible that the choice of functional outcome measures may influence measurement of treatment effects. This prospective observational study aims to measure the correlation and agreement across six functional outcome measures in patients with traumatic foot and ankle injuries. Methods. Patients 18 years of age or older with a traumatic foot or ankle injury completed the Short Form-12 (SF-12), Short Musculoskeletal Functional Assessment (SMFA), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Questionnaire and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale at a single follow-up visit. Raw scores were calculated and transformed to a functional level of excellent, very good, good, fair or poor. Pearson correlation co-efficients providing measures of correlation and agreement between functional levels were assessed. Results. Fifty-two patients were enrolled at a mean follow-up of 15.5 months. Moderate to strong correlations were found for most pair-wise comparisons of raw scores and functional levels (?=0.43-0.92, p< 0.002). The strongest correlations were found between the SMFA, FFI, FAAM and AAOS Foot and Ankle Questionnaire. Despite significant correlation between scores, considerable disagreement between functional levels was observed. None of the 52 subjects attained the same functional level on all 6 outcome measures. Conclusion. High correlations between scores and functional level suggest it is unnecessary to use more than one outcome measure when examining functional outcome in patients with foot and ankle trauma. However, inconsistencies between functional levels attained with the different instruments suggest a need for further validation and scrutiny

Aims

Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity).

Introduction: The literature regarding the functional outcome following C1–C2 surgeries for non-rheumatoid C1–C2 pathologies following selective arthrodesis is sparse. Aim: To determine the long term correlation between functional outcome and radiological determinants following C1–C2 fusion for conditions other than RA. Methods: All C1–C2 surgeris performed between 1988–2002 for non-RA etiologies were reviewed retrospectively. Selective C1–C2 fusion performed in 32 pts with a min f/u of 5 yrs formed the study group. The mean age at surgery was 57.2 yrs (r 22–84yrs). The etiologies were trauma (15), non-union (6), congenital AAD (2), C1–C2 deg. arthropathy (2), os odontoideum (2), tumours (4) and instability due to TB (1). Neurodeficit were present in 7 pts. Transarticular (TA) screws supplemented with posterior wiring was performed in 27 & posterior wiring alone in 5 pts respectively. A monocortical H-shaped autograft from iliac crest was used in all cases. There were two deaths & two pts were lost for F/U. The mean F/U was 7.8 yrs (r 5–13 yrs). Disability & pain using NDI & VAS and subjective satisfaction were recorded in all pts. We measured 1) C1/2 fixation angle, 2) Inclination of C1, 3) Anterior shift of C2 and 4) C2–7 lordosis on pre and final F/U lateral x-rays. Results: Optimal TA screw placement was seen in 78.5% of pts. The mean improvement in NDI & VAS were from 55.4% to 19.6% and 8.4 to 1.6 respectively and was better in younger pts. Fusion was seen radiologically in 82.1% of pts at 12 mo post surgery. Segmental stability and resolution of symptoms was seen in all patients despite implant failure in 4 and incomplete fusion 5 cases respectively. Two wound dehiscences needed debridement of which one elderly pt died of MRSA sepsis 2 mo post-op. The C1–C2 segmental lordosis was significantly increased by surgery (−4.2 0 vs. −11.80; P=0.016). The subaxial cervical spine became less lordotic in initial few months post-op but eventually regained more lordosis as time progressed. The C1 inclination came into more extended position w.r.t horizontal line post-op with minimal loss of inclination subsequently. C1–C2 fixation angle and anterior shift of C2 did not have significant correlation with long term functional outcome i.e. NDI and VAS (r=0.35, p=0.17). Conclusion: The functional outcome following C1–C2 arthrodesis is usually good despite metalwork issues and incomplete fusion in these selective group of non-rheumatoid arthritis pathologies

This study demonstrates that harvesting a vascularized fibular graft has a significant number of minor complications. These complications do not result in significant morbidity but could be avoided by other newer methods of managing bony defects and avascular necrosis such as porous bone substitute rods. The purpose of this study was to evaluate functional outcomes of the foot and ankle following vascularized fibula graft harvest, using validated outcome measures. This study agrees with previous reports in that minor complications are commonly associated with free fibula harvest. Functional outcome scores demonstrate significant differences in pain and disability; however, the disability associated with daily activities is small. This is the first study to assess the outcomes of vascularized fibular grafts with validated outcomes measures. It is one of a few studies to assess the outcomes of vascularized fibular grafts on an otherwise normal lower extremity. Twenty-two patients were available for study, with ten attending for examination. All had undergone free fibula transfer for mandibular reconstruction. Functional outcome was assessed using MODEMS (includes SF-36) and Foot Function Index (FFI). A radiographic analysis was performed. All patients had a normal contralateral foot and ankle which was used as a control. Mean follow-up is 3.1 years. Sixty percent of patients were satisfied following surgery. Subjective complaints of weakness, instability and numbness were reported. Minor wound complications were seen in twenty-three percent of patients and clawing of the lesser toes in eighteen percent. No significant difference was seen in the SF-36 categories when compared to population norms. The FFI identified significant differences in Pain and Disability means when compared to the contralateral side. Radiographic analysis failed to demonstrate increased arthritic change or instability. Two patients had undergone further surgery for toe clawing and persistent ankle pain

Background. The position of the hip-joint centre of rotation (HJC) within the pelvis is known to influence functional outcome of total hip replacement (THR). Superior, lateral and posterior relocations of the HJC from anatomical position have been shown to be associated with greater joint reaction forces and a higher incidence of aseptic loosening. In biomechanical models, the maximum force, moment-generating capacity and the range of motion of the major hip muscle groups have been shown to be sensitive to HJC displacement. This clinical study investigated the effect of HJC displacement and acetabular cup inclination angle on functional performance in patients undergoing primary THR. Methods. Retrospective study of primary THR patients at the RNOH. HJC displacement from anatomical position in horizontal and vertical planes was measured relative to radiological landmarks using post-operative, calibrated, anterior-posterior pelvic radiographs. Acetabular cup inclination angle was measured relative to the inter-teardrop line. Maximum range of passive hip flexion, abduction, adduction, external and internal rotation were measured in clinic. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires. Data analysed using a linear regression model. Results. 109 THRs were studied in 104 patients (69 Female). Mean age at THR=63 years (22-88). Mean follow-up=17 months (11-39 months). Median OHS=16, WOMAC=8. Increasing vertical HJC displacement (in either superior or inferior direction) from anatomical position was associated with worsening OHS (p<0.05) and WOMAC scores (p<0.05) and a reduced range of passive hip flexion (p<0.05). No relationship was found between either horizontal HJC displacement or acetabular cup inclination angle and patient functional outcome. Conclusion. A significant relationship was identified between increasing vertical displacement of the HJC and worsening patient functional outcome. This supports current opinion regarding the disadvantageous consequences of a superiorly displaced HJC in terms of survivorship and function. We therefore advocate an anatomical restoration of HJC position wherever possible