The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated

The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to free hand orthopaedic operation notes. A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to free hand operation notes. 97 cases were identified, of which 74 were free hand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes vs 0 (0%) in the free hand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the free hand op-note group (templated median 14, range 12-14, vs. free hand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by Registrars or Consultants identified Registrars as more likely to document the antibiotic prophylaxis given (p = 0.025). Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations

Abstract. INTRODUCTION. In the NHS the structure of a “regular healthcare team” is no longer the case. The NHS is facing a workforce crisis where cross-covering of ward-based health professionals is at an all-time high, this includes nurses, doctors, therapists, pharmacists and clerks. Comprehensive post-operative care documentation is essential to maintain patient safety, reduce information clarification requests, delays in rehabilitation, treatment, and investigations. The value of complete surgical registry data is emerging, and in the UK this has recently become mandated, but the completeness of post-operative care documentation is not held to the same importance, and at present there is no published standard. This project summarises a 4-stage approach, including 6 audit cycles, >400 reviewed operation notes, over a 5 year period. OBJECTIVE. To deliver a sustainable change in post operative care documentation practices through quality improvement frameworks. METHODS. Stage 1: Characterise the problem and increase engagement through: SMART aims, process mapping, hybrid action-effect and driver diagram and stakeholder analysis. Multi disciplinary stakeholders were involved in achieving a consensus of evidence-based auditable criteria. Stage 2: Baseline audit to assess current practice. Stage 3: Intervention planning by stakeholders. Stage 4: Longitudinal monitoring through run charts and iterative refinement. RESULTS. Stage 1: Process mapping identified numerous downstream effects of the absence of critical information from operation notes, and the action-effect diagram highlighted the multiple unnecessary mitigating actions performed by ward staff. An MDT consensus was achieved on 15 essential criteria for complete documentation, including important negative fields. Interest-influence matrix identified stakeholder groups with high influence but low interest who needed engagement to deliver change. Stage 2: Baseline audit demonstrated unexpectedly poor documentation: >75% compliance in 4 criteria, and <50% compliance in 10 criteria, which elevated the interest of key stakeholders. Stage 3: A post-operative care template based on the 15 criteria was embedded within the existing IT software. It allowed use of existing operative templates, with a non-overwriting suffix requiring only two mouse clicks. Stage 4: Re-audit at 3 and 12 months showed improved and sustained compliance. At 24 months compliance had declined. Questionnaire of template usage identified problems of criteria response options, and lack of awareness of template by newly appointed staff. Template update improved compliance over the next 6 months (>75% compliance in 11 criteria). Finally, a further reaudit conducted 12 months after the template update (5 years post baseline audit) showed a sustained improvement in compliance (>75% compliance in 13 criteria). CONCLUSIONS. Simple innovation through quality improvement frameworks has changed documentation practices by 1) achieving a consensus from stakeholders, 2) a “shock and awe” moment to highlight existing poor documentation and increase engagement 3) implementing change which fit easily into existing systems, 4) respecting autonomy rather than enforcing change and 5) longitudinal monitoring using run charts and an iterative process to ensure the template remains fit for purpose. This model has now successfully been translated to other subspecialities within the orthopaedic department. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Purposes of study. Evaluation of the pre-operative documentation of neurovascular status in children presenting with Gartland Grades 2 and 3 supracondylar fractures and the development of an Emergency Department Proforma. Methods and results. A retrospective case-note review was performed on patients with Gartland Grade 2 and 3 supracondylar fractures observed in a two-year period from July 2008 – July 2010. 137 patients were included; sixteen patients (11.7%) sustained a Gartland Grade 2a fracture, sixty patients (43.8%) a Gartland Grade 2b fracture and sixty-one (44.5%) a Gartland Grade 3 fracture. Mean patient age at presentation was 5.59 years (range 12 months to 13 years). Nineteen patients (13.9%) had evidence of neurological deficit at presentation and thirteen patients (9.5%) presented with an absent radial pulse. Only twelve patients (8.8%) and nineteen patients (13.9%) respectively had a complete pre-operative neurological or vascular assessment documented. Regarding the individual nerves, fifty-nine (43.1%) patients had median nerve integrity documented, fifty-five (40.1%) ulnar nerve and forty-nine (35.8%) radial nerve integrity documented. Only eighteen patients (13.1%) had their anterior interosseous nerve function documented. Ten patients (7.3%) had post-operative neurological dysfunction, consisting of eight ulnar nerve injuries, and two radial nerve injuries. vi) Conclusions. Pre-operative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of anterior interosseous nerve examination was particularly poor. We propose the introduction of a proforma (Liverpool Upper-limb Fracture Assessment – LUFA) to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries

