Aims. The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m. 2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results. In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m. 2. (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion. SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691

Aims. Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent function is quite variable. Some patients require greater time and rehabilitation than others. To determine if psoas muscle recovery is associated with changes in ambulatory function, we retrospectively evaluated psoas muscle size and limb-length discrepancy (LLD) before and after treatment and their correlation with objective functional outcomes. Methods. T1-weighted MR images were evaluated at three intervals for 12 pelvic sarcoma patients following interval hemipelvectomy without reconstruction. Correlations between the measured changes and improvements in Timed Up and Go test (TUG) and gait speed outcomes were assessed both independently and using a stepwise multivariate regression model. Results. Increased ipsilesional psoas muscle size from three months postoperatively to latest follow-up was positively correlated with gait speed improvement (r = 0.66). LLD at three months postoperatively was negatively correlated with both TUG (r = -0.71) and gait speed (r = -0.61). Conclusion. This study suggests that psoas muscle strengthening and minimizing initial LLD will achieve the greatest improvements in ambulatory function. LLD and change in hip musculature remain substantial prognostic factors for achieving the best clinical outcomes after internal hemipelvectomy. Changes in psoas size were correlated with the amount of functional improvement. Several patients in this study did not return to their preoperative ipsilateral psoas size, indicating that monitoring changes in psoas size could be a beneficial rehabilitation strategy. Cite this article: Bone Joint J 2023;105-B(3):323–330

Background. Knee osteoarthritis (OA) is a major cause of ambulatory disabilities. Although total knee arthroplasty (TKA) has been reported as the most effective treatment for severe knee OA, quantitative evaluation of ambulatory function have not been well investigated. We hypothesized that better functional recovery would result in better patient satisfaction. The purpose of this study was to quantitatively evaluate ambulatory functional recovery and assess the influence on patient satisfaction after TKA. Material and Methods. 90 patients (80 females and 10 males) were involved in this study. The mean age at TKA was 75.2 ± 5.8 years. Patients were subjected to 3 meters timed up and go test (TUG) to evaluate ambulatory function. TUG was performed at 6 time periods; before surgery, 2 weeks, 1, 3, 6 months, and 1 year after surgery. We also asked the patients to fill out the questionnaire of patient satisfaction category in the New Knee Society Score at 1 year after TKA. The sequential changes in TUG were analyzed using repeated measures ANOVA (p<0.05). The influences of each parameter (age, TUGs) on the patient satisfaction score were analyzed with simple regression analysis (p<0.05). Results. The mean TUGs were 12.2, 16.7, 13.3, 11.1, 10.7, 10.4 seconds at before surgery, 2 weeks, 1, 3, 6 months, and 1 year after surgery respectively. TUG time significantly increased at 2 weeks after TKA and decreased afterward until 3 months. We found TUG significantly decreased at 3 months comparing to preoperative measurement. No significant changes in TUG were found from 3 months to 1 year after TKA. The mean patient satisfaction score was 29.2 ± 6.3 (12–40) points. There was a significant negative correlation between age and satisfaction. Patient satisfaction was negatively correlated to preoperative TUG and TUG at 1 year. Discussion. In this study, we evaluated sequential changes of ambulatory function in detail using TUG test during 1 year after TKA. Ambulatory function significantly deteriorated at 2 weeks, followed by gradual improvement and reached to significantly better level at 3 months after TKA comparing to preoperative level. We also found that the patient satisfaction was affected equally by both preoperative and 1 year postoperative TUG time. Although our patients' age was relatively elder than in the major literature, significant improvement in ambulatory function was observed as short as 3 months. This is shorter than previous reports. We provided a rehabilitation program in hospital for 3 weeks after TKA. This would be beneficial for early ambulatory functional recovery even with elder patients. The ambulatory function generally deteriorates as patients get old. Therefore TKA should be considered before patients get too old. Conclusion. Ambulatory function significantly improved at 3 months after TKA, and no more improvement was found afterward. The younger age and better preoperative ambulatory function would be beneficial for the patient satisfaction after TKA in elderly population

Introduction. As the aging society progresses rapidly, the number of patients underwent total knee arthroplasty (TKA) is increasing especially for the elderly population. In Japan, the average age for TKA is around 75 years old. Japanese Orthopaedic Association indicated a new clinical entity of musculoskeletal ambulation disability symptom complex (MADS) to define the higher risk of fall and ambulatory disability in the elderly population in 2006. The diagnosing criteria for MADS consists of 2 simple performance tests. 3m timed up and go test (TUG) evaluates ambulatory function, and one leg standing time (ST) assesses balancing ability. Objective. In this study, we analyzed the effect of TKA on the ambulatory function by quantitative measurement using 2 simple performances test: TUG and ST. Materials & Methods. Forty four patients (6 males and 38 females) with varus type osteoarthritic knees underwent TKA were involved. The mean age of surgery was 72.7 years old. TUG and ST were performed at 4 time periods; pre-operatively, 2 weeks after surgery, at hospital discharge (average 24.1 days) and 1year after surgery. Ambulatory disability (MADS) was diagnosed if TUG was not less than 11 seconds and/or ST was less than 15 seconds. 36 patients (82%) were diagnosed to MADS preoperatively. We divided these 36 patients into two groups depending on the performance tests one year after TKA. 24 patients (67%) still suffered from MADS (Group1), and remaining 12 patients (33%) recovered from MADS (Group2). We compared preoperative factors (age, femoro-tibial angle, ROM, etc.) and the results of ST and TUG between Group 1 and Group 2 using the Mann-Whitney test (p<0.05). Results. The complication rates of MADS in all 44 patients were 82.0, 88.9, 83.3, and 55.6% at 4 time periods respectively. Significant functional recoveries were observed with decrease of TUG and increase of ST at 1 year after surgery (Fig. 1). Average age at surgery was significantly higher in Group 1 (74.7yo) comparing to Group 2 (69.3yo). The sequential change of mean TUG and ST at 4 time periods were shown for each group in Fig. 2 and Fig. 3. We found no significant difference in TUG but significant difference in ST between two groups. Patient in Group 2 could stand on one leg longer than Group 1 preoperatively even with no significant difference in TUG. Discussions. We evaluated the ambulatory function using 2 simple performance tests, and found significant improvements in both balancing ability (ST) and ambulatory function (TUG) one year after TKA. However, more than 50% of our patient population still suffered from ambulatory disability (MADS) at 1 year after surgery. As much as 70% of preoperatively MADS complicated patients were found to meet MADS criteria even one year after TKA. Only 30% of preoperatively MADS complicated patient could recover from MADS. This group was relatively younger and showed better balancing ability preoperatively. Our results suggested that standing time measurement would be simple and useful predictor for the functional recovery after TKA

To assess long and short term kinematic gait outcomes after rectus femoris transfers (RFT) in ambulatory children with cerebral palsy (CP). A retrospective review was conducted of ambulatory children with spastic diplegic CP, who had RFT plus motion analysis preoperatively and 1 year post-operatively. Those with 5 and 10 year post-operative motion analysis were also included. The primary variables were: peak knee flexion range of motion in swing (PKFSW), timing of peak knee flexion in swing as a percent of the gait cycle (PKF%GC), and knee range of motion from peak to terminal swing (KROM). Responders and non-responders were identified. Descriptive, kinematic and kinetic variables were evaluated as predictors of response. 119 ambulatory children (237 limbs) with spastic diplegic CP who had RFT were included. Mean age at surgery was 10.2 years (range 5.5 to 17.5). Sixty-seven participants were classified at GMFCS Level II and 52 at GMFCS Level III. All participants (237 limbs) had a preoperative and 1 year postoperative motion analysis. Motion analysis at 5 and 10 years post-operatively included 82 limbs and 28 limbs, respectively. Ninety-three (39%) limbs improved in both PKFSW and PKF%GC. PKFSW improved in 59% of limbs. Responders started 1.2 SD below the mean PKFSW preoperatively, and improved by an average of 1.9 SD to reach a normal range at 1 year post-operatively (p < 0.05). Improvement was maintained at 5 and 10 years postoperatively. Those at GMFCS level II were more likely [OR 1.71, CI 1.02, 2.89] to have improved PKFSW at 1 year postoperatively than those at GMFCS level III. PKF%GC improved in 70% of limbs. Responders had delayed PKF%GC, starting 10 SD above the mean (later in the gait cycle) preoperatively. Their timing improved towards normal values: 5 SD, 5.9 SD, 3.5 SD from the mean, (earlier in the gait cycle) at 1, 5 and 10 years postoperatively, respectively (p<0.05). KROM improved in only 24% of limbs. For all variables, there was a significant difference in mean preoperative values between responders and non-responders (p<0.05). RFT improves short and long-term kinematic gait outcomes. The majority of children responded to RFT with improvements in PKFSW or PKF%GC at 1, 5, and 10 years post RFT. GMFCS level is a predictor of improved PKFSW, with children at GMFCS Level II having an increased likelihood of improvement at 1 year post surgery. Children who have worse preoperative values of PKFSW, PKF%GC, and KROM have a greater potential for benefit from RFT. Characteristics associated with responders who maintain long term positive outcomes need to be identified

Background. In recent literatures, medial instability after TKA was reported to deteriorate early postoperative pain relief and have negative effects on functional outcome. Furthermore, lateral laxity of the knee is physiological, necessary for medial pivot knee kinematics, and important for postoperative knee flexion angle after cruciate-retaining total knee arthroplasty (CR-TKA). However, the influences of knee stability and laxity on postoperative patient satisfaction after CR-TKA are not clearly described. We hypothesized that postoperative knee stability and ligament balance affected patient satisfaction after CR-TKA. In this study, we investigated the effect of early postoperative ligament balance at extension on one-year postoperative patient satisfaction and ambulatory function in CR-TKAs. Materials & Methods. Sixty patients with varus osteoarthritis (OA) of the knee underwent CR-TKAs were included in this study. The mean age was 73.6 years old. Preoperative average varus deformity (HKA angle) was 12.5 degrees with long leg standing radiographs. The knee stability and laxity at extension were assessed by stress radiographies; varus-valgus stress X-ray at one-month after operation. We measured joint separation distance (mm) at medial compartment with valgus stress as medial joint opening (MJO), and distance at lateral compartment with varus stress as lateral joint opening (LJO) at knee extension position. To analyze ligament balance; relative lateral laxity comparing to the medial, varus angle was calculated. New Knee Society Score (NKSS) was used to evaluate the patient satisfaction at one-year after TKA. We measured basic ambulatory functions using 3m timed up and go test (TUG) at one-year after surgery. The influences of stability and laxity parameters (MJO, LJO and varus angle at extension) on one-year patient satisfaction and ambulatory function (TUG) was analyzed using single linear regression analysis (p<0.01). Results. MJOs at knee extension one-month after TKA negatively correlated to patient satisfaction (r=−0.37, p<0.01) and positively correlated to TUG time (r=0.38, p<0.01). LJOs at knee extension had no statistically significant correlations to patient satisfaction and TUG. The extension varus angle had significant positive correlation with patient satisfaction (r=0.40, p<0.01). Discussions. In our study, we have found significant correlations of the early postoperative MJOs at extension to postoperative patient satisfaction and TUG one-year after CR-TKA. Our results suggested that early postoperative medial knee stabilities at extension were important for one-year postoperative patient satisfaction and ambulatory function in CR-TKA. Other interest finding was that postoperative patient satisfaction was positively correlated with extension varus angle. This finding suggested that varus ligament balance; relative lateral laxity to medial stability, was beneficial for postoperative patient satisfaction after CR-TKA. Intra-operative soft tissue balance had been reported to significantly affect postoperative knee stabilities. Therefore, with our findings, surgeons might be better to manage intra-operative soft tissue balance to preserve medial stability at extension with permitting lateral laxity, which would enhance patient satisfaction and ambulatory function after CR-TKA for varus type OA knee. Conclusion. Early postoperative medial knee stability and relative lateral laxity would be beneficial for patient satisfaction and function after CR-TKA

[Introduction]. Rapid increase of aged population has been one of major issue affecting national health care plan in Japan. In 2006, Japanese Orthopaedic Association indicated a new clinical entity of musculoskeletal ambulation disorder symptom complex (MADS) to define the higher risk of fall and ambulatory disability in the elderly population caused by musculoskeletal disorders. Osteoarthritis of the knee is one of major cause of MADS. The number of patients with MADS underwent total knee arthroplasty (TKA) had been increased in Japan, and also expected to increase worldwide in the near future. The effectiveness of TKA for the patient with MADS would be a key issue for the patient satisfaction in TKA. In the present study, we analyzed the influence of pre-operative factors on the ambulatory functions in the patients of primary TKA. [Material & Method]. 132 patients with osteoarthritic knees implanted with posterior-stabilized (PS) TKAs were subjected to this study. There were 113 female and 19 male patients. The mean age of the patients was 73.6 years (range, 59 to 87 years). Patients were pre-operatively subjected to 2 functional performance tests which were essential tests for MADS diagnosis. Firstly, 3 meter timed up and go test (TUG) was used to evaluate ambulation ability. Secondary one leg standing time (ST) with open eyes was measured with both operated and non-operated leg to assess balancing ability. MADS was diagnosed if TUG and ST were not less than 11 seconds and/or less than 15 seconds respectively. The influence of each pre-operative factor was evaluated simple linear regression analysis (p < 0.05). Pre-operative factors consisted of age, sex, weight, height, BMI, standing femoro-tibial angle (FTA) and active knee range of motion. [Results]. Pre-operatively, 74% of the patients was diagnosed as MADS, with the results of 64, 74 and 64% of the patient matched to the MADS criteria with the evaluation of TUG and ST with operated and non-operated leg respectively (Fig 1). Firstly, pre-operative TUG was found to be negatively correlated to the weight (R = −0.25), ST with non-operated leg (R = −0.24) and active knee flexion angle (R = −0.28, Fig 2). Secondary, ST with operated leg was significantly affected by age (R = −0.32), standing FTA (R = −0.38) and ST with non-operated leg (R = 0.66, Fig 3). [Discussion & Conclusion]. As much as 74% of our patients was suffered from MADS before primary TKA. Majority of patient had both ambulatory and balancing disability with higher risk of fall and ambulatory dysfunction. We found ST with non-operated leg significantly affected both TUG representing ambulatory function and ST representing balancing function. This means the contra-lateral lower extremity function would play an important role on the pre-operative functional ability in the patient of TKA. Furthermore, we found pre-operatively that active knee flexion influenced ambulatory function, and coronal knee deformity deteriorated balancing ability. Then we should evaluate these pre-operative factors in analyzing the effectiveness of TKA on the functional recovery in the elderly patient underwent primary TKA

Objective. As the aging society progresses rapidly in Japan, the number of elderly patients underwent TKA is increasing. These elderly patients do not expect to do sports, but regain independency in the activity of daily living. Therefore, we measured basic ambulatory function quantitatively using 3m timed up and go (TUG) test. We clinically experienced patient with medially unstable knee after TKA was more likely to result in the unsatisfactory outcome. We hypothesized that post-operative knee stability influenced ambulatory function recovery after TKA. In this study, we evaluated ambulatory function and knee stability quantitatively, and analyzed the effect of knee stability on the ambulatory function recovery after TKA. Materials & Methods. Seventy nine patients with varus type osteoarthritic knees underwent TKA were subjected to this study. The mean age of surgery was 72.4 years old. Preoperative standing coronal deformity was 9.6 degrees in varus. TUG test results in less duration with faster ambulatory function. TUG (seconds) was measured at 3 time periods; pre-operatively, at hospital discharge and 1year after surgery. To standardize TUG recovery time during 1 year after TKA, we defined TUG recovery rate as the percentage of recovery time to the pre-operative TUG as shown in the following equation. TUG recovery rate (%) = (TUG pre-op –TUG 1y po) / TUG pre-op ×100. We also evaluated the knee stability at hospital discharge and 1year after surgery. The knee stability at extension and flexion were assessed by varus and valgus stress radiography using Telos (10kg) and stress epicondylar view with 1.5kg weight at the ankle respectively. Image analyzing software was used to measure joint separation distance (mm) at medial as medial joint opening (MJO) and at lateral as lateral joint opening (LJO) at both knee extension and flexion. (Fig.1). The sequential change of TUG was analyzed using repeated measures ANOVA (p<0.05). The influence of joint opening distances (MJO and LJO at extension and flexion) on TUG 1y po and TUG recovery rate were analyzed using simple linear regression analysis (p<0.05). Results. The mean TUGs were 13.4, 13.7 and 10.8 seconds pre-operatively, at hospital discharge and 1 year after TKA respectively. Significant decrease was found at 1 year after surgery. TUG pre-op did not show significant correlation to any joint openings. TUG 1y po was positively correlated with both flexion and extension MJO at hospital discharge. (Fig.2) TUG recovery rate negatively correlated to flexion-MJO at hospital discharge. (Fig.3). Discussions. The most interesting findings in the present study were that both flexion and extension MJO at hospital discharge were positively correlated with TUG 1y po and negatively correlated with TUG recovery rate. This indicated that early post-operative medial stability played an important role in the recovery of ambulatory function. The early post-operative medial instability would cause pain and deteriorate functional recovery after surgery. There is some disagreement regarding the importance of pursuing the perfect ligament balance, which would be more likely to result in medial instability. Consequently, surgeons should prioritize medial stability for better ambulatory functional recovery after TKA

Purpose: Patients hospitalized for osteomyelitis due to multi-resistant strains are often given prolonged parenteral antibiotics. Ambulatory parenteral antibiotic therapy is an alternative allowing outpatient care. The purpose of this study is to assess tolerance, cost and efficacy of this type of treatment. Material and methods: Thirty-nine patients followed for osteomyelitis were included in this study. These patients were given antibiotics in a continuous infusion using a portable diffuser connected to an implanted chamber. Mean duration of treatment was four months, range 1.5–12 months. The follow-up team included the primary care physician, an infectious diseases specialist, and a nurse with special training in prolonged ambulatory antibiotic treatments. Results of weekly blood tests were transmitted to the referral hospital physician. Adverse effects and cost of prolonged ambulatory antibiotic therapy were recorded. Cost included costs for nurses, physical therapists, and physicians as well as drugs, supplies and laboratory tests. The cost of hospitalisation was determined on the basis of the standard cost for one day of hospitalisation in France. Results: There were three cases of thrombophlebitis and one case of allergic reaction, both required re-hospitalisation. Cure was achieved in 93% of the patients. Mean follow-up since cure with discontinuation of the antibiotics was 18 months (14–22). Home care was possible in 100% of the patients and 23% of the patients were able to resume their occupational activity; 25% resumed their schooling. Self-administered schemes were possible in 23% of the patients. Compared with conventional hospitalisation, ambulatory parenteral antibiotic therapy enabled a cost savings of 1352 euros per patient. Discussion: These results demonstrate that ambulatory antibiotic therapy is a very good alternative to classical hospitalisation enabling low morbidity, early resumption of social activities without loss of efficacy

Objective: To evaluate the effect of spinal fusion from T1, T2 to the sacrum with pelvic fixation using unit rod instrumentation on the ambulatory potential of pediatric patients with cerebral palsy. Study Design: A retrospective study of 24 ambulatory pediatric patients with spastic cerebral palsy and neuromuscular scoliosis was performed. Summary of Background Data: Spinal deformities, occurring in patients with cerebral palsy and good ambulatory capacity, are infrequently associated with pelvic obliquity, and so instrumented spinal fusions traditionally do not extend to the pelvis. Methods: The medical charts and radiographs were reviewed, and the patients’ ambulatory ability was assessed clinically, with video tape or complete gait analysis. A questionnaire assessing patients` functional improvement was given to the caretakers. Results: The study group included 17 female and 7 male patients, 19 quadriplegics and 5 diplegics. Follow-up evaluations for ambulatory function occurred at a mean of 2.86 years after surgery. Mean age at surgery was 15.4 years. Twenty patients underwent posterior spinal fusions and 4 patients combined anterior-posterior procedures. The patients were evaluated clinically pre-operatively, postoperatively and at follow-up with no alteration in their ambulatory status, except one patient who developed bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Thirteen patients had both preoperative and postoperative gait analysis, showing no change in their ambulatory function. The surgical outcome survey demonstrated significant improvement in the child’s physical appearance, head and trunk balance, sitting ability, amount of back pain, respiration, and no change in ambulatory capacity. Conclusions: Spine surgery with fusion extending to the pelvis in ambulatory patients with cerebral palsy provided excellent deformity correction and preserved their ambulatory function

The aim of this study was to assess the use of early ambulatory halo-thoracic immobilisation in paediatric patients with spinal instability. The case notes, radiographs and clinical findings at follow-up of 12 patients treated this way were reviewed. The mean age was 8.6 years (4 to 16). The aetiology was trauma in six, os odontoidium in one, tuberculosis in three, and Morquios syndrome and chronic granulomatous osteitis in one each. The instabilities were atlanto-axial rotatory subluxation in one patient, transverse ligament rupture in six, dens anomalies in two, anterior destruction by tuberculosis in two, and a dens fracture. The halo jackets were applied under general anaesthetic. In addition, posterior C1/2 fusions were performed in seven patients, posterior occipitocervical decompression and fusions in two, and posterolateral thoracotomies in two. No surgery was done on the patient with the dens fracture. Autograft was used in all cases except one posterior C1/2 fusion. This patient, who was HIV-positive, was the only one in whom union did not occur. There was one case of minor pin-tract sepsis. All patients mobilised in the halo jacket and, where possible, were managed as outpatients. Despite radiological nonunion in one patient, spinal stability was achieved in all. Early ambulatory halo jacket immobilisation is a useful, safe and well-tolerated technique in the paediatric patient group

INTRODUCTION. Clinical trials have generally failed to demonstrate superior clinical effectiveness of minimally invasive surgical approaches for total knee arthroplasty (TKA). The hypothesis of the current study was that avoiding incision of the quadriceps tendon would result in a significantly faster recovery of ambulatory function after total knee arthroplasty, compared to a technique that incised the quadriceps tendon. METHODOLOGY. The MIKRO (Minimally Invasive Knee Replacement Outcomes) Study is a prospective, level 1 RCT that enrolled 128 patients with knee osteoarthritis who had failed non-operative treatment, and had decided to proceed with TKA. After skin incision, 64 patients each were randomized to either a subvastus (SV) or medial parapatellar arthrotomy (MPPA) approach. All surgeries were done with the same TKA implant, with anesthesia, post-operative analgesia, and physical therapy standardized for both groups. A Patient Diary methodology was used as the primary outcome measure for ambulatory function. During the first 8 weeks after TKA, a research assistant blinded to treatment assignment telephoned each patient and completed study forms that documented indoor and outdoor walking relative to use of ambulatory devices, as well as Knee Society Score (KSS) and the UCLA activity scale. The UCLA score and change in KSS from baseline at 4- and 12-week follow-up were used to begin the validation process for an Ambulatory Function Score (AFS) derived from diary indoor and outdoor scores. RESULTS. There was a trend for the SV group to report more independent ambulation than the MPPA group at week 1 after surgery, as indicated by self-reported AFS (p < .052). Both treatment groups demonstrated significant week to week AFS gains through 5 weeks, after which weekly changes were minimal. As expected, outdoor AFSs were initially slower to improve than indoor AFSs, but by 6 weeks the initial 20-pt difference was less than 10-pts. AFS scores were significantly correlated with UCLA scores across all 8 weeks. Knee Society Scores (KSS) at baseline were rarely correlated with AFS scores across the 8 weeks. However, 1-month and 3-month KSS scores were significantly correlated with AFS scores at p < .05 beginning with weeks 2 or 3 and through week 8. CONCLUSION. Avoiding incision of the quadriceps tendon during primary TKA resulted in a short-lived trend of quicker improvement in the AFS score in the SV TKA group versus the MPPA group. However, there appeared to be a similar rate of subsequent AFS improvement across the subsequent 8 weeks between the two groups. Preliminary results suggest a pattern of results – general improvement across 5–6 weeks that was maintained through the 8 weeks of evaluation, and significant correlations with UCLA and KSS scores after 2–3 weeks – that are consistent with the notion that the AFS is sensitive to change, and is variable depending on context (indoor vs. outdoor ambulation). Although related to UCLA and KSS scores, observed correlation magnitudes were not so high as to suggest that UCLA or KSS scores might be reasonable proxies for AFS

Background: Mobile-bearing knee replacements have some theoretical advantages over fixed-bearing devices. However, very few randomized controlled clinical trials have been published to date, and studies showed little clinical and subjective advantages for the mobile-bearing using traditional systems of scoring. The choice of the ideal outcome measure to assess total joint replacement remains a complex issue. However, gait analysis provides objective and quantifying evidences of treatment evaluation. Significant methodological advances are currently made in gait analysis laboratories and ambulatory gait devices are now available. The goal of this study was to provide gait parameters as a new objective method to assess total knee arthroplasty outcome between patients with fixed- and mobile-bearing, using an ambulatory device with minimal sensor configuration. This randomized controlled double-blind study included to date 14 patients: the gait signatures of four patients with mobile-bearing were compared to the gait signatures of nine patients with fixed-bearing pre-operatively and post-operatively at 6 weeks, 3 months and 6 months. Each participant was asked to perform two walking trials of 30m long at his/her preferred speed and to complete a EQ-5D questionnaire, a WOMAC and Knee Society Score (KSS). Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. A new method for a portable system for gait analysis has been developed with very encouraging results regarding the objective outcome of total knee arthroplasty using mobile- and fixed-bearings

Introduction: Ankle arthropathy is associated with a decreased motion of the ankle-hindfoot during ambulation. Ankle arthrodesis was shown to result in degeneration of the neighbour joints of the foot. Inversely, total ankle arthroplasty conceptually preserves the adjacent joints because of the residual mobility of the ankle but this has not been demonstrated yet in vivo. It has also been reported that degenerative ankle diseases, and even arthrodesis, do not result in alteration of the knee and hip joints. We present the preliminary results of a new approach of this problem based on ambulatory gait analysis. Patients and Methods: Motion analysis of the lower limbs was performed using a Physilog® (BioAGM, CH) system consisting of three-dimensional (3D) accelerometer and gyroscope, coupled to a magnetic system (Liberty©, Polhemus, USA). Both systems have been validated. Three groups of two patients were included into this pilot study and compared to healthy subjects (controls) during level walking: patients with ankle osteoarthritis (group 1), patients treated by ankle arthrodesis (group 2), patients treated by total ankle prosthesis (group 3). Results: Motion patterns of all analyzed joints over more than 20 gait cycles in each subject were highly repeatable. Motion amplitude of the ankle-hindfoot in control patients was similar to recently reported results. Ankle arthrodesis limited the motion of the ankle-hindfoot in the sagittal and horizontal planes. The prosthetic ankle allowed a more physiologic movement in the sagittal plane only. Ankle arthritis and its treatments did not influence the range of motion of the knee and hip joint during stance phase, excepted for a slight decrease of the hip flexion in groups 1 and 2. Conclusion: The reliability of the system was shown by the repeatability of the consecutive measurements. The results of this preliminary study were similar to those obtained through laboratory gait analysis. However, our system has the advantage to allow ambulatory analysis of 3D kinematics of the lower limbs outside of a gait laboratory and in real life conditions. To our knowledge this is a new concept in the analysis of ankle arthropathy and its treatments. Therefore, there is a potential to address specific questions like the difficult comparison of the benefits of ankle arthroplasty versus arthrodesis. The encouraging results of this pilot study offer the perspective to analyze the consequences of ankle arthropathy and its treatments on the biomechanics of the lower limbs ambulatory, in vivo and in daily life conditions

We performed rotational acetabular osteotomy in order to treat dysplasia of the hip in five ambulatory adults with cerebral palsy. There was one man and four women, with a mean age of 21 years (16 to 27) who were followed up for a mean of 12 years and two months. The mean Sharp angle improved from 52° to 43°, the mean acetabular index from 30.2° to 2.8°, the mean centre-edge angle from −5.6° to 29.2°, and the mean acetabular head index from 49.2 to 88.2. There was no progression of joint degeneration and relief from pain was maintained. Our results suggest that rotational acetabular osteotomy is a valuable option for the treatment of acetabular dysplasia in adults with cerebral palsy who have incapacitating pain in the hip

Background: Mobile-bearing knee replacements have some theoretical advantages over fixed-bearing devices. However, very few randomized controlled clinical trials have been published to date, and studies showed little clinical and subjective advantages for the mobile-bearing using traditional systems of scoring. The choice of the ideal outcome measure to assess total joint replacement remains a complex issue. However, gait analysis provides objective and quantifying evidences of treatment evaluation. Significant methodological advances are currently made in gait analysis laboratories and ambulatory gait devices are now available. The goal of this study was to provide gait parameters as a new objective method to assess total knee arthroplasty outcome between patients with fixed- and mobile-bearing, using an ambulatory device with minimal sensor configuration. Methods: This randomized controlled double-blind study included to date 31 patients: the gait signatures of 12 patients with mobile-bearing were compared to the gait signatures of 19 patients with fixed-bearing pre-operatively and post-operatively at 6 weeks, 3 months and 6 months. Each participant was asked to perform two walking trials of 30m long at his/her preferred speed and to complete a EQ-5D questionnaire, a WOMAC and Knee Society Score (KSS). Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. Results: Better relative differences between pre-operative and post-operative 3 months and 6 months KSS (122% vs 34% at 3 months, 138% vs 36% at 6 months) and KSS function (154% vs 8% at 3 months, 183% vs 42% at 6 months) scores were observed for the fixed-bearing compared to the mobile-bearing. The same better improvements for fixed-bearing were also found with the range of knee angles (Affected side: 31% vs −5% at 3 months, 47% vs 5% at 6 months), (Unaffected side: 16% vs 5% at 3 months, 15% vs 6% at 6 months) and peak swing speeds of shank (Affected side: 18% vs −2% at 3 months, 30% vs 4% at 6 months), (Unaffected side: 8% vs −3% at 3 months, 7% vs 4% at 6 months). Conclusions: A new method for a portable system for gait analysis has been developed with very encouraging results regarding the objective outcome of total knee arthroplasty using mobile- and fixed-bearings

Compared with general anaesthesia, brachial plexus (BP) anaesthesia improves patient satisfaction and accelerates hospital discharge after ambulatory hand surgery; however, variable success rates and typical onset times up to 30 minutes have limited its widespread use. Increasing availability of high-resolution portable ultrasound has renewed interest in more proximal approaches to the BP, previously thought to carry unacceptable risk. The aim of this study was to compare the onset times of ultrasound guided supraclavicular and infraclavicular BP block in patients undergoing ambulatory hand surgery. With ethics committee approval, patients presenting for hand surgery were prospectively randomised to either supraclavicular (trunks/divisions) or infraclavicular (cords) BP block. A single experienced operator (MF) placed all blocks using ultrasound only guidance. A blinded observer (AP, SY) assessed pinprick sensory and motor block on 3-point scale (normal=2, reduced=1, absent=0) in the median, ulnar, radial and musculocutaneous nerve territories every five minutes, or until blocks were complete. A single general anaesthesia without influence from the unblended anaesthetist. Of the first 27 patients recruited, block placement details and Intraoperative data are presented in There was a trend to faster onset times and higher success in group infraclavicular, however, this did not reach statistical significance. Interim results are so far inconclusive for the superiority of one approach. Both techniques were well tolerated and had a high success rate for surgical anaesthesia

Purpose of the study: Reconstruction of the anterior cruciate ligament (ACL) controls laxity but does not enable restoration of strictly normal 3D kinematics. The purpose of this study was to compare the kinematics of the pathological knee with that of the healthy knee after ACL plasty. This study applied a new ambulatory system using miniature captors. Material and method: Five patients with an isolated injury of the ACL participated in this study. The patients were assessed after injury (T1), at five months (T2), and at 14 months (T3) after surgery. The assessment included laxity (KT-1000), the IKDC score and the Lysholm score. The 3D angles of the knees were measured when walking 30 m on flat ground using a system composed of to small inertia units (3D accelerometer and 3D gyroscope) and a portable recorder. Functional settings were optimised and validating to ensure easy precise measurement of the 3D angles. Symmetry of the two knees was quantified using a symmetry index (SI) (difference in amplitude normalised in relation to mean amplitude) and the correlation coefficient CC. Results: Clinical indicators improved during the follow-up (IKDC T1: 3C, 2C; T2: 5B; T3: 2A, 3B; subjective IKD: 53–95; Lysholm 67–96). Mean laxity improved from 8.6m to 2.5 mm. The gait analysis showed increased symmetry in terms of amplitude for flexion-extension (SI: −17% at T1, −1% at T2, 1% at T3), and an increase in symmetry in terms of the rotation signature (CC: 0.16 at T1, 0.99 at T2, 0.99 at T3). There was no trend to varus-valgus. Discussion: This study demonstrates the clinical application of the new ambulatory system for measuring 3D angles of the knee joint. Joint symmetry increased after ACL plasty but still showed some perturbation at 14 months. The results observed here are in agreement with the literature. Other patients and other types of gait are being analysed. Conclusion: This portable system allows gait analysis outside the laboratory, before and after ACL injury. It is very useful for follow-up after surgery

Aim: To evaluate the effectiveness of distal rectus femoris (RF) release versus transfer to treat gait abnormalities of the knee in ambulatory children with cerebral palsy. Patients & Methods: Thirty-nine children were included in this study. Thirty patients (55 limbs) underwent RF transfer at a mean age of 11.8 years. and nine (16 limbs) underwent distal rectus release at a mean age of 12.5 years. Indications for surgery included RF contracture and abnormal activity during swing phase in dynamic electromyography (EMG), whether with the presence of kinematic characteristics of stiff-knee gait or not. All patients had pre- and postoperative gait analysis and EMG. To evaluate functional outcomes, patients were grouped by pre-operative knee kinematics (normal; swing-phase peak knee flexion (PKF) < 50°; and peak knee flexion > 50° happening later than 77% of the cycle). All data was analyzed statistically. Results: For the group of patients with PNF< 50°, this value increased significantly after rectus transfer (p=.005). Children with PNF> 50° and later than 77% of the cycle, showed significant improvement in timing after both procedures (p=.001; p=.02). When kinematic parameters were normal before surgery, they did not improved, although patients experienced a significant decrease of muscle contractures. Conclusions: According to the results of this study, RF transfer would be the preferred procedure for those patients with preoperative swing-phase knee flexion < 50°. For the rest of patients, both procedures brought similar results. We opt for distal RF release since is technically easier, particularly when one-stage multilevel procedures are being performed

INTRODUCTION. Mobile-bearing knee prostheses have been designed in order to provide less constrained knee kinematics compared to fixed-bearing prosthesis. Currently, there is no evidence to confirm the superiority of either of the two implants with regard to walking performances. It has been shown that subjective outcome scores correlate poorly with real walking performance and it has been recommended to obtain an additional assessment of walking ability with objective gait analysis. OBJECTIVES. We assessed recovery after total knee arthroplasty (TKA) with mobile- and fixed-bearing between patients during the first postoperative year, and at 5 years follow-up, using a new objective method to measure gait parameters in real life conditions. METHODS. 56 patients with mobile- and fixed-bearing of the same design were included in this randomised controlled double-blinded study and evaluated pre- and post-operatively at 6 weeks, 3 months, 6 months 1 year and 5 years. At each visit a WOMAC and Knee Society Score were calculated and each participant completed an EQ-5D questionnaire. To assess the patients' gait five miniature angular rate sensors mounted respectively on the sacrum and each shank and thigh measured lower limb movement and rotation. The patients walked 30 metres on a flat surface and gait parameters were recorded with a small ambulatory device in order to carry out an objective gait analysis. RESULTS. Objective recovery was strongly correlated with patients' age. When the whole population was considered, there was no significant difference between groups at any time in objective gait parameters. After separating the population according to their age (less than 71 years old, compared to those of more than 71 years old) a secondary analysis showed that the bearing type can lead to opposite results in different age groups. At five years follow-up, most of the recorded gait parameters (stride length, knee max rotation speed, shank and thigh range of motion, and limp) showed better results for mobile bearing in younger patients, while better gait performances were found systematically with fixed-bearing TKA in older patients. CONCLUSION. To our knowledge, this is the first study where similarly designed posterior-stabilised knee replacements with fixed- and mobile-bearing have been compared with gait analysis in real-life conditions. We observed systematically differences between mobile and fixed bearing groups, which are confirmed by multivariate analysis. Our results suggest that older patients might not benefit from a mobile bearing TKA and that extended age controlled study should be performed to identify an age, above which fixed bearing should not be the recommended choice. Before choosing the bearing type, surgeons should take into account the age of the patient

Purpose of the study: Prevention of operative site infections (OSI) in orthopaedic surgery requires strict observation of validated practices during hospitalisation and in the operative theatre, review of morbidity and mortality, and surveillance of OSI. Certain intrinsic patient-related risk factors of OSI cannot be controlled without direct implication of the patient and the referring physician. Search for Staphylococcus aureus (SA) colonisation and bacteriuria should be done in the ambulatory setting, before hospitalisation. The purpose of this work was to evaluate the feasibility of a search for SA in the nasal swabs and urine samples in patients scheduled for prosthesis surgery. Material and methods: This was a prospective study on 335 patients who had a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) from January 1, 2007 to December 31, 2008. Bacteriological tests were performed before hospitalisation. Before hospitalisation, the patient and the primary care physician were give information on the proper procedure for chemical decontamination. The results of these laboratory tests were analysed and OSI were followed. Results: Three hundred thirty-five patients (195 THA and 143 TKA) were included; the sex-ratio was 0.95 M/F. Sixty-one patients (18%) exhibited SA colonization, including two meticillin resistant strains. Urine samples were positive in 30/323 patients (9.3%). Three patients presented an early OSI: two infections of a revision THA and one infection of a revision TKA. Two of these patients had an SA infection, including one who was colonized and had applied the chemical decontamination protocol before hospitalization. Discussion: By treating bacteriuria before hospitalization, deferral of the scheduled operations could be avoided. Laboratories must run two sets of tests to search for both met-S and met-R SA, which in our experience was not always the case despite written prescriptions. Implementation of chemical decontamination of the nasal passages and skin before surgery requires a well-established cooperation between the primary care physician and the hospital. The three infections recorded in this series involved revision procedures, with a context of rheumatoid polyarthritis for two patients. Conclusion: Systematic screening for SA colonization in orthopaedic surgery remains a subject of debate, particularly concerning the cost-efficacy balance, but can be quite useful in certain situations such as revision or prosthetic surgery in immunodepressed patients

After exclusions, 265 patients with tuberculosis of the thoracic and/or lumbar spine were followed for three years from the start of treatment. They were randomly allocated to four daily regimens of chemotherapy: 1) isoniazid plus rifampicin for 6 months (6HR, 65); 2) the same drugs as in 1) but for 9 months (9HR, 71); 3) isoniazid plus paraaminosalicylic acid (PAS) or ethambutol for 9 months (9P/EH, 62); or 4) the same drugs as in 3) but for 18 months (18P/EH, 67). All patients were ambulatory from the start of chemotherapy and no form of splintage or support or operation was used in any case. Over half (55%) the patients were children and one-third had sinuses or clinically evident abscesses. At three years a favourable status, defined as no sinus nor clinically evident abscess, no myelopathy with functional impairment, no surgery nor additional chemotherapy, full physical activity with disease quiescent clinically and radiographically, was achieved in 203 patients (77%) and in another 41 (15%) in all respects except radiographically. Only 20 patients (8%) had an unfavourable status the proportion being highest (19%) in the 9P/EH series. Thirteen of these were classified as unfavourable solely because they had needed additional chemotherapy; only seven still had an unfavourable status at three years. The clinical results at three years were thus excellent in all series except the 9P/EH, in which more patients had required additional chemotherapy. In the 88 patients with sinuses or abscesses on admission, the rate of resolution was similar in all the series; most lesions (83%) had resolved by 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast carcinoma is the most common cause for bony metastases. Skeletal complications in women with meta-static breast carcinoma often occur multiple times in a single patient and significantly contribute to the patient morbidity. We describe a 62 year old lady with a known metastatic breast carcinoma who presented with simultaneous quadruple extremity diaphyseal long bone fractures after a trivial fall. To the author’s best knowledge, similar report has never been previously described in the literature.

The wish and general condition of the patient, and concurrent occurrence of four long bone fractures dictated the non-operative mode of treatment in this case.Where the life expectancy is assumed to be less than six weeks, the multidisciplinary team should give careful consideration on selection of best treatment choice between simultaneous or sequential surgical fixation of multiple long bone fractures and conservative palliative treatment. With treatment suited for an end-of-life circumstance, the educational lesson for dissemination to the readers is that in a patient where there is an extremely high likelihood of imminent perioperative mortality after sustaining quadruple extremity diaphyseal proximal long bone fractures simultaneously, conservative palliative treatment should be primarily considered over an aggressive operative fixation.

Purpose of the study: Drilling along yields disappointing results for osteonecrosis of the femoral head due to the high failure rate despite prolonged rest and also because of the risk of fracture. To prevent these problems, we have developed a new drilling technique which was evaluated prospectively.

Material and methods: The procedure performed percutaneously uses a lateral cortical orifice measuring 5mm, non-concentrated autologous bone marrow was injected after drilling. Osteoinductive protein (BMP7) was associated in random fashion (groups BMP+ and BMP−). Ficat stage 1 and 2 necrosis was included. Outcome was the rate or revision for prosthesis.

Results: Forty hips (36 patients) were included and assessed at mean four years (range 2–6). The necrosis was related to: alcoholism (n=5), cortisone (n=25), barotraumas (n=2), metabolic disease (n=4), idiopathic condition (n=4). Group BMP- (drilling+bone marrow) included 24 hips and group BMP+ (drilling+bone marrow+BMP7) 16 hips. The groups were comparable regarding necrosis stage (15% stage 3, 65% stage 2, 20% stage 1) and mean Koo index (27 BMP+ vs 34 BMP-; NS). There were no infections and no fractures despite immediate and complete weight-bearing. The revision rate for prosthesis was higher in the BMP- group (67%) than in the BMP+ group (43%) but the difference did not reach significance (p=0.10). The failure rate was not affected by the severity of the necrosis in the BMP+ group: all stage 3 hips were revised in the BMP- group versus none in the BMP+ group. The only variable predictive of revision for prosthesis was the Koo index (p=0.02).

Discussion: Adjunction of BMP did not improve significantly the success rate of drilling with bone marrow adjunction but adding BMP appeared to limit the unfavourable impact of server necrosis observed in the BMP- group. To reach a statistical power of 80%, 40 cases would be needed in each arm. This threshold has not yet been reached. It can be noted however that the proposed method does ensures early weight bearing without the risk of complications. Similarly, since it is a percutaneous procedure, later arthroplasty is not compromised. The principle confounding factor, the richness of the bone marrow, was not assessed, motivating a new randomized trial with measurement of CFU-F.

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

The August 2023 Knee Roundup. 360. looks at: Curettage and cementation of giant cell tumour of bone: is arthritis a given?; Anterior knee pain following total knee arthroplasty: does the patellar cement-bone interface affect postoperative anterior knee pain?; Nickel allergy and total knee arthroplasty; The use of artificial intelligence for the prediction of periprosthetic joint infection following aseptic revision total knee arthroplasty; Ambulatory unicompartmental knee arthroplasty: development of a patient selection tool using machine learning; Femoral asymmetry: a missing piece in knee alignment; Needle arthroscopy – a benefit to patients in the outpatient setting; Can lateral unicompartmental knees be done in a day-case setting?

The June 2024 Hip & Pelvis Roundup. 360. looks at: Machine learning did not outperform conventional competing risk modelling to predict revision arthroplasty; Unravelling the risks: incidence and reoperation rates for femoral fractures post-total hip arthroplasty; Spinal versus general anaesthesia for hip arthroscopy: a COVID-19 pandemic- and opioid epidemic-driven study; Development and validation of a deep-learning model to predict total hip arthroplasty on radiographs; Ambulatory centres lead in same-day hip and knee arthroplasty success; Exploring the impact of smokeless tobacco on total hip arthroplasty outcomes: a deeper dive into postoperative complications

Aims. The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes. Methods. A total of 76 patients treated for an IPFF from February 1985 to April 2018 were reviewed. Prior to fracture, at the hip/knee sites respectively, 46 femora had primary/primary, 21 had revision/primary, three had primary/revision, and six had revision/revision components. Mean age and BMI were 74 years (33 to 99) and 30 kg/m. 2. (21 to 46), respectively. Mean follow-up after fracture treatment was seven years (2 to 24). Results. Overall, 59 fractures were classified as Vancouver C (Unified Classification System (UCS) D), 17 were Vancouver B (UCS B). In total, 57 patients (75%) were treated with open reduction and internal fixation (ORIF); three developed nonunion, three developed periprosthetic joint infection, and two developed aseptic loosening. In all, 18 patients (24%) underwent revision arthroplasty including 13 revision THAs, four distal femoral arthroplasties (DFAs), and one revision TKA: of these, one patient developed aseptic loosening and two developed nonunion. Survivorship free from any reoperation was 82% (95% confidence interval (CI) 66.9% to 90.6%) and 77% (95% CI 49.4% to 90.7%) in the ORIF and revision groups at two years, respectively. ORIF patients who went on to union tended to have stemmed knee components and greater mean interprosthetic distance (IPD = 189 mm (SD 73.6) vs 163 mm (SD 36.7); p = 0.546) than nonunited fractures. Patients who went on to nonunion in the revision arthroplasty group had higher medullary diameter: cortical width ratio (2.5 (SD 1.7) vs 1.3 (SD 0.3); p = 0.008) and lower IPD (36 mm (SD 30.6) vs 214 mm (SD 32.1); p < 0.001). At latest follow-up, 95% of patients (n = 72) were ambulatory. Conclusion. Interprosthetic femur fractures are technically and biologically challenging cases. Individualized approaches to internal fixation versus revision arthroplasty led to an 81% (95% CI 68.3% to 88.6%) survivorship free from reoperation at two years with 95% of patients ambulatory. Continued improvements in management are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):122–128

Aims. The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC. Methods. Among a single-surgeon cohort of 970 patients who underwent arthroplasty at an ASC, 854 (88.0%) were matched one-to-one with inpatients based on age, sex, American Society of Anesthesiologists (ASA) grade, BMI, and procedure (105 could not be adequately matched and 11 lacked 90-day follow-up). The cohort included 281 total hip arthroplasties (THAs) (32.9%), 267 unicompartmental knee arthroplasties (31.3%), 242 primary total knee arthroplasties (TKAs) (28.3%), 60 hip resurfacings (7.0%), two revision THAs (0.3%), and two revision TKAs (0.3%). Outcomes included readmissions, reoperations, visits to the emergency department, unplanned clinic visits, and complications. Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The reoperation rate was 0.9% in both cohorts (p = 1.000). Rates of readmission (2.0% inpatient vs 1.6% outpatient), any complications (5.9% vs 5.6%), minor complications (4.2% vs 3.9%), visits to the emergency department (2.7% vs 1.4%), and unplanned clinic visits (5.7% vs 5.5%) were lower in the outpatient group but did not reach significance with the sample size studied. A learning curve may exist, as seen by significant reductions in the reoperation and overall complication rates among outpatient arthroplasties over time (p = 0.032 and p = 0.007, respectively), despite those in this group becoming significantly older and heavier (both p < 0.001) during the study period. Conclusion. Arthroplasties performed at ASCs appear to be safe in appropriately selected patients, but may be associated with a learning curve as shown by the significant decrease in complication and reoperation rates during the study period. Cite this article: Bone Joint J 2021;103-B(7 Supple B):84–90

The February 2023 Spine Roundup. 360. looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery; Anterior cervical discectomy or fusion and selective laminoplasty for cervical spondylotic myelopathy; Surgery for cervical radiculopathy: what is the complication burden?; Hypercholesterolemia and neck pain; Return to work after surgery for cervical radiculopathy: a nationwide registry-based observational study

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:. 1). the volume and variations of arthroscopic knee debridement across Canada. 2). The costs associated with potentially unnecessary arthroscopy. 3). The characteristics of surgeons performing knee arthroscopy in older adults. Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age. The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001). Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care

Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection bias and intangible characteristics that were not adequately controlled for through matching

Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection bias and intangible characteristics that were not adequately controlled for through matching

Aims. COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic. Methods. An orthopaedic research consortium at a multi-hospital tertiary care academic medical system developed a three-part survey examining provider perspectives on strategies to expand orthopaedic patient care and financial recovery. Section 1 asked for preferences regarding extending clinic hours, section 2 assessed surgeon opinions on expanding surgical opportunities, and section 3 questioned preferred strategies for departmental financial recovery. The survey was sent to the institution’s surgical and nonoperative orthopaedic providers. Results. In all, 73 of 75 operative (n = 55) and nonoperative (n = 18) providers responded to the survey. A total of 92% of orthopaedic providers (n = 67) were willing to extend clinic hours. Most providers preferred extending clinic schedule until 6pm on weekdays. When asked about extending surgical block hours, 96% of the surgeons (n = 53) were willing to extend operating room (OR) block times. Most surgeons preferred block times to be extended until 7pm (63.6%, n = 35). A majority of surgeons (53%, n = 29) believe that over 50% of their surgical cases could be performed at an ambulatory surgery centre (ASC). Of the strategies to address departmental financial deficits, 85% of providers (n = 72) were willing to work extra hours without a pay cut. Conclusion. Most orthopaedic providers are willing to help with patient care backlogs and revenue recovery by working extended hours instead of having their pay reduced. These findings provide insights that can be incorporated into COVID-19 recovery strategies. Level of Evidence: III. Cite this article: Bone Jt Open 2021;2(7):562–568

Abstract. Introduction. Knee braces are limited to providing passive support. There is currently no brace available providing both continuous monitoring and active robot-assisted movements of the knee joint. This project aimed to develop a wearable intelligent motorised robotic knee brace to support and monitor rehabilitation for a range of knee conditions including post-surgical rehabilitation. This brace can be used at home providing ambulatory continuous passive movement obviating the need for hospital admissions. Methodology. A wearable sensing system monitoring knee range of motion was developed to provide remote feedback to clinicians and real-time guidance for patients. A prototype of an exoskeleton providing dynamic motion assistance was developed to help patients complete their exercise goals and strengthen their muscles. The accuracy and reliability of those functions were validated in human participants during exercises including knee flexion/extension (FE) in bed and in chair, sit-to-stand and stand-to-sit. Results. The knee FE measurement from the sensing system showed high accuracy (correlation coefficient of 0.99°) in human participants. The real-time FE data during exercises showed that the desired exoskeleton rotation fitted well with the participant's knee rotation. This indicated the exoskeleton could coordinate with the participant's knee motion by providing consistent motion assistance. The development of user interfaces to provide feedback is currently underway. Conclusion. A wearable robotic knee brace to monitor and support knee rehabilitation exercises was successfully developed. Further development of this device with the use of artificial intelligence has the potential to aid patient rehabilitation in a variety of knee conditions

There is a paucity of data available for the use of Total Femoral Arthroplasty (TFA) for joint reconstruction in the non-oncological setting. The aim of this study was to evaluate TFA outcomes with minimum 5-year follow-up. This was a retrospective database study of TFAs performed at a UK tertiary referral revision arthroplasty unit. Inclusion criteria were patients undergoing TFA for non-oncological indications. We report demographics, indications for TFA, implant survivorship, clinical outcomes, and indications for re-operation. A total of 39 TFAs were performed in 38 patients between 2015–2018 (median age 68 years, IQR 17, range 46–86), with 5.3 years’ (IQR 1.2, 4.1–18.8) follow-up; 3 patients had died. The most common indication (30/39, 77%) for TFA was periprosthetic joint infection (PJI) or fracture-related infection (FRI); and 23/39 (59%) had a prior periprosthetic fracture (PPF). TFA was performed with dual-mobility or constrained cups in 31/39 (79%) patients. Within the cohort, 12 TFAs (31%) required subsequent revision surgery: infection (7 TFAs, 18%) and instability (5 TFAs, 13%) were the most common indications. 90% of patients were ambulatory post-TFA; 2 patients required disarticulation due to recurrent PJI. While 31/39 (79%) were infection free at last follow-up, the remainder required long-term suppressive antibiotics. This is the largest series of TFA for non-oncological indications. Though TFA has inherent risks of instability and infection, most patients are ambulant after surgery. Patients should be counselled on the risk of life-long antibiotics, or disarticulation when TFA fails

Extensive and severe bone loss of the femur may be a result of a failed total hip arthroplasty (THA) or total knee arthroplasty (TKA) with multiple revision surgeries which may be caused by factors such as infection, periprosthetic fracture or osteolysis. The aim of this study was to assess outcomes of using the “Push-Through Total Femoral Prosthesis” (PTTF) for revision of a total hip replacement with extreme bone loss. Fourteen patients who had extensive bone defects of the femur due to failed THR's and were treated with PTTF between 2012 and 2020 were included in this study. Primary functional outcomes were assessed using Harris Hip Score (HHS), Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scores. Range of motion, complications, and ambulatory status were also recorded to assess secondary outcomes. Two of 14 patients underwent surgery with PTTF for both knee and hip arthroplasty revision. The mean time between index surgery and PTTF was 15 years (3 to 32 yrs.). Acetabular components were revised in six of 14 patients. After a mean follow-up of 5.9 years, hip dislocations occurred in 3 patients. All dislocated hips were in patients with retained non-constrained acetabular bearings. Patient satisfaction was high (MSTS: 67%, HHS: 61.2%, TESS 64.6%) despite a high re-operation rate and minor postoperative problems. PTTF is a unique alternative that may be considered for a failed THA revision procedure in patients with an extreme femoral bone defect. Patients are able to ambulate pain free relatively well. Routine usage of constrained liners should be considered to avoid hip dislocation which was our main problem following the procedure

Abstract. Introduction. Knee osteotomy, both high tibial and distal femoral osteotomy, is a well-recognised treatment for young, active patients with unicompartmental knee osteoarthritis. Osteotomy around the knee is usually performed as an inpatient procedure. The aim of this study was to assess the effectiveness and patient satisfaction of our day-case protocol for knee osteotomy. Methodology. All patients who underwent day-case knee osteotomy at the study unit, over a three-year period, were reviewed to assess the success of ambulatory care for knee osteotomy. Patients were sent questionnaires to assess functional outcome and patient satisfaction with our day-case process. Results. Thirty-three knee osteotomies were performed as a day-case protocol, of which same day discharge was achieved in 24 patients (73%) and discharge within 24 hours achieved in 32 patients (97%). The mean post-operative Knee Osteoarthritis Outcome Score (KOOS) was 67.1 and 79% of patients rated their care as good or excellent. Return to sporting activities was achieved in 75% of patients, and 88% of patients reported they would be happy to undergo day-case knee osteotomy again. Conclusion. Knee osteotomy, both high tibial and distal femoral osteotomy, can be successfully performed as a day-case procedure with similar improvements in functional outcomes and no increased complication rate, compared to in-patient osteotomy

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

The purpose of this study was to measure the effect of the implementation of a LEAN continuous process improvement initiative on the waitlist in an ambulatory pediatric orthopaedic clinic. LEAN is a set of principles that guide organizational thinking and form a comprehensive approach to continuous process improvement. In 2016, our health centre began its journey towards becoming a LEAN organization. The health centre's Strategy and Performance portfolio collaborated with the Orthopaedic Clinic Team to facilitate a Value Stream Analysis, which mapped the clinic process from referral to discharge from care. This informed the plan for targeted improvement events designed to identify and reduce non-value added activity, while partnering with patients and families to share their experiences with care in the clinic. Improvement events included: In-Clinic Patient Flow; Scheduling Process Review; Standardized Triage Process; Clinician Schedule; 5-S Large Cast and Sample Exam Rooms; Booking Orthopedics Clinic; and Travelling and Remote Care. During each event, solutions were identified to improve the patient experience, access, and clinic flow. These solutions have been standardized, documented, and continuously monitored to identify additional improvement opportunities. Comparison of wait-list and percentage of new patients seen within target window was performed from August 2017 to December 2018. The LEAN initiative resulted in a 48% decrease in wait-list for new patients, which translated to an improvement from 39% to 70% of new patients seen within their target window. There was a 19% decrease in the 3400+ patient wait-list for follow-up appointments, an 85% reduction in follow-up patients waiting past their target date for an appointment, and the number of patients waiting over a year beyond their target appointment improved from over 300 patients to 0 patients. There was a 15% improvement in average length of clinic visit. Without the addition of new resources, the implementation of a LEAN continuous process improvement initiative improved the waitlist for new patients in an ambulatory pediatric orthopaedic clinic by almost 50%. Solutions identified and implemented through the LEAN process have contributed to unprecedented improvements in access to care. In fulfilling one of the LEAN theory principles to “pursue perfection”, the paediatric orthopaedic clinic team has embraced a culture of continuous improvement and continues to use LEAN tools such as daily huddles and visual management to monitor solutions and identify gaps

Aims. We have evaluated the survivorship, outcomes, and failures of an interlocking, reconstruction-mode stem-sideplate implant used to preserve the native hip joint and achieve proximal fixation when there is little residual femur during large endoprosthetic reconstruction of the distal femur. Methods. A total of 14 patients underwent primary or revision reconstruction of a large femoral defect with a short remaining proximal femur using an interlocking, reconstruction-mode stem-sideplate for fixation after oncological distal femoral and diaphyseal resections. The implant was attached to a standard endoprosthetic reconstruction system. The implant was attached to a standard endoprosthetic reconstruction system. None of the femoral revisions were amenable to standard cemented or uncemented stem fixation. Patient and disease characteristics, surgical history, final ambulatory status. ,. and Musculoskeletal Tumor Society (MSTS) score were recorded. The percentage of proximal femur remaining was calculated from follow-up radiographs. Results. All 14 at-risk native hip joints were preserved at a mean final follow-up of 6.0 years (SD 3.7), despite a short residual femur, often after proximal osteotomies through the lesser trochanter. Overall, 13 of 14 stems had long-term successful fixation. Eight patients required no reoperation. Three patients required reoperation due to implant-related issues, and three patients required reoperation for wound healing problems or infection. There were no dislocations or fractures. At final follow-up the mean MSTS score was 24.9 (SD 4.1). Nine patients required no ambulation aids, and only one had a Trendelenburg gait. Conclusion. This interlocking, reconstruction-mode stem-sideplate reliably preserves native hip joint anatomy and function after large femoral resection with a short remaining proximal femur, both in the primary and revision setting. This is particularly important for preventing or delaying total femoral arthroplasty in young patients after oncological reconstruction. Hip abductor strength and function could be maintained by this method, and the risk of dislocation eliminated. The success of this technique in this modest series should be verified in a larger collaborative study and will be of interest to revision surgeons and oncologists. Cite this article: Bone Joint J 2021;103-B(2):398–404

A Morel-Lavallee lesion (MLL) is a benign cystic lesion that occurs due to injury to the soft-tissue envelope's perforating vascular and lymphatic systems, resulting in a distinctive hemolymphatic fluid accumulation between the tissue layers. The MLL has the potential to make a significant impact on the treatment of orthopaedic injuries. A 79-year-old male patient community ambulatory with assisting aid (cane) known case of Diabetes mellitus, hypertension, bronchial asthma and ischemic heart disease. He was brought to the Emergency, complaining of right hip discomfort and burning sensation for the last 5 days with no history of recent trauma at all. Patient had history of right trochanteric femur fracture 3 years ago, treated with DHS in a privet service. Clinical and Radiological assessment showed that the patient mostly has acute MLL due to lag screw cut out. We offered the patient the surgical intervention, but he refused despite explaining the risks of complications if not treated and preferred to receive the conservative treatment. Compression therapy management explained to him including biker's shorts (instructed to be worn full-time a day) and regular follow up in clinic. Symptom's improvement was reported by the patient in the subsequent visits. In the polytrauma patient, a delayed diagnosis of these lesions is conceivable due to the presence of more visible injuries. It's located over the greater trochanter more commonly, but sometimes in other areas such as the lower lumbar region, the thigh, or the calf. Incorrect or delayed diagnosis and care can have unfavorable outcomes such as infection, pseudocyst development, and cosmetologically deformity. Magnetic resonance imaging (MRI) and ultrasound will aid in MLL diagnosis. However, the effectiveness of MLL therapy remains debatable. We strongly believe that the MLL caused due to tangential shear forces applied to the soft tissue leads to accumulation of the blood and/or lymph between the subcutaneous and overlying fascia and it often misdiagnosed due to other distracting injuries. Nontheless, in our case we reported MLL occur due to internal pressure on the fascia caused by cut out of DHS lag screw

Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows earlier weight bearing, at the cost of longer operation times

Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021. Methods. A retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard. Results. A total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week. Conclusion. SBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway

Osteoarthritis is one of the major causes of immobility. Most commonly, osteoarthritis manifests at the knee joint. Prevalence of knee osteoarthritis (KNOA) increases with age. Another important risk factor for KNOA is obesity. Research has shown that obese subjects have almost four times the risk of developing KNOA, which may be explained by both an increased knee loading. In medial compartment KNOA, the knee adduction moment (KAM) during gait is considered a marker for disease severity. KAM is dependent of the magnitude of the ground reaction force and its moment arm relative to the knee joint centre. In addition, obesity has been reported to augment KAM during gait. However, after removal of the direct contributions of body weight, KAM parameters may be different due to obesity-related gait adaptations to limit knee loading. While KAM has been thoroughly investigated during gait, little is known about KAM during stair negotiation, during which knee loads are higher compared to gait. The aim of the current study is therefore to compare normalized KAM during the stance phase of stair negotiation between lean KNOA patients, obese KNOA patients, and healthy controls. This case control study included 20 lean controls, 14 lean KNOA patients, and 16 obese KNOA patients. All subjects ascended and descended a two-step staircase at a self-selected, comfortable speed. Radiographic imaging and MRI were used to evaluate knee cartilage and KNOA status. Motion analysis was performed with a three-dimensional motion capture system. Kinetic data were obtained by one force platform. The parameters of study included: stance phase duration, toe-out angle, KAM peaks and KAM impulse. During stair ascent obese KNOA patients showed a longer stance phase than healthy controls (P 0.050). Despite high between-subject variability, KAM impulse was found 45% higher in the obese KNOA group during stair descent, when compared to healthy controls (P =0.012). The absence of a significant effect of groups on the normalized KAM during stair negotiation may be explained by a lower ambulatory speed in the obese KNOA group, that effectively lowers GRFz. Decreasing ambulatory speed may be an effective strategy to lower KAM during stair negotiation

In Canada, hip and knee replacements are each among the top three surgeries performed annually. In 2020, surgeries across the country were cancelled in response to the COVID-19 pandemic. We examined the impact on these joint replacement surgeries throughout the year. Using the Discharge Abstract Database and National Ambulatory Care Reporting System, we developed a dataset of all 208,041 hip and knee replacements performed in Canada (except from Quebec) between January 1, 2019 to December 31, 2020. We compared patient and surgical characteristics (including sex, age, main diagnosis, and type of surgery (planned/urgent, primary/revision, inpatient/day surgery) in 2020 to 2019. In 2020, hip and knee replacements volumes decreased by 18.8% compared to 2019. In April and May 2020, hip and knee replacements fell by 69.4% and 93.8%, respectively, compared to the same period in 2019. During those months, 66.5% of hip replacements were performed to treat hip fracture versus 20.2% in April and May 2019, and 64.5% of knee replacements were primaries versus 93.0% in April and May 2019. Patterns by patient age group and sex were similar compared to 2019. These patterns were similar across all provinces. By the summer, planned surgeries resumed across the country and volumes mostly returned to pre-pandemic monthly levels by the end of the year. We also found that there was an increase in the proportion of hip and knee replacements done as day surgery, with 4% in 2020 versus 1% in 2019, and patients undergoing day surgery replacement for osteoarthritis were older, with a median age of 64 for hip patients and 65 for knee patients, versus 63 for both joints the previous year. As a result of the COVID-19 pandemic, there was a notable drop in 2020 of hip and knee replacements performed in Canada. With the demand for joint replacements continuing to grow, the resulting backlog will have an immediate, significant impact on wait lists and patient quality of life. The shift to a greater proportion of joint replacements performed as day surgeries may have an effect on patient outcomes as well shifts in access to care. It will be important to continue monitor patient outcomes following day surgery and the impact on patients for which day surgery was not an option

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article: Bone Joint Open 2020;1-6:222–228

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

The coronavirus pandemic has reduced the capability of Canadian hospitals to offer elective orthopaedic surgery requiring admission, despite ongoing and increasing demands for elective total hip and total knee arthroplasty surgery (THA and TKA). We sought to determine if the coronavirus pandemic resulted in more outpatient THA and TKA in Nova Scotia, and if so, what effect increased outpatient surgery had on 90 day post-operative readmission or Emergency Department/Family Doctor (FD) visits. The study cohort was constructed from hospital Discharge Abstract Data (DAD), inpatient admissions, and National Ambulatory Care Reporting System (NACRS) data, day surgery observations, using Canadian Classification of Health Intervention codes to select all primary hip and knee procedures from 2005-2020 in Nova Scotia. Emergency Department and General Practitioner visits were identified from the Physician Billings data and re-admissions from the DAD and NACRS. Rates were calculated by dividing the number of cases with any visit within 90 days after discharge. Chi-squared statistics at 95% confidence level used to test for statistical significance. Knee and hip procedures were modelled separately. There was a reduction in THA and TKA surgery in Nova Scotia during the coronavirus pandemic in 2020. Outpatient arthroplasty surgery in Nova Scotia in the years prior to 2020 were relatively stable. However, in 2020 there was a significant increase in the proportion and absolute number of outpatient THA and TKA. The proportion of THA increased from 1% in 2019 to 14% in 2020, while the proportion of TKA increased from 1% in 2019 to 11% in 2020. The absolute number of outpatient THA increased from 16 cases in 2019, to 163 cases in 2020. Outpatient TKA cases increased from 21 in 2019, to 173 in 2020. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED following TKA but not THA which was not statistically significant. For outpatient THA and TKA, there was a decrease in 90 day readmissions, and a statistically significant decrease in FD presentations. Outpatient THA and TKA increased significantly in 2020, likely due to the restrictions imposed during the coronavirus pandemic on elective Orthopaedic surgery requiring admission to hospital. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED for TKA, and a decrease in 90 day readmissions and FD presentations for THA and TKA. Reducing the inpatient surgical burden may result in a post-operative burden on ED, but does not appear to have caused an increase in hospital readmission rates

Aim. The aim of this paper is to analyse the cause of neuropathic diabetic foot ulcers and discuss their preventive measures. Methods. Review of patients with foot ulcers managed in our diabetic MDT clinics since Feb 2018 were analysed. Based on this observation and review of pertinent literature, following observations were made. Results. Forefoot. Progressive hindfoot equinus from contraction of gastroc-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus muscles and, progressive plantar flexed metatarsal heads secondary to claw toe deformity results in increased forefoot plantar pressures. In patients with insensate feet, this result in ulcer formation under the metatarsal heads from shear stress when walking. Callosity under the metatarsal heads is the earliest clinical sign. Most patients by this time have fixed tightness of the muscle groups as assessed by negative Silfverskiold test. Percutaneous tendo-Achilles lengthening (TAL) has shown to reduce the mid-forefoot plantar pressures by 32% and ulcer healing in 96% of patients within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. Proximal metatarsal osteotomies further reduce the forefoot pressures to near normality. Midfoot. Midfoot ulcers are secondary to rocker-bottom deformity a consequence of Charcot neuroarthropathy (CN). Hindfoot equinus as described and relative osteopenia from neurally mediated increased blood flow (neurovascular theory) and repeated micro-trauma (neurotraumatic theory) result in failure of medial column osseo-ligamentous structures. As the disease progress to the lateral column, the cuboid height drops resulting in a progressive rocker bottom deformity. The skin under this deformity gradually breaks down to ulceration. In the pre-ulcerative stages of midfoot CN, TAL has shown to stabilise the disease progression and in some patents’ regression of the disease process was noted. The lump can excised electively and the foot accommodated in surgical shoes. Hindfoot. These develop commonly at the pressure areas and bony exostosis in non-ambulatory patients. In ambulatory patients, the most common cause are factors that result in over lengthening of tendo-Achilles such as after TAL, spontaneous tears, or tongue-type fractures. Conclusions. Early identification of factors that result in plantar skin callosity and treating the deforming forces prevent progression to ulceration. Total contact cast without treatment of these deforming forces results in progression of these callosities to ulceration while in the cast or soon after completion of cast treatment

Aims. Accurate placement of the acetabular component is essential in total hip arthroplasty (THA). The purpose of this study was to determine if the ability to achieve inclination of the acetabular component within the ‘safe-zone’ of 30° to 50° could be improved with the use of an inclinometer. Patients and Methods. We reviewed 167 primary THAs performed by a single surgeon over a period of 14 months. Procedures were performed at two institutions: an inpatient hospital, where an inclinometer was used (inclinometer group); and an ambulatory centre, where an inclinometer was not used as it could not be adequately sterilized (control group). We excluded 47 patients with a body mass index (BMI) of > 40 kg/m. 2. , age of > 68 years, or a surgical indication other than osteoarthritis whose treatment could not be undertaken in the ambulatory centre. There were thus 120 patients in the study, 68 in the inclinometer group and 52 in the control group. The inclination angles of the acetabular component were measured from de-identified plain radiographs by two blinded investigators who were not involved in the surgery. The effect of the use of the inclinometer on the inclination angle was determined using multivariate regression analysis. Results. The mean inclination angle for the THAs in the inclinometer group was 42.9° (95% confidence interval (CI) 41.7° to 44.0°; range 29.0° to 63.8°) and 46.5° (95% CI 45.2° to 47.7°; range 32.8° to 63.2°) in the control group (p < 0.001). Regression analysis identified a 9.1% difference in inclination due to the use of an inclinometer (p < 0.001), and THAs performed without the inclinometer were three times more likely to result in inclination angles of > 50° (odds ratio (OR) 2.8, p = 0.036). The correlation coefficient for the interobserver reliability of the measurement of the two investigators was 0.95 (95% CI 0.93 to 0.97). Conclusion. The use of a simple inclinometer resulted in a significant reduction in the number of outliers compared with a freehand technique. Cite this article: Bone Joint J 2018;100-B:862–6

Introduction. The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFF). Our study aimed to assess treatment methodologies, implant survivorship, and clinical outcomes of patients with IPFF. Methods. 77 patients treated for an IPFF from 1985–2017 at a single large referral center were reviewed. Prior to the fracture, at the hip/knee sites respectively 46 femurs had primary/primary, 21 had revision/primary, 3 had primary/revision and 7 had revision/revision components. Mean age and BMI were 74 years and 30 kg/m. 2. , respectively. Mean follow-up after fracture treatment was 7 years. Results. Sixty fractures were classified as Vancouver C (UCS D) while 17 were Vancouver B (UCS B). Fifty-seven patients (74%) were treated with ORIF; 3 developed a non-union, 3 developed a PJI, and 2 developed aseptic loosening. Nineteen patients (25%) were treated with revision arthroplasty including: 13 revision THAs, 4 distal femoral replacements, 1 revision TKA, and 1 total femoral replacement of which 2 developed aseptic loosening and 2 developed a non-union. Survivorship free from any reoperation for the entire cohort was 79% at 2 years. Patients in the ORIF group who went on to union tended to have stemmed components and greater interprosthetic distance (IPD=189mm vs. 163mm, p=0.55) than non-united fractures. Patients who went on to nonunion in the revision arthroplasty group had higher medullary diameter: cortical width ratio (2.5 vs. 1.3, p=0.01) and lower IPD (36mm vs. 202mm, p=0.002). 95% of patients were ambulatory at latest follow-up. Conclusion. Interprosthetic femur fractures are technically and biologically challenging cases. An individualized approach of internal fixation versus revision arthroplasty led to a 79% success rate free of reoperation at 2 years with 95% of patients ambulatory. Continued improvements in management are warranted

Aims. Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care. Methods. This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance. Results. Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits. Conclusion. These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity. Cite this article: Bone Jt Open 2021;2(7):493–502

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control

Introduction. Osseointegration is a potential treatment option for transfemoral amputees experiencing socket related problems. Till this date, there is little data assessing the feasibility and advantages of osseointegration in individuals with transtibial amputations. Materials and Methods. We prospectively followed 91 patients undergoing transtibial osseointegration from 2014–2018 who either 1) reported pain or mobility dissatisfaction with socket prosthesis; 2) had an intact limb with incapacitating pain, complex deformity, or profound distal weakness or 3) were recent amputees preferring osseointegration. Adverse events were monitored including infection, periprosthetic fracture, implant breakage, aseptic loosening, revision surgery/additional amputation and death. Functional outcomes were measured using the Questionnaire of persons with a Trans-femoral amputation (Q-TFA) and mobility was assessed using Six Minute Walk Test (6MWT) and Time Up and Go (TUG). Results. Following osseointegration surgery, there was a significant increase in the Q-TFA global score, the 6MWT and the K-levels during follow-up. At one year following Osseointegration surgery, all patients were pain-free, the 11 patients who were wheelchair-bound prior to surgery were ambulatory, and the other 27 patient unable to walk prior to surgery, demonstrated improved mobility. There were 7 cases of implant removals due to pain and loosening and 10 cases of revisions within an average of 1.8 years, of which 1 was aseptic loosening, 6 due to infection, 1 failure to integrate and 2 implant fractures. No periprosthetic bone fractures occurred. Conclusions. Transtibial osseointegration results in improved functional outcomes after amputation. Complications are manageable and should decrease with surgical and implant improvements

Aims. Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. Methods. The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. Results. A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. Conclusion. After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84

At our tertiary, large, academic healthcare system, we have access to an academic medical center (AMC), a community based, orthopedic friendly, efficient hospital (CBH) and several ambulatory care centers (ASC) which are being prepared to provide same day discharge (SDD) TJA and UKA. We had a near-capacity AMC with an excellent ability to care for medically and technically complicated TJA patients. However, efficiency was less than desired regardless of case complexity with an average effective case time of 4 hours. Concurrently, the orthopaedically, under-utilized community-based hospital (CBH) wanted to increase volume, improve margins, and become a TJA Center of Excellence with the ability to provide an efficient Hospital Outpatient Department (HOPD) and SDD TJA surgery experience. Methods. The CBH had a main operating floor and a separate floor of four OR suites which were repurposed with the goal of utilizing these rooms for TJA four days per week with an average of 3.5 cases per room per day. We preferentially performed primary, uncomplicated TJA, UKA, and minimally invasive TJA at the CBH. Revision surgeries, patients with extensive medical comorbidities, and complex primary surgeries would be performed at the AMC. Our goals were to decrease costs, readmissions, length of stay, and increase margins at the CBH while increasing efficiency, revenue and volume. Protocols were developed to facilitate SDD UKA and THA at both hospitals as well as rapid recovery protocols for TKA at both hospitals with the understanding that the CBH would perform more of these cases but the efficiency could also be implemented at the AMC when possible. We also needed a strategy to deal with TKA and eventually THA being removed from the Inpatient Only (IPO) list. CMS has utilized the “Two-Midnight Rule” to define outpatient status for both THA and TKA. This has distinct financial implications for the facility's reimbursement with outpatient being $10,123 on average versus $12,380 for inpatient status. A protocol-based system was put in place to make both hospitals compliant with the removal of TKA from the IPO List in order to avoid Quality Improvement Organization (QIO) and Recovery Audit Contractor (RAC) after implementation. Results. Comparing FY 2018 to FY 2019, volume increased 26.4% at the CBH. Outpatient case volume rose substantially from 14 cases to 243. Volumes were slightly decreased at the AMC (−4.57%) resulting in a substantial increase in margin contribution for the parent enterprise. Quality metrics at the CBH (surgical site infections (SSI), length of stay (LOS), readmissions, and mortality) were improved. LOS improved from 52% to 71% discharge before 48 hours. The LOS decreased 12% for THA and 8.1% for TKA. CBH readmission rates decreased from 1.38% to 0.9% with no deaths. Surgeon satisfaction is greatly improved as their volume, efficiency, quality metrics, and finances were enhanced. Financial performance was improved in aggregate and per case for the CBH. Although the CBH per-case revenue was 80.3% and 74.4% of the AMC for THA and TKA: the net margins were 3.6% and 18.8% higher for THA and TKA, respectively. The increased efficiency, lower hospital cost and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. Conclusions. A shifting reimbursement landscape, value-based payment initiatives, and increasing volume have challenged traditional TJA delivery systems. This demonstrates one strategy to help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient settings including ambulatory surgery centers which will be subjected to even further decreases in net revenue per patient

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations). Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions. Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion. MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden

BACKGROUND. Ideal treatment of displaced femoral neck fragility fractures in the previously ambulatory patient remains controversial. Treating these patients with total hip arthroplasty has improved patient reported outcomes and reduced rates of revision surgery compared to those treated with hemiarthroplasty. However, possible increased risk of dislocation remains a concern with total hip arthroplasty. The anterolateral and direct anterior approaches to total hip replacement have been applied in the femoral neck fracture population to minimize dislocation rates. However, the anterolateral approach has been associated with abductor injury and increased rates of heterotopic ossification while the anterior approach has been associated with peri-prosthetic femur fracture, lateral femoral cutaneous nerve injury, and wound complications. The Supercapsular Percutaneously Assisted (SuperPATH) approach was developed to minimize disruption of the capsule and short-external rotators in an effort to reduce the risk of dislocation and assist in quicker recovery in the elective hip arthroplasty setting. To achieve this, the SuperPATH technique allows the femur to be prepared in situ and the acetabulum to be reamed percutaneously once the femoral head is removed. This study investigates the post-operative time to ambulation, length of stay, discharge destination, and early dislocation rate of previously ambulatory patients with a displaced femoral neck fragility fracture that were treated with a total hip arthroplasty via the SuperPATH technique. METHODS. A retrospective chart review was performed of previously ambulatory patients consecutively treated for a displaced femoral neck fragility fracture with a total hip replacement using the SuperPATH technique. Thirty-five patients were included in the study and examined for demographic data, time to ambulation, length of stay, major and minor complications during their hospital stay. Phone interviews were conducted to check for dislocation events. RESULTS. Thirty-five patients were included in the study with an average age of 75.7 years old (range 51–95). Patients spent an average of 5.35 ± 1.61 days in the hospital and were discharged on post-operative day 3.6 ±1.38. 89% of patients were able to stand and ambulate by post-operative day 1, and 97% of patients were able to stand and ambulate before discharge from the hospital. 26% of patients were able to be discharged home, 46% were discharged to in-patient rehabilitation, 23% were discharged to a skilled nursing facility, and one patient was discharged to hospice. There were no iatrogenic femoral fractures caused, no incidents of symptomatic heterotopic bone formation, and no superficial or deep wound infections. 88.5% of patients had adequate follow up averaging 370.6 ±235.18 days, with no dislocation events observed. CONCLUSION. These early results indicate that minimally invasive total hip arthroplasty utilizing the SuperPATH technique is a safe and effective treatment for displaced femoral neck fragility fractures in the previously ambulatory patient. Additionally, this technique allows for early ambulation without an increased risk of dislocation

Aims. The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality. Methods. All orthopaedic trauma cases at the Wrightington Wigan and Leigh NHS Foundation Trust from ‘lockdown’ (23 March 2020) to date (15 June 2020) were collated and split into three groups. Adult ambulatory trauma surgeries (upper limb trauma, ankle fracture, tibial plateau fracture) and regional-specific referrals (periprosthetic hip fracture) were performed at a stand-alone elective site that accepted COVID-19-negative patients. Neck of femur fractures (NOFF) and all remaining non-NOFF (paediatric trauma, long bone injury) surgeries were performed at an acute site hospital (mixed green/blue site). Patients were swabbed for COVID-19 before surgery on both sites. Age, sex, nature of surgery, American Society of Anaesthesiologists (ASA) grade, associated comorbidity, length of stay, development of post-surgical COVID-19 infection, and post-surgical COVID-19-related deaths were collected. Results. At the elective site, 225 patients underwent orthopaedic trauma surgery; two became COVID-19-positive (0.9%) in the immediate perioperative period, neither of which was fatal. At the acute site, 93 patients underwent non-NOFF trauma surgery, of whom six became COVID-19-positive (6.5%) and three died. A further 84 patients underwent NOFF surgery, seven becoming COVID-19 positive (8.3%) and five died. Conclusion. At the elective site, the rate of COVID-19 infection following orthopaedic trauma surgery was low, at 0.9%. At the acute mixed site (typical district general hospital), for non-NOFF surgery there was a 6.5% incidence of post-surgical COVID-19 infection (seven-fold higher risk) with 50% COVID-19 mortality; for NOFF surgery, there was an 8.3% incidence of post-surgical COVID-19 infection, with 71% COVID-19 mortality. This is likely to have significance when planning a resumption of elective orthopaedic surgery and for consent to the patient. Cite this article: Bone Joint Open 2020;1-9:556–561

Objective: To evaluate the effect of spinal fusion from T1, T2 to the sacrum with pelvic fixation using unit rod instrumentation on the ambulatory potential of pediatric patients with cerebral palsy. Study Design: A retrospective study of 24 ambulatory pediatric patients with spastic cerebral palsy and neuro-muscular scoliosis was performed. Summary of Background Data: Spinal deformities, occurring in patients with cerebral palsy and good ambulatory capacity, are infrequently associated with pelvic obliquity, and so instrumented spinal fusions traditionally do not extend to the pelvis. Methods: The medical charts and radiographs were reviewed, and the patients’ ambulatory ability was assessed clinically, with video tape or complete gait analysis. A questionnaire assessing patients’ functional improvement was given to the caretakers. Results: The study group included 17 female and 7 male patients, 19 quadriplegics and 5 diplegics. Follow-up evaluations for ambulatory function occurred at a mean of 2.86 years after surgery. Mean age at surgery was 15.4 years. Twenty patients underwent posterior spinal fusions and 4 patients combined anterior-posterior procedures. The patients were evaluated clinically pre-operatively, postoperatively and at follow-up with no alteration in their ambulatory status, except one patient who developed bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Thirteen patients had both preoperative and postoperative gait analysis, showing no change in their ambulatory function. The surgical outcome survey demonstrated significant improvement in the child’s physical appearance, head and trunk balance, sitting ability, amount of back pain, respiration, and no change in ambulatory capacity. Conclusions: Spine surgery with fusion extending to the pelvis in ambulatory patients with cerebral palsy provided excellent deformity correction and preserved their ambulatory function

Aims. Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. Methods. All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos’ Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board’s electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status. Results. A total of 58 surgical procedures were undertaken at the OSU during the study period; 93% (n = 54) of patients completed the telephone follow-up. Open reduction and internal fixation of ankle and wrist fractures were the most common procedures. None of the patients nor members of their households had developed symptoms suggestive of COVID-19 or required testing. No staff members reported sick days or were advised by occupational health to undergo viral testing. Conclusion. This study provides optimism that orthopaedic patients planned for surgery can be protected from COVID-19 nosocomial transmission at separate COVID-19-free sites. Cite this article: Bone Joint Open 2020;1-6:302–308

Aim. Knee arthrodesis (KA) and above knee amputation (AKA) have been used for salvage of failed total knee arthroplasty (TKA) in the setting of periprosthetic joint infection (PJI). The factors that lead to a failed fusion and progression to AKA are not well understood. The purpose of our study was to determine factors associated with failure of a staged fusion for PJI and predictive of progression to AKA. Method. We retrospectively reviewed a single-surgeon series of failed TKA for PJI treated with two-stage KA between 2000 and 2016 with minimum 2-year follow-up. Patient demographics, comorbidities, surgical history, tissue compromise, and radiographic data were recorded. Outcomes were additional surgery, delayed union, Visual Analog Pain scale (VAS) and Western Ontario and McMaster Activity score (WOMAC). No power analysis was performed for this retrospective study. Medians are reported as data were not normally distributed. Results. Fifty-one knees underwent fusion with median follow-up of 7 years (interquartile range (IQR) of 2–18 years). Median age was 71 years old (IQR 47 – 98), with a M:F ratio of 23:28. Median BMI was 34.3 kg/m2 (IQR 17.9–61). Infection was eradicated in 47 knees (92.2%); 24 knees (47.0%) required no additional surgery. 41 patients (83.6%) remained ambulatory after knee fusion, with 21% of these patients (10 total) requiring no ambulatory assistive device. Median VAS following arthrodesis was 4.6 (range 0–10). Median WOMAC was 36.2 (range 9–86). Three TKAs (5.9%) underwent AKA for overwhelming infection. Predictors of AKA were chronic kidney disease (OR 4.0, 95% CI 0.6–26.8), peripheral vascular disease (OR 3.5, 95% CI 0.3–44.7), AORI III bone loss (OR 2.6, 95% CI 0.4–35.2), instability (OR 2.2, 95% CI 0.2–15.9), and immunosuppression (OR 1.1, 95% CI 0.1–7.8). Tobacco use (OR 8.6, 95%CI 2.4–31.4), BMI>25 (OR 3.8, 95% CI 0.43–32.5) and instability prior to arthrodesis (OR 2.51, 95% CI 0.77–8.21) were associated with non-union. All other risk factors (gender, diabetes mellitus, chronic kidney disease, peripheral vascular disease, massive bone stock loss, and immunosuppression) were not associated with arthrodesis failure. Conclusions. Staged KA for PJI in severely compromised hosts provides a functional limb free of infection and rarely results in conversion to AKA. Given our small sample size, ability to establish statistical significance of predictive factors for AKA after PJI was limited, but CKD, peripheral vascular disease, AORI III bone loss, instability, and immunosuppression trended towards significance as predictors of failure of KA after PJI predisposing to AKA

The brief answer is no….I do not believe that outpatient total joint arthroplasty is the emergent standard of care. However, for some patients and some surgeons I do believe that outpatient total joint arthroplasty can be performed safely and with greater comfort and convenience for the patient. Further, for the surgeon, it can provide greater control over the care environment if performed at an ambulatory surgery center. Patient selection is paramount in my opinion for safely performing outpatient total joint arthroplasty. While some have attempted to define specific criteria, our own criteria include patients with simple orthopaedic problems who are healthy, trustworthy and have a good support system of family or friends to assist them. As surgeons we must also be self-aware as the margin for error, particularly at a freestanding ambulatory surgery center, is narrow. Operative times should be reliably brief and blood loss should be minimal to allow for a safe discharge on the same day. Further the incidence of intraoperative complications such as fractures at the time of total hip arthroplasty or ligament injuries during total knee arthroplasty should be low. The surgeon should also be prepared with the equipment to address these common issues, if they do occur. In our review of the NSQIP data set we matched 1,236 outpatient TJA 1:1 with inpatients based on propensity scores. The risk of 30-day readmissions and complications was no different between groups, although inpatients had a higher rate of VTE and outpatients had a higher risk of re-operation. Risk factors for adverse events included patient age > 85 years old, diabetes and BMI > 35. Likewise in a review of results from my own practice, we have seen no difference in the risk of complications. As health care providers we must keep the safety of our patients paramount at all times. Further, we must be fiscally responsible to avoid costly complications, reoperations and readmissions. With conservative patient selection and careful surgical technique I believe that outpatient TJA offers an attractive alternative that is safe, cost effective and associated with high satisfaction for both patients and surgeons

Background. Assessment of functional outcome after total hip arthroplasty (THA) often involves subjective patient-reported outcome measures (PROMs) whereas analysis of gait allows more objective assessment. The aims of the study were to compare longitudinal changes of WOMAC function score and ambulatory gait analysis after THA, between patients with low and high self-reported levels of physical function. Methods. Patients undergoing primary THA (n=36; m/f=18/18; mean age=63.9; SD=9.8yrs; BMI=26.3 SD=3.5) were divided in a high and low function group, on their preoperative WOMAC function score. Patients were prospectively measured preoperatively and 3 and 12 months postoperatively. WOMAC function scores 0–100) were compared to inertial sensor based ambulatory gait analysis. Results. WOMAC function scores significantly improved in both low and high groups at 3 months postoperatively whereas gait parameters only improved in with a low pre-operative function. Between 3 and 12 months postoperatively, function scores had not significantly further improved whereas several gait parameters significantly improved in the low function group. WOMAC function scores parameters were only moderately correlated (Spearman's r = 0.33–0.51). Discussion. In routine longitudinal assessment of physical function following THA, ambulatory gait analysis can be supplementary to WOMAC. As gait significantly improved during the first 3 months and following 9 months after THA in patients with a low preoperative level of physical function only, assessment of more demanding tasks than gait may be more sensitive to capture functional improvement in patients with high preoperative function. Acknowledgements. This article presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (RP-PG-0407-10070). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The research team acknowledges the support of the NIHR, through the Comprehensive Clinical Research Network

Aims. The aim of this study is to evaluate the clinical results of operative intervention for femoral metastases which were selected based on expected survival and to discuss appropriate surgical strategies. Methods. From 2002 to 2017, 148 consecutive patients undergoing surgery for femoral metastasis were included in this study. Prognostic risk assessments were performed according to the Katagiri and revised Katagiri scoring system. In general, the low-risk group underwent resection and reconstruction with endoprosthetic replacement (EPR), while the high-risk group underwent internal fixation (IF) and radiation therapy. For the intermediate-risk group, the operative choice depended on the patient’s condition, degree of bone destruction, and radio-sensitivity. Overall survival, local failure, walking ability, and systemic complications were evaluated. Results. A total of 83 patients underwent EPR (low-risk, 23%; intermediate-risk, 60%; high-risk, 17%) and 65 patients underwent IF (low-risk, 0%; intermediate-risk, 32%; high-risk, 68%). The one-year survival rate was 71% for EPR and 15% for IF (p < 0.001). The one-year local failure-free survival was 93% for EPR and 67% for IF, and the two-year and five-year local failure-free survival for EPR were both 88% (p = 0.016). Although the ambulatory rate was 99% for EPR and 60% for IF, the median time to ambulation was shorter in the IF (EPR, 28 days, interquartile range (IQR) 25 to 35; IF, 23 days, IQR 18 to 28; p < 0.001) The cause of non ambulation was mainly due to progression of cancer (89%). The rate of systemic complications was comparable between the two groups (EPR, 18%; IF, 22%; p = 0.598). Conclusion. Selective use of EPR where survival is expected to be good offers correspondingly good long-term results. IF is less invasive with shorter treatment period, which is beneficial for patients with short-term expected survival. Prognosis is an important indicator in selecting operative procedures for femoral metastasis. Cite this article: Bone Joint J 2020;102-B(3):285–292

Problem. Total hip replacement (THA) is among the most common and highest total spend elective operations in the United States. However, up to 7% of patients have 90-day complications after surgery, most frequently joint dislocation that is related to poor acetabular component positioning. These complications lead to patient morbidity and mortality, as well as significant cost to the health system. As such, surgeons and hospitals value navigation technology, but existing solutions including robotics and optical navigation are costly, time-consuming, and complex to learn, resulting in limited uptake globally. Solution. Augmented reality represents a navigation solution that is rapid, accurate, intuitive, easy to learn, and does not require large and costly equipment in the operating room. In addition to providing cutting edge technology to specialty orthopedic centers, augmented reality is a very attractive solution for lower volume and smaller operative settings such as ambulatory surgery centers that cannot justify purchases of large capital equipment navigation systems. Product. HipInsight™ is an augmented reality solution for navigation of the acetabular component in THA. HipInsight is a navigation solution that includes preoperative, cloud based surgical planning based on patient imaging and surgeon preference of implants as well as intraoperative guidance for placement of the acetabular component. Once the patient specific surgical plan is generated on the cloud-based planning system, holograms showing the optimal planned position of the acetabular component are exported in holographic format to a Microsoft HoloLens 2™, which the surgeon wears during placement of the acetabular component in total hip arthroplasty. The pelvis is registered using the HipXpert™ mechanical registration device, which takes 2–3 minutes to dock in the operating room. The surgeon then is able to view the patient's anatomy and optimal placement of the acetabular component under the skin in augmented reality. The surgeon then aligns the real cup impactor with the augmented reality projection of the cup impactor resulting in precise placement of the cup. Timescales. HipInsight was FDA cleared on January 28, 2021 for intraoperative use for placement of the acetabular component in total hip arthroplasty. The first case was performed in February 2021, and the product was launched to a select group of orthopedic surgeons in March 2021. Funding. HipInsight has been self-funded to date, and is beginning to engage in discussions to raise capital for a rapidly scaling commercial launch

Purpose: To determine the wound healing rate, perioperative mortality and ambulatory status of patients following knee disarticulation. Method: Retrospective review of all cases performed by one surgeon at tertiary center. Charts reviewed for demographic data, surgical and follow-up data. Ambulatory status preop and postop graded after Volpicelli et al. Descriptive statistics applied. Results: 34 knee disarticulations in 28 patients. 3 perioperative deaths (11%). Report on 31 procedures in 25 patients with mean follow-up of 7 months. 20 males, 5 females. Mean age 73 (55–92). PVD 21/25. Diabetes Mellitus 13/25 (52%). Chronic infection 2, Scleroderma 1 and squamous cell carcinoma 1. Primary wound healing 25 (81%). Delayed healing 6 (19%). Reoperation 1. Revision of amputation 0. Mean ambulatory status preop 2.5/6. Mean ambulatory status postop 1.8/6. Conclusion: Knee disarticulation is a reliable surgical procedure with 81% primary healing in high risk population. Knee disarticulation should be considered as an option to above knee amputation for patients with PVD and complications of diabetes

Introduction. Extraction of implants due to periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive hardware can be a daunting undertaking for surgeon and patient alike. We question whether irrigation and debridement (I&D) has a role in this difficult situation with respect to infection control, reoperation, and function. Methods. rTKAs for PJI from 2005–2016 were reviewed. Extensive hardware was defined as: metaphyseal cone/sleeve fixation, distal femoral replacement, periprosthetic fracture hardware, or stems >75mm. Cases were categorized by treatment (I&D or 2-stage exchange). Results. 87 patients were identified with extensive hardware and PJI − 63 I&Ds and 42 2-stages. Follow-up was 3.7 years. Success defined as no re-operation for infection was similar − 38/63 (60.3%) I&D vs 28/42 (66.7%) 2-stage (p=0.54). 26/42 (61.9%) 2-stages required static spacers for post-extraction bone loss or wound problems. Only 14/42 (33%) 2-stages were successfully replanted without re-infection. 11/42 (26.1%) 2-stages had retained spacers while 7/42 (16.7%) 2-stages were eventually fused. In contrast, 38/63 (60.3%) I&Ds maintained original implants without further surgery. 8/63 (12.7%) required repeat I&D; 9/63 (14.3%) underwent eventual 2-stage. Chronic antibiotic suppression was utilized in 53/63 (84.1%) I&Ds and 17/42 (40.5%) 2-stages (p<0.001). Amputation rates were similar − 9/63 (14.3%) I&D vs 7/42 (16.7%) 2-stage (p=0.79). Ambulatory rates were similar − 46/63 (73.0%) I&D vs 24/42 (57.1%) 2-stage (p=0.09). More patients who underwent I&D had a functional TKA at final follow-up (53/63 (84.1%) I&D vs 20/42 (47.6%) 2-stage; p<0.001). Mortality was high − 22/59 (37.3%) I&D vs 13/37 (35.1%) 2-stage (p=1.00). Conclusion. In the setting of PJI following rTKA with extensive hardware, morbidity and mortality is high. I&D with chronic suppression appears as effective as 2-stage procedures in preventing reoperation for infection and maintaining ambulatory status while avoiding the morbidity of 2-stage exchange

Aims. To examine incidence of complications associated with outpatient total hip arthroplasty (THA), and to see if medical comorbidities are associated with complications or extended length of stay. Patients and Methods. From June 2013 to December 2016, 1279 patients underwent 1472 outpatient THAs at our free-standing ambulatory surgery centre. Records were reviewed to determine frequency of pre-operative medical comorbidities and post-operative need for overnight stay and complications which arose. Results. In 87 procedures, the patient stayed overnight for 23-hour observation, with 39 for convenience reasons and 48 (3.3%) for medical observation, most frequently urinary retention (13), obstructive sleep apnoea (nine), emesis (four), hypoxia (four), and pain management (six). Five patients (0.3%) experienced major complications within 48 hours, including three transferred to an acute facility; there was one death. Overall complication rate requiring unplanned care was 2.2% (32/1472). One or more major comorbidities were present in 647 patients (44%), including previous coronary artery disease (CAD; 50), valvular disease (nine), arrhythmia (219), thromboembolism history (28), obstructive sleep apnoea (171), chronic obstructive pulmonary disease (COPD; 124), asthma (118), frequent urination or benign prostatic hypertrophy (BPH; 217), or mild chronic renal insufficiency (11). Conclusion. The presence of these comorbidities was not associated with medical or surgical complications. However, presence of one or more major comorbidity was associated with an increased risk of overnight observation. Specific comorbidities associated with increased risk were CAD, COPD, and frequent urination/BPH. Outpatient THA is safe for a large proportion of patients without the need for a standardised risk assessment score. Risk of complications is not associated with presence of medical comorbidities. Cite this article: Bone Joint J 2018;100-B(1 Supple A):31–5

Accurate placement of the acetabular component is essential in Total Hip Arthroplasty (THA). The purpose of this study is to determine if an analog spirit level can improve the surgeon's ability to achieve acetabular inclination within the “safe-zone” of 30 to 50 degrees. We reviewed 167 primary THAs performed by a single surgeon over 14 months. Procedures were performed at two facilities, an inpatient hospital where a spirit level was utilized and an ambulatory facility where it was not. We excluded 47 patients with a BMI>40, age>68 or a surgical indication other than osteoarthritis who were not candidates for the ambulatory center. Cup inclination angles were measured from de-identified plain radiographs by two blinded investigators not involved in the index procedures. The effect of level usage on inclination angle was determined using multivariate regression analysis. The mean inclination angle for the 68 hips performed with the level was 42.9 degrees (95% CI: 41.7–44.0) compared to 46.5 degrees (95% CI: 45.2–47.7) for the 52 hips without it (p<.001). Regression analysis demonstrated a 9.1% difference in cup inclination due to the level (p<.001), and THAs performed without the level were 3 times more likely to result in inclinations > 50 degrees (OR 2.8, p=.036). The two investigators' measurements demonstrated a correlation of 0.95 (95% CI: 0.93–0.97). Use of a simple spirit level resulted in a significant reduction in the number of outliers compared to the freehand technique. The spirit level may be a simple and inexpensive tool to improve acetabular component abduction angles

Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and ambulatory surgery centers (ASC) in a large metropolitan healthcare system were retrospectively reviewed. All surgeons were experienced and beyond learning curves. 247 cases were excluded to eliminate confounds. Operating room (OR) in and out times and surgical times were collected via EMR electronic and manual data extraction with verification. Multivariate statistical analyses were utilized with p<0.05 significant. Results. 1261 DA approach (43%) and 1647 posterior approach (57%) THAs were analyzed. Mean total OR time, including anesthesia and positioning, was greatest for hospital-based DA THAs (146 mins), followed by hospital posterior approach THAs (126.4 mins), ASC-based DA THAs (118.1 mins) and ASC posterior THAs (90.1 mins) (p<0.001). In multivariate analysis, compared to the optimal ASC posterior approach group, the total OR time predictive model added 31 minutes per ASC DA THA, 33 minutes per hospital posterior THA, and 56 minutes for hospital DA THA (p<0.001). Similar predictive effect was observed for surgical time, which added 18 minutes per ASC-based DA THA, 22 minutes for hospital posterior THA and 29 minutes for hospital DA THA (p<0.001). Conclusion. In the COVID era, efficiency should be enhanced to maximize patient access for elective procedures and facilitate the healthcare system financial recovery. Despite equivocal clinical results, DA approach THA consumes substantially more OR time when compared to the posterior approach in both the hospital and ASC setting

Aim. We present the long-term surgical outcomes, complications, implant survival and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins. Patients and Methods. A cohort of 50 consecutive patients who underwent the modified Harrington procedure along with cemented THA for peri-acetabular metastasis or haematological malignancy between 1990 and April 2018 were studied. The median follow-up time for all patients was 14 years (interquartile range, 9 – 16 years). Results. The 5-year overall survival rate was 33% for all the patients. However, implant survival rates were 100% and 46% at 5 and 10 years respectively. Eight patients survived beyond 5 years. There was no immediate peri-operative mortality or complications. Fifteen late complications occurred in 11 patients (22%). Five (10%) patients required additional surgeries to treat complications. The most frequent complication was pin breakage without evidence of acetabular loosening (6%). Two patients (4%) underwent revision for aseptic loosening at 6.5 and 8.9 years after surgery. Ambulatory status improved in 83%. Conclusions. The modified Harrington procedure for acetabular destruction showed low complication rates, good functional outcome and improved pain relief in selected patients. Long-term results are acceptable in this high risk group of patients. The described procedure using antegrade fully threaded large diameter pins combined with standard arthroplasty showed low rates of complications in this high risk cohort of patients with significant improvement in mobility and pain. This method of reconstruction remains robust for at least 5 years in appropriately selected group of patients

Aim. Calcaneal osteomyelitis is an uncommon and challenging condition. In this systemic review we aim to analyse the concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis. Method. A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis. Results. Of the 20 studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients. In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status showed preservation or even improvement of the preoperative ambulatory status. Conclusions. Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is necessary for treatment success. Based on the localisation and size of the bone and soft tissue defect, decision for surgical treatment should be made

Aims. The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins. Patients and Methods. A cohort of 50 consecutive patients who underwent the modified Harrington procedure for periacetabular metastasis or haematological malignancy between January 1996 and April 2018 were studied. The median follow-up time for all survivors was 3.2 years (interquartile range 0.9 to 7.6 years). Results. The five-year overall survival rate was 33% for all the patients. However, implant survival rates were 100% and 46% at five and ten years, respectively. Eight patients survived beyond five years. There was no immediate perioperative mortality or complications. A total of 15 late complications occurred in 11 patients (22%). Five patients (10%) required further surgery to treat complications. The most frequent complication was pin breakage without evidence of acetabular loosening (6%). Two patients (4%) underwent revision for aseptic loosening at 6.5 and 8.9 years after surgery. Ambulatory status and pain level were improved in 83% and 89%, respectively. Conclusion. The modified Harrington procedure for acetabular destruction has low complication rates, good functional outcome, and improved pain relief in selected patients. Cite this article: Bone Joint J 2019;101-B:1557–1562

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

We performed a randomized feasibility trial to examine the impact of preoperative femoral nerve block (FNB) on elderly patients with hip fractures, including those with mild to moderate cognitive impairment. We evaluated the impact of preoperative FNB on the following outcomes within 5 days of surgical fixation: 1. Pain levels, 2. Total narcotic consumption, 3. Postoperative mobilization. Randomized allocation of 73 patients in a 2:1 intervention:control ratio. To allow comparison between the 2 groups as well as sub- analysis of the intervention group to examine treatment fidelity (i.e. the ability to deliver the intervention as planned). Inclusion criteria: Patient age≥ 65 years admitted with a low energy hip fracture, ambulatory preinjury, Mini Mental State Exam MMSE score≥13 (moderate dementia), Able to provide direct or proxy consent. Exclusion criteria: Admission ≥ 30 hours after injury, prior regular use of opiates. Potential participants were identified and either participants or proxy respondents provided signed informed consent. Participants allocated to the intervention group received a FNB administered by the UAH acute pain service (APS) within 20 hours of admission to hospital in addition to the usual care. Participants in the control group received usual care. Participants were followed for 5 days postoperatively with daily assessment of pain, narcotic consumption, delirium and mobility. Main outcome measure: (1) Pain at rest and activity (2) Preoperative and postoperative opioid consumption, (3) Mobilization in POD#1. Overall, 73 participants were enrolled (23 Control: 50 FNB). The FNB group was slightly older (mean [SD] 80.1 [8.7] vs. 76.2 [9.2], p=0.09) and had more males (21 [42%] vs. 5 [22%], p=0.09) than the Control group. The mean MMSE score for both groups was >24 (p=0.35 for group comparison), suggesting minimal cognitive impairment of participants. The FNB group reported significantly less pain at rest and activity than the control group over time (p < 0 .001 for both). Opioid consumption were non-significantly higher and more variable in the control group preoperatively (Median [25, 75 quartile] 10.6 [0, 398] vs 7.5 [0, 125], p=0.26) and postoperatively (13.1 [0, 950] vs 10 [0, 260], p=0.31). 41 (85%) of FNB participants mobilized on day 1 vs. 16 (73%) of control participants (p=0.21). Preoperative FNB significantly reduced pain. Opioid consumption was not significantly different, but more variable in the control group. Although not significant, more FNB patients successfully mobilized on day 1 postoperatively. Participants with cognitive impairment were not enrolled due to difficulty in obtaining proxy consent. A definitive randomized trial would be feasible and add valuable information about pain management following hip fracture

Introduction. The advent of ambulatory total joint replacements has called for measures to reduce postoperative length of stay, while improving patient function and postoperative satisfaction. This prospective, randomized trial evaluated the efficacy of one-on-one preoperative physical therapy (PT) education with a supplemental web-based PT web-portal on discharge disposition, postoperative function and patient satisfaction after total joint replacement. Materials & Methods. Between February and June 2015, 126 patients underwent unilateral total knee (n=63) or total hip arthroplasty (n=63). All patients attended a group preoperative education (preopEd) class [standard of care] and were subsequently randomized into two groups. One group received no further education as per the standard of care [control; TKA= 31; THA=32] and the other received an in-person one-on-one preoperative PT education session (preopPTEd) as well as access to a web-portal during the postoperative period [experimental; TKA=32; THA=31]. Discharge disposition was attained from hospital records. Patient satisfaction and WOMAC scores were evaluated by a series of patient administered questionnaires. Results. The group that received preopPTEd trended towards a reduction in hospital length of stay compared to the current standard of care (2.4 days vs. 2.6 days; p=0.077). However, the group that received preopPTEd met the postoperative functional discharge requirements significantly faster (1.6 days vs. 2.7 days, respectively; p<0.001) and required fewer postoperative PT visits (3.3 vs. 4.4 visits respectively; p<0.001) than those who did not. With respect to satisfaction, patients who received the preopPTEd felt they were better prepared to leave the hospital postoperatively and were overall more satisfied with their postoperative education (p<0.001 and p<0.001, respectively). The majority (69.8%) of patients who did not receive preopPTEd reported that they would have benefitted from additional preopPTEd. There were no clinically relevant improvements in the WOMAC subscores or total score between the groups. All findings were consistent in both the TKA and THA sub-groups. Conclusion. Patients who received the preopPTEd required fewer PT visits and met the postoperative functional PT discharge criteria faster than those who did not. Patients who received preopPTEd also reported being better prepared to leave the hospital after surgery and better overall satisfaction compared to the current standard of care. The one-on-one preoperative PT education session with supplemental web-portal education pathway may be an adjunct to help reduce postoperative length of stay for ambulatory total joint replacements

Revision is a key negative outcome of joint replacements. The purpose of this abstract is to present revision risk curves for hip and knee replacements based on the most recently available national data sources. Having a better understanding of determinants of revision risk can help inform clinical and health care system improvements. We explored revision risk of primary joint replacement stratified by key clinical, prosthesis, and surgeon-level factors using data from three databases managed by CIHI: the Canadian Joint Replacement Registry (CJRR), the Discharge Abstract Database, and the National Ambulatory Care Reporting System. To investigate early revisions, we used Kaplan-Meier analysis stratified by demographic factors to determine the risk of revision within up to five years of primary surgery. This analysis identified the primary cohort from the CJRR from April 1, 2012 to March 31, 2017 and was limited to mandatory reporting provinces (British Columbia, Manitoba and Ontario) to ensure maximal coverage of prosthesis information. Bearing surface was obtained from the International Prosthesis Library maintained by the International Consortium of Orthopaedic Registries (ICOR) and the International Society of Arthroplasty Registers (ISAR). The total revision risk cohort contained 283,620 primary surgeries, of which 5,765 (2%) had at least one revision. For total hip arthroplasties, revision risk at the end of the follow-up period did not differ by age, by sex or across bearing surface (metal on cross-linked polyethylene [XLPE], ceramic on XLPE, ceramic on ceramic, metal on non-cross-linked polyethylene). For hemiarthroplasties in hip fracture patients, cement fixation was significantly associated with decreased revision risk. Surgeon volume had a positive effect on survivorship with cementless fixation (2.7% at one year [95% CI 2.3%, 3.1%] for high-volume vs 3.2% [2.7%, 3.7%] for low-volume). However, surgeon volume did not have an effect on survivorship with cemented fixation (2% at one year [95% CI 1.3%, 2.6%] for high-volume vs. 2% [1.4%, 2.6%] for low-volume). For total knee replacements, revision risk increased with decreasing age and male sex. For patients aged 75 and older, four-year revision risks were 1.5% (95% CI 1.3%, 1.7%) for women and 2.0% (1.7%, 2.3%) for men, but for patients under 55 years old, they were 4.3% (3.7%, 5%) for women and 5.9% (4.9%, 6.9%) for men. Additional results from the upcoming 2019 CJRR annual report, including data up to March 31, 2018, will be presented. Revisions represent a key failure of the primary replacement, they are costly to the health care system and negatively affect patients' quality of life. CJRR's coverage is currently 72%, increased coverage and follow-up time will allow increasingly comprehensive reporting on hip and knee prostheses in Canada. Future work in this area involves exploring additional prosthesis attributes for stratification of revision risk curves and calculation of hazards ratios adjusted by age and sex

Aims

To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials.

The April 2024 Trauma Roundup³⁶⁰ looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?.

Introduction. Rapid increase of aged population has been one of major issue affecting national health care plan in Japan. In 2006, Japanese Orthopaedic Association proposed the clinical entity of musculoskeletal ambulation disorder symptom complex (MADS) to define the elderly population with high risk of fall and ambulatory disability caused by musculoskeletal disorders. Osteoarthritis of the knee is one of major cause of MADS. The number of patients with MADS underwent total knee arthroplasty (TKA) had been increased in Japan, and also expected to increase worldwide in the near future. The effectiveness of TKA for the patient with MADS has not been well evaluated. In the present study, we analyzed the early post-operative functional recovery after TKA using 2 simple performance tests to diagnose MADS. Material & Method. Fifty patients with varus type osteoarthritic knees implanted with posterior-stabilized (PS) TKAs were subjected to this study. There were 44 female and 6 male patients. The mean age of the patients was 71.6 years (range, 59 to 84 years). Patients were subjected to 2 functional performance tests which were essential tests for MADS diagnosis. Firstly, 3 meter timed up and go test (TUG) was used to evaluate ambulation. Secondary one leg standing time with open eyes was measured to assess balancing ability. 2 tests were performed pre-operatively, 2 weeks after surgery and at discharge (23.8 days po). MADS was defined to be diagnosed if TUG and one leg standing time was not less than 11 seconds and/or less than 15 seconds respectively. Each parameter was compared among at above mentioned three time points -using a repeated measured analysis of variance (p<0.05). Results. The number of the patients with MADS were 37, 44 and 38 in 50 patient pre-operatively, 2 weeks after surgery and at hospital discharge respectively. Mean TUG was 12.9, 16.9 and 14.0 sec. respectively [fig 1]. TUG significantly increased during 2 weeks after TKA, followed by significant decrease at discharge. There were no significant improvements in ambulation during hospital stay. Mean one leg standing time with operated and non-operated side leg at three time points were 11.0, 12.4, 17.9 sec, and 18.4, 17.9, 24.2 sec. each respectively [fig 2]. There were no significant improvements during initial 2 weeks after surgery. Significant increase of one leg standing time was found after 2 weeks, and balancing ability was found to be improved during hospital stay. Discussion & Conclusion. Although both parameters assessing ambulatory and balancing function were found to be improved post-operative 2 weeks, still as much as 76% of patients were suffered from MADS at hospital discharge in our patient population. These results indicate that the patient after TKA has still exposed to high risk of fall and ambulatory dysfunction at discharge. We should reconsider the appropriate rehabilitation protocol especially for the elderly patient with MADS to meet with patient expectation and enhance early post-operative care

Acetabular cup positioning remains a real challenge and component malpositioning after total hip arthroplasty (THA) can lead to increased rates of dislocation and wear. It is a common cause for revision THA. A novel 3D imageless mini-optical navigation system was used during THA to provide accurate, intraoperative, real-time, and non-fluoroscopic data including component positioning to the surgeon. This retrospective comparative single surgeon and single approach study examined acetabular component positioning between traditional mini-posterolateral THA and mini-posterolateral THA using the 3D mini-optical navigation system. A retrospective chart review was conducted of 157 consecutive (78 3D mini-optical navigation and 79 traditional non-navigation methods) THAs performed by the senior author using a mini-posterolateral approach at an ambulatory surgery center and hospital setting. Two independent reviewers analyzed postoperative radiographs in a standardized fashion to measure acetabular component positioning. Demographic, clinical, surgical, and radiographic data were analyzed. These groups were found to have no statistical difference in age, gender, and BMI (Table I). There was no difference between groups in acetabular components in the Lewinnek safe zone, 31.2% vs 26.6% (p = 0.53). Cup anteversion within the safe zone did not differ, 35.1% vs 40.5% (p = 0.48); while cup inclination within the safe zone differed, with more in the navigation group, 77.9% vs 51.9% (p < 0.01). Change in leg length was significantly different with the navigation group's leg length at 1.9 ± 6.3, less than the traditional at 5.4 ± 7.0 (p < 0.01). There was no difference in mean change in offset between groups (4.5 ± 5.9 vs 6.2 ± 7.9, p = 0.12); navigation, traditional) (Table II). The 3D mini-optical navigation group did have significantly longer operative time (98.4 ± 17.5 vs 89.3 ± 15.5 p < 0.01). Use of the novel 3D Mini-optical Navigation System significantly improved cup inclination compared to traditional methods while increasing operative time. For any figures or tables, please contact the authors directly

Fragility fractures associated with osteoporosis (OP) reduce quality of life, increase risk for subsequent fractures, and are a major economic burden. In 2010, Osteoporosis Canada produced clinical practice guidelines on the management of OP patients at risk for fractures (Papaioannou et al. CMAJ 2010). We describe the real-world incidence of primary and subsequent fragility fractures in elderly Canadians in Ontario, Canada in a timespan (2011–2017) following guideline introduction. This retrospective observational study used de-identified health services administrative data generated from the publicly funded healthcare system in Ontario, Canada from the Institute for Clinical Evaluative Sciences. The study population included individuals ≥66 years of age who were hospitalized with a primary (i.e. index) fragility fracture (identified using ICD-10 codes from hospital admissions, emergency and ambulatory care) occurring between January 1, 2011 and March 31, 2015. All relevant anatomical sites for fragility fractures were examined, including (but not limited to): hip, vertebral, humerus, wrist, radius and ulna, pelvis, and femur. OP treatment in the year prior to fracture and subsequent fracture information were collected until March 31, 2017. Patients with previous fragility fractures over five years prior to the index fracture, and those fractures associated with trauma codes, were excluded. 115,776 patients with an index fracture were included in the analysis. Mean (standard deviation) age at index fracture was 80.4 (8.3) years. In the year prior to index fracture, 32,772 (28.3%) patients received OP treatment. The incidence of index fractures per 1,000 persons (95% confidence interval) from 2011–2015 ranged from 15.16 (14.98–15.35) to 16.32 (16.14–16.51). Of all examined index fracture types, hip fractures occurred in the greatest proportion (27.3%) of patients (Table). The proportion of patients incurring a second fracture of any type ranged from 13.4% (tibia, fibula, knee, or foot index fracture) to 23% (vertebral index fracture). Hip fractures were the most common subsequent fracture type and the proportion of subsequent hip fractures was highest in patients with an index hip fracture (Table). The median (interquartile range [IQR]) time to second fracture ranged from 436 (69–939) days (radius and ulna index fracture) to 640 (297–1,023) days (tibia, fibula, knee, or foot index fracture). The median (IQR) time from second to third fracture ranged from 237 (75–535) days (pelvis index fracture) to 384 (113–608) days (femur index fracture). This real-world study found that elderly patients in Ontario, Canada incurring a primary fragility fracture from 2011–2015 were at risk for future fractures occurring over shorter periods of time with each subsequent fracture. These observations are consistent with previous reports of imminent fracture risk and the fragility fracture cascade in OP patients (Balasubramanian et al. ASBMR 2016, Toth et al. WCO-IOF-ESCEO 2018). Overall, these data suggest that in elderly patients with an index fragility fracture at any site (with the exception of the radius or ulna), the most likely subsequent fracture will occur at the hip in less than 2 years

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

Introduction. Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have focused on payer type and have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry plays a role in quality outcomes and discharge disposition following THA. Methods. The electronic medical record at our institution was retrospectively reviewed for all primary, elective, unilateral THA between January 2016 and June 2018. THA recipients were categorized as either Hospital Ambulatory Clinic Centers (HACC) with Medicaid as the primary payer or private office patients with a non-Medicaid primary payer based on a previous visit to our institution's HACC within the 6-months prior to surgery. Only patients who had been operated on by a surgeon with at least 10 HACC and 10 private office patients were included. Results. A total of 426 patients were included in this study, with 114 HACC and 312 private office patients. HACC patients were significantly younger (p<0.01), more likely to be black or “other” race (p<0.01), and more likely to be a current smoker (p<0.01). In the unadjusted model, length of stay (p=0.15) and surgical time (p=0.03) were greater in HACC patients. There was no difference in discharge disposition (p=1). After adjusting for patient risk factors, LOS was greater for HACC patients, whereas surgical time and facility discharge were lower. Conclusion. There was a significant difference in surgical time between HACC and private clinic patients. After controlling for patient risk factors, LOS, surgical time, and facility discharge were similar between the two groups. These results indicate that similar outcomes can be achieved for Medicaid patients as compared to non-Medicaid patients as long as the surgeon and patient care setting are similar. For any tables or figures, please contact the authors directly

Objective: To identify the demographics, risk factors and guidelines for treatment in a population of cerebral palsy (CP) children with fractures. Materials and Methods: One hundred and fifty children with CP received treatment for fractures from 1948 through 2000. To identify changes in demographics, patients treated before 1992 were compared to those treated after 1992. The latter group was matched by age and gender to a group of CP children without fractures and compared for: CP pattern, bone density, ambulatory status, presence of G-tube, weight for height-age Z score, surgical procedures during the previous year, presence of contractures in the proximity of the fracture and seizure medications. All data was analyzed statistically. Results: 67% of patients had a spastic quadriplegic pattern of CP and 89% were non-ambulatory; 78% of fractures occurred in lower limbs, 48% of the fractures were delayed in diagnosis, and 62% of patients showed osteo-penia. Children treated after 1992 had higher incidence of multiple fractures, less contractures, and less surgical procedures. The risk factors identified for increased fracture risk were: the use of seizure medication (p=.001), quadriplegic CP pattern (p=.005), decreased ambulatory status (p=.001), and lower bone density (p=.001). Most fractures were treated with soft bulky dressing. Conclusions: Ambulatory status and the presence of seizure medication are the greatest risk factors for fracture in children with CP. As a consequence, a low bone density occurs. Future research should focus on underlying fracture mechanisms and prevention

The August 2023 Trauma Roundup³⁶⁰ looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

The outcome of complex acetabular reconstruction was evaluated in twenty-one patients who were confined to a wheelchair or bed because of pain from acetabular metastases. Reconstruction rings were used where bone loss exceeded 50% of the acetabulum. Six roof reinforcement-rings, eight ilioischial-rings and eight Harrington reconstructions were performed. All but two patients(90%) became ambulatory without pain. Median survival was nine months. Two patients underwent acetabular revision for recurrence. These results support the role of acetabular reconstruction for palliation of pain in appropriate patients with acetabular metastases. Metastatic disease of the acetabulum is painful and disabling. Operative intervention is indicated in certain patients with pathologic fractures, and non-responders to adjuvant treatment. The functional outcome of hip arthroplasty with reconstruction rings was evaluated in twenty-one patients with acetabular metastases between 1989 and 2001. Preoperatively all patients were confined to a wheelchair or bed and used significant narcotic medications. Preoperative radiotherapy was employed in eighteen cases (90%) and 30% had undergone chemotherapy. AAOS classification of the acetabular lesion revealed: six-type II, seven-type III and eight-type IV deficiencies. All cases required a reconstruction ring due to bone loss exceeding 50% of the acetabular dome. Six roof reinforcement rings, eight ilioischial rings and eight Harrington reconstructions with rings were performed in this group. Determination of the reconstructive technique was based on preoperative computerized tomography and intraoperative examination of the acetabular deficiency. All but two patients (90%) became ambulatory without significant pain. Eleven patients used a walker or two canes and nine walked with one or no canes. Median survival was nine months and patients with visceral involvement had a shorter duration. Eight early post-operative complications developed in six patients (29%). In two patients the acetabular construct failed with cup migration due to locally recurrent disease; both were successfully revised. The results of complex acetabular reconstruction for metastatic disease validate its role for palliation of pain and to improve ambulatory status. Preoperative planning with computerized tomography can assist in classifying acetabular bone loss and determining optimal reconstruction technique

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

The June 2023 Wrist & Hand Roundup³⁶⁰ looks at: Residual flexion deformity after scaphoid nonunion surgery: a seven-year follow-up study; The effectiveness of cognitive behavioural therapy for patients with concurrent hand and psychological disorders; Bite injuries to the hand and forearm: analysis of hospital stay, treatment, and costs; Outcomes of acute perilunate injuries - a systematic review; Abnormal MRI signal intensity of the triangular fibrocartilage complex in asymptomatic wrists; Patient comprehension of operative instructions with a paper handout versus a video: a prospective, randomized controlled trial; Can common hand surgeries be undertaken in the office setting?; The effect of corticosteroid injections on postoperative infections in trigger finger release.

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Introduction. Hip arthroplasty is considered common to patients aged 65 and over however, both Jennings, et al., (2012) and Bergmann (2016) found THA patients are substantially younger with more patients expecting to return to preoperative activity levels. With heavier, younger, and often more active patients, devices must be able to support a more demanding loading-regime to meet patient expectations. McClung (2000) demonstrated that obese patients can display lower wear-rates with UHMWPE bearing resulting from post-operative, self-induced reduced ambulatory movement, thus questioning if obese kinematics and loading are indeed the worst-case. Current loading patterns used to test hip implants are governed by ISO 14242-1 (2014). This study aimed to characterize a heavy and active population (referred to as HA) and investigate how the gait profile may differ to the current ISO profile. Method. A comprehensive anthropometric data set of 4082 men (Gordon, CC., et.al., 2014) was used to characterize a HA population. Obese and HA participants were classed as BMI ≥30 however HA participants were identified by applying anthropometric ratios indicative of lower body fat, namely “waist to height” (i.e. WHtR <0.6) and “waist to hip” (i.e. WHpR <0.9). Findings. Of 491 obese participants 61 were identified as HA (i.e. BMI> 30, WHpR<0.9; WHtR<0.6) (Figure 1). These characteristics were validated against a population of elite rugby players that were found to be a true reflection of HA patients (Figure 2). Combining the Army and Rugby populations resulted in a weight of 123kg for the 95. th. percentile, which based on 3× body weight (as referenced in ISO14242-1) would equate to a peak simulator load of 3620N. Conclusion. Characterization of a HA population was successfully defined as clinically obese by BMI, but with WHtR and WHpR associated with lower body fat. The author was unable to identify gait characteristics of a HA population through existing literature. Future Work. A gait-lab based study will be used to compare literature-based kinematics of obese subjects to those of HA subjects. A worst-case gait cycle can then be established for standard walking and other activities and translated into hip simulator parameters for HA patients

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal peri-operative management reducing pain, nausea, and length of stay leading to outpatient joint replacement surgery with recovery at home. The surgical procedures included in the outpatient program have expanded from Partial Knee Arthroplasty to Primary TKA, Primary THA, and selected revision cases. Emerging data demonstrate safety, reduced cost, and reduced resources. Since 2011, we helped develop and implement an outpatient program as part of 76 participating physician-owned ambulatory facilities in 19 states − 19,415 joint replacements have been performed. The cohort included 6,146 TKA, 5,102 THA, 7,227 partial knee replacements, and 940 revisions and TSA. Patients had a mean age of 58 years and 50% of the patients were female; 97% of patients were discharged same day, the deep infection rate was 0.2%, and the readmission rate was 0.3%. The outpatient program centers on the patient needs, family engagement, essentials of home recovery, pre-operative education, efficient surgery, and a surgeon controlled environment with highly standardised care. This is a distinct shift in today's health care environment, which has seen the expansion of regulatory demands; focus on Electronic Health Records (EHR), and distractions from real discussions of demonstrated value creation. The future is bright for both ASC and hospital development of successful outpatient joint replacement program for patients and surgeons alike