Background and Aims. Daily senior review is of paramount importance to provide optimal clinical care and facilitate timely discharge. Also, the General Medical Council state in Good Medical Practice 2013 that “work should be recorded clearly, accurately and legibly…containing relevant clinical findings, decisions made and actions agreed”. This audit aims to evaluate whether all trauma and elective Orthopaedic patients at one unit receive a daily senior review, which is fully documented in the case-notes, and whether a Comprehensive Unit-based Safety Programme (CUSP) toolkit can better facilitate this?. Methods. Case-notes for all patients admitted under Trauma and Orthopaedics on three separate non-consecutive days during a two-week period were scrutinized, examining them for the presence of CUSP toolkits and whether these were adequately completed. Results. 71 case-notes containing 291 CUSP toolkits were analysed. 46.4% had a completed toolkit for everyday since admission; however for those that did not, over half (55.2%) did not have a senior review documented elsewhere for the missing days. Only 1.4% of case-notes had a full complement of up-to-date CUSP toolkits completed entirely correctly. For patients on Orthopaedic wards, most common errors were failure to document date and time (69.7% incorrect), ward and bed number (30.7% incorrect), patient alerts (70.7% incorrect) and overall compliance in documentation of required parameters such as MRSA status, investigations, observation and fluid charts (23% incorrect). Conclusion. In conclusion, better education for clinical staff is needed to improve compliance both with daily senior review, CUSP toolkits and overall documentation to provide optimum patient care

Background. The British Orthopaedic Association Standards for Trauma (BOAST) for peripheral nerve injuries. 1. states:. “A careful examination of the peripheral nervous and vascular systems must be performed and clearly recorded for all injuries. This examination must be repeated and recorded after any manipulation or surgery.”. This study investigated whether this standard was met for patients with upper limb trauma at a busy London Accident and Emergency (A&E) Department. Method. Data was gathered prospectively from A&E admission notes for 30 consecutive patients with upper limb injuries from the week beginning 11. th. March 2013. Eligibilty: All patients with upper limb injuries. Results. 30 patients: 18 Males mean age of 39.2 and 12 Females mean age of 40.1. 17 patients (56.6%) had documentation of examination of neurovascular status. 14 patients required manipulation and/or splinting of their injury. Of these, no patients had their neurovascular examination documented after the procedure. Poor adherence to the standard is evident across all grades of doctors: FY2, SHO and SpR. Conclusion. There is clear scope to improve documentation of neurovascular status in upper limb injuries. It is especially important to clearly document neurovascular status following manipulation or splinting from a medico-legal perspective. This applies to all grades of staff in A&E. Recommendations. 1. Education of A&E staff of all grades at the departmental induction. 2. Posters in A&E with simple treatment algorithm for managing fractures and dislocated joints. 3. Re-audit in 6 months

Introduction. Medical Exposure Directive of the European Commission, 97/43/Euratom recommended setting-up local national diagnostic reference levels (DRLs) for the most common radiological examinations in order to comply with the law and to maintain safe clinical practice. There are no guidelines for spinal diagnostic and therapeutic procedures. The aims of this study were to evaluate local radiation doses & screening times for diagnostic spinal blocks, to look at PACS image intensifier films for diagnostic representation and to assess the accuracy of data in IR(ME) document. Materials and Methods. Between 1/01/2009 and 15/07/2010, all spinal blocks done under care of three spinal surgeons (LB/NC/AAC) were reviewed. Images revisited on PACS for confirmation. We reviewed 229 patients (included single & two levels nerve root blocks, facet joint and lysis blocks). Data were collected with regard to radiation dose, screening times, third-quartile values used to establish DRLs, IR(ME) documentation and PACS fluoroscopic image documentation. Results. Third quartile single level NRB DAP (Dose area product) was 111.5 cGyCm2. Single level NRB screening time was mean-0.13, third quartile-0.2 min. Nerve specific dosimetry included L5 nerve (0.2 min; 119cGyCm2) and S1 nerve (0.2 min; 118.7cGyCm2). Mean ‘Click: Block ratio’ (last click for PACS/Block) was 22.4 (SD=7.05, range 10 to 48). Local fluoroscopic documentation was 87.2%. Conclusions. There are no national standards in radiation dosimetry for diagnostic spinal blocks. We recommend that all spinal units in the UK should evaluate their own DRLs to help establish national guidelines for fluoroscopy-guided spinal procedures. Representative fluoroscopic image documentation on PACS was 87% locally. It is a joint responsibility of radiographer & operating surgeon to make it 100% to reduce medicolegal risks

Background: The interpretation of safety data from clinical studies such as complication risks requires clear definition of targeted and documented complication events. In addition a standardized classification of complications is required to allow appropriate comparison of safety data between studies and treatment groups. This presentation highlights a proposal for a standardized management and classification of complication data to initiate and seek consensus among trauma surgeons active in clinical documentation and research. Methods: Complication events are examined regarding their timing of occurrence as well as their potential causal inter-relationship for any given patient. While independent events are numbered sequentially, directly associated events (e.g. a fracture collapse and implant screw perforation into a joint) receives the same complication number. Complications are described and categorized according to a pre-defined list of anticipated complication types, or as un-anticipated complications. They are further classified as local or general; local complications occur at or directly around the injuries and are further classified as being “Implant/Surgical procedure”, “Bone/Fracture” or “Soft tissue/Wound” events. Information regarding their operative and/or non-operative treatment and their outcome is recorded. Further assessments are made regarding their seriousness, their relation to the implant used. Final classification of complication events is better determined after independent review by a panel of experienced clinicians. Results: Our classification process was applied successfully to a series of clinical studies at our department. In a study of 185 distal radius fractures treated by LCP, at least one complication occurred in 21 patients, and in seven cases there was a combination of associated events (e.g. one CTS with tendon rupture). Complication risks ranging from 0% to 11.4% were noted depending on which complications and time frames were considered. There was no risk to obtain a LCP implant specific related complication, whereas the risk for a local complication within 6 months after surgery was 6% (95% CI: 3% – 11%). Conclusions: This management and classification system proved valuable in the documentation and analysis of safety data from clinical studies. It facilitates communication and understanding of definitions between clinicians, as well as allows a prompt, standardised and accurate analysis and reporting of complication events and risks. We encourage other clinical researchers and professionals to participate in the further development and acceptance of a universal classification system for complications in traumatology and orthopaedics

Background: The number of total ankle replacements has been raising in the last years. Most publications present short- and medium-term results. Comparison of outcomes is difficult because of inconsistent terminology and different parameters used. Moreover, poorly performing implants cannot be identified quickly because of low numbers, delayed reporting or publication bias. Methods: Therefore, we have developed a module for total ankle prostheses in the framework of the International Documentation and Evaluation System (IDES) for standardized and centralized documentation of TAA outcomes. Content validation was conducted with a single surgeon series of 74 HINTEGRA_ ankle replacements. Results: Between March 2004 and February 2008 74 patients were treated. The preoperative diagnosis was 18.9% osteoarthritis, 32.4% rheumatoid arthritis, 43.3% posttraumatic, 1.4% osteonecrosis and 4% others. There were intraoperative complications in 4%, local postoperative complications in 17.6% and revision surgeries in 16.2% of patients. The AOFAS hind-foot score improved from 23.8 points preoperative to 75.3 points after a mean followup time of 8.4 months. No significant differences in outcome were revealed between the various diagnostic groups. Conclusion: The IDES-forms facilitate a structured and standardized data collection that is feasible in a research orientated but also purely clinical setting; this because of the different extents to which data can be recorded. The consistent use of the system assures a stringent internal quality assurance, and more interesting, an external quality assurance by means of comparisons and benchmarking with other users feeding the data pool with the exact same variables and outcomes. The Hintegra ankle appeared as a safe device with low complication rates in the hands of a foot and ankle specialist. A surgical learning curve was seen in the first two years

The 1995 Audit Commission report, “Setting the Record Straight- A study of hospital medical records,” criticised the poor standard of NHS record keeping. A retrospective audit of documentation of patients undergoing a closed manipulation of distal radius fractures (Colles type) in the Accident and Emergency department of the Queen Alexandra Hospital revealed that note keeping still needs to be improved. Only 15% of patients had adequate documentation

Integrated care pathways (ICPs) have been shown to have many benefits in clinical practice and are being widely adopted in orthopaedic surgery. A high standard of medical record keeping is important for safe patient care and provides information for research, audit and medico-legal purposes. This study compares the quality of medical notation in an ICP with traditional record keeping. During a 3 month period 53 total hip replacements (ICP notation) and 30 total knee replacements (traditional notation) were performed in our unit. The records of each patient were scrutinised using a standardised scoring system, based on The Royal College of Surgeons’ guidelines on medical record keeping. Each set of records (83) were scored for admission clerking, subsequent entries, consent form, operation note and discharge letters. The time taken to retrieve this information was also recorded. The overall score for traditional records (mean 70%) was significantly higher than for the ICP records (mean 62%), p=0.001. The mean scores for initial clerking, subsequent entries and consent form were higher in the traditional record group. It took 35% longer to retrieve information from the ICP group (p < 0.001). In this study the quality of record keeping was higher when using the traditional notation than an established Integrated Care Pathway. In both groups the standard of clinical documentation was disappointing and must be improved if the potential clinical advantages of ICPs are to be realised. Better education of junior staff and regular auditing of medical records could improve this

This paper will focus on the use and including a demonstration of Digital photography for the purpose of clinical documentation, audit, teaching and research. Digital photography is particularly suitable in upper & lower limb surgery because of the discrete regional anatomy and radiology. Digital images once created and stored do not deteriorate, unlike pictures or slides. Digital camera that uses a single floppy disc has an added advantage of simplicity and ease of storage. Pre-op, intra-op, and post-op images of patients undergoing hand surgery and treatment are easily documented with the camera. The information can be archived using commercially available filing software such as File MakerPro. The information can be retrieved at a later stage to be used in audit, teaching and research, with the images retained in their original, unmodified condition. Existing clinical, historical and teaching library slides, pictures or images can be archived to ensure the quality of the images do not deteriorate further, and for ease of retrieval and subsequent application. Archiving in this manner would require a slide scanner. The ease of file retrieval, reliability and accuracy of this imaging system has been tested using a minimum of 2000 patient files, using both PC and Macintosh systems, with no computer error and minimal operator errors found. The software used has “auto save” feature built in, hence computer “crash resistance.” The only limitation of the technology is the set up costs, and the resolution of the images. Fortunately, both these limitations are improving rapidly

One of the ethical and legal requirements of valid consent for treatment is that patients must be fully informed about the complications involved. The General Medical Council (UK) insists that all adverse outcomes of a treatment, which are serious or frequently occurring, must be discussed with the patient.

Previous studies have found a large variance in the risks documented on consent forms for orthopaedic hip operations. The aim of this study was to compare the risks documented for three orthopaedic hip operations against pre-constructed operation-specific consent forms endorsed by the British Orthopaedic Association.

We retrospectively analysed 300 consent forms for total hip replacements, hip hemiarthoplasties and dynamic hip screw operations (n=100 for each) and noted the risks documented, whether the form was completely legible, the grade of the Doctor obtaining consent and whether a copy of the consent form was given to the patient.

We found that of the 300 operations, only 43.1% of the complications were documented as recommended by the British Orthopaedic Association. Furthermore, 26.3 % of consent forms were illegible, 72.7% of patients were consented by the Senior House Officer and only 13.7% of patients were offered a copy of the consent form.

Our results indicate that the Methods: of obtaining consent and filling in the consent forms for orthopaedic hip operations could be vastly improved. One method which could be utilized to achieve this would be the incorporation of procedure specific templates in the consenting process. These templates are already in the public domain and free to use at www.orthoconsent.com. This would allow the patient to weigh up the risks and make a valid informed decision about their treatment and also protect the Doctors from any possible litigation.

Tourniquet is a commonly used tool in orthopaedic practice. Incidence of complications is low but if any develops, it is devastating. Transient nerve damage, ischemia or skin burns are the possible tourniquet related complications. There is big variation in practice regarding the limb occlusion pressure. 51 procedures in 50 patients were reviewed retrospectively in our district general hospital. We looked at quality of documentation guided by the BOAST standard (The Safe Use of Intraoperative Tourniquets, published in October 2021). Limb occlusion pressure and ischemic time were analysed. Intra-operative and post-operative notes were reviewed to assess quality of documentation and post-operative complications. Although limb occlusion pressure was above the recommended range in more than 75% of cases, there were no significant complications observed. Two cases only developed transient neuropraxia in common peroneal nerve and median nerve following tibial plateau ORIF and trapeziectomy simultaneously. Tibial ORIF fixation case had prolonged ischemic time (more than 120 minutes) and the limb occlusion pressure for the hand case was above the recommended range. Both have recovered within few days with no long-term consequences. Minimum documentation threshold was not met with regarding tourniquet site condition, method of skin isolation and padding, and exsanguination method. This relatively new standard with no previous similar guidance needs time until it is followed by the health care professionals especially when there is no high incidence of complications related to the use of the tourniquet. However, it is crucial to increase the theatre staff awareness of such standards. This will prevent devastating complications specifically in vulnerable patients. Adjustments to theatre checklist have been suggested to improved documentation. Additionally, local teaching sessions will be delivered to theatre personnel aiming at improving our compliance to this standard

The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation. Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12-month period in a single-centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores. A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading. This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritise improving documentation of informed consent for orthopaedic trauma patients to ensure a patient-centred approach to healthcare

Trauma, across the United Kingdom, is managed using several software, paper based lists on Microsoft Word/Excel or Teams. There is usually poor handover or no handover in a standard format- during the on call, in the trauma meetings or in the wards. The software in the market for trauma management are not cost friendly or adaptable to local demands. The alternatives like Microsoft WORD based lists are fraught with their own problems. We endeavoured to make our trauma management effective. A Quality Improvement Project was done. The goals to achieve at end of a year were:. Daily Trauma Handover in standardised format >90%. Ward Handover in standardised format >90%. Availability of outcomes of patients in clinic >80%. Reduction of paper usage >90% at the end of six months. Availability of updated “outliers” information >90% at the weekend ward round. Documentation from the Trauma Meeting > 90%. On-Call documentation in standardised format >90%. Doctor Satisfaction >75% in terms of: ease of us;, searchability of patient; ward round experience; morning trauma meeting experience; handover experience; inter-specialty communication; reliability; daily time saving; on-call time saving; patient care/safety; overall satisfaction. We used Microsoft Sharepoint List to manage our trauma workload and have named the tool as “The List”. The List has achieved all objectives as above in one year's time, except Outlier information which was at 67% in a recent PDSA (Plan-Do-Study-Act) cycle. The survey showed excellent doctor satisfaction and 90% respondents felt that The List saved an hour or more during the on-call and also during the ward rounds. We conclude that The List is a very powerful tool making trauma meetings efficient and handover effective. It is indigenous, adaptable, safe, sustainable, cost neutral and easy to use

Introduction. Compartment syndrome can be a life changing consequence of injury to a limb. If not diagnosed and treated early it can lead to permanent disability. Neurovascular observations done on the ward by nursing staff, are often our early warning system to those developing compartment syndrome. But are these adequate for detecting the early signs of compartment syndrome? Our aim was to compare the quality and variability of charts across the UK major trauma network. Materials & Methods. All major trauma centres in England and Scotland were invited to supply a copy of the neurovascular chart routinely used. We assessed how such charts record relevant information. Specific primary data points included were pain scores, analgesia requirements, pain on passive stretch and decreased sensation in the first web space specifically. As secondary objectives, we assessed how late signs were recorded, whether clear instructions were included, quantitative scores and the use of regional blocks recorded. Results. A response rate of 46% was achieved. Of the charts reviewed, 25% documented pain scores or pain on passive movement. Pain on movement and analgesia requirements were documented in 33% and 8% respectively. Specific sensation within the 1. st. webspace was recorded in 16%. No charts recorded use of regional block. All charts recorded global sensation, movement (unspecified), pulse and colour whilst 66% documented capillary refill and 83% temperature. Instructions were included in 41% of charts. Conclusions. In 2016, the BOA supported publication of an observation chart for this purpose however, it is not widely used. In our study, late signs of compartment syndrome were generally well recorded. However, documentation of early signs and regional blocks was poor. This may lead to delays in diagnosis with significant clinical and medicolegal consequences. Standardisation of documentation by updating and promoting the use of the pre-existing chart would ensure highest quality care across the network

Aims. The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective. Methods. The OBC and the patellotrochlear index were used as part of the Oswestry Patellotrochlear Algorithm (OPTA) to guide the surgical treatment of patients with patellar instability. Patients were assigned to one of four treatment groups: medial patellofemoral ligament reconstruction (MPFLr); MPFLr + tibial tubercle distalization (TTD); trochleoplasty; or trochleoplasty + TTD. A prospective analysis of a longitudinal patellofemoral database was performed. Between 2012 and 2018, 202 patients (233 knees) with a mean age of 24.2 years (SD 8.1), with recurrent patellar instability were treated by two fellowship-trained consultant sports/knee surgeons at The Robert Jones and Agnes Hunt Orthopaedic Hospital. Clinical efficacy of each treatment group was assessed by Kujala, International Knee Documentation Committee (IKDC), and EuroQol five-dimension questionnaire (EQ-5D) scores at baseline, and up to 60 months postoperatively. Their safety was assessed by complication rate and requirement for further surgery. The pattern of clinical outcome over time was analyzed using mixed regression modelling. Results. In all, 135 knees (mean age 24.9 years (SD 9.4)) were treated using a MPFLr. Ten knees (7.4%) required additional surgery. A total of 50 knees (mean age 24.4 years (SD 6.3)) were treated using MPFLr + TTD. Ten (20%) required additional surgery. A total of 20 knees (mean age 19.5 years (SD 3.0)) were treated using trochleoplasty + TTD. Three patients (15%) required additional surgery. In each treatment group, there was a significant improvement in Kujala, IKDC, and EQ-5D at one year postoperatively (p < 0.001) with a recognized level of overall complication rate. Conclusion. The OBC is a valid assessment tool to grade patients with trochlear dysplasia and, when used as part of the OPTA, helps to determine treatments that are safe and effective. This fulfils the requirements for its application in mainstream clinical practice. Cite this article: Bone Joint J 2021;103-B(10):1586–1594

Aims. The aim of this retrospective study was to determine if there are differences in short-term clinical outcomes among four different types of matrix-associated autologous chondrocyte transplantation (MACT). Methods. A total of 88 patients (mean age 34 years (SD 10.03), mean BMI 25 kg/m. 2. (SD 3.51)) with full-thickness chondral lesions of the tibiofemoral joint who underwent MACT were included in this study. Clinical examinations were performed preoperatively and 24 months after transplantation. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Brittberg score, the Tegner Activity Scale, and the visual analogue scale (VAS) for pain. The Kruskal-Wallis test by ranks was used to compare the clinical scores of the different transplant types. Results. The mean defect size of the tibiofemoral joint compartment was 4.28 cm. 2. (SD 1.70). In total, 11 patients (12.6%) underwent transplantation with Chondro-Gide (matrix-associated autologous chondrocyte implantation (MACI)), 40 patients (46.0%) with Hyalograft C (HYAFF), 21 patients (24.1%) with Cartilage Regeneration System (CaReS), and 15 patients (17.2%) with NOVOCART 3D. The mean IKDC Subjective Knee Form score improved from 35.71 (SD 6.44) preoperatively to 75.26 (SD 18.36) after 24 months postoperatively in the Hyalograft group, from 35.94 (SD 10.29) to 71.57 (SD 16.31) in the Chondro-Gide (MACI) group, from 37.06 (SD 5.42) to 71.49 (SD 6.76) in the NOVOCART 3D group, and from 45.05 (SD 15.83) to 70.33 (SD 19.65) in the CaReS group. Similar improvements were observed in the VAS and Brittberg scores. Conclusion. Two years postoperatively, there were no significant differences in terms of outcomes. Our data demonstrated that MACT, regardless of the implants used, resulted in good clinical improvement two years after transplantation for localized tibiofemoral defects. Cite this article: Bone Joint Res 2021;10(7):370–379

Abstract. Introduction. Total knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR. The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs). There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation. Methodology. Trial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were contacted to understand their capacity to implement the intervention locally. Results. The STAR care pathway was successfully implemented into NHS practice with a screening response rate of 83%. It is now permanently part of usual care at North Bristol NHS Trust. Trial centres indicated that lack of availability of STAR trained ESPs as a barrier to implementation. The trial manual and training session were adapted for online delivery in partnership with Health Education England. Conclusion. The STAR care pathway has been successfully embedded into NHS care. A toolkit and online clinician training package enables national implementation

Photobiomodulation (PBM), the use of light for regenerative purposes, has a long history with first documentations several thousand years ago in ancient Egypt and a Nobel Price on this topic at the beginning of last century (by Niels Finsen). Nowadays, it is in clinical use for indications such as wound healing, pain relief and anti-inflammatory treatment. Given the rising numbers of in vitro studies, there is increasing evidence for the underlying mechanisms such as wavelength dependent reactive oxygen production and adenosine triphosphate generation. In cartilage regeneration, the use of PBM is controversially discussed with divergent results in clinics and insufficient in vitro studies. As non-invasive therapy, PMB is, though, of particular importance, since a general regenerative stimulus would be of great benefit in the otherwise only surgically accessible tissues. We therefore investigated the influence of different wavelengths - blue (475 nm), green (516 nm) or red (635 nm) of a low-level laser (LLL) - on the chondrogenic differentiation of chondrocytes and adipose derived stromal cells of different human donors and applied the light in different settings (2D, 3D) with cells in a proliferative or differentiating stage. All assessed parameters (spheroid growth, histology, matrix quantification and gene expression) revealed an influence of LLL on chondrogenesis in a donor-, wavelength- and culture-model-dependent manner. Especially encouraging was the finding, that cells with poor chondrogenic potential could be improved by one single 2D treatment. Amongst the three wave lengths, red light was the most promising one with the most positive impact. Although in vivo data are still missing, these in vitro results provide evidence for a proper biofunctional effect of LLL

Abstract. Aims. Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods. Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results. 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal technique were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion. Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures

Background. Advanced spinal practitioner physiotherapists (ASPPs) assess and manage spinal referrals, as advocated by the National Low Back Pain Pathway in the United Kingdom. The ASPP pathway relies on multi-disciplinary team (MDT) meetings where potential surgically appropriate or complex cases can be discussed. Meetings were held with two different Consultant Spinal Neurosurgeons (total 2 meetings per month). The aim of this service evaluation was to assess MDT meeting outcomes and surgical listing. Methods. This retrospective service evaluation used routinely collected MDT meeting documentation between May 2019 and October 2021. Data was extracted by two ASPPs, and 20% checked by a third ASPP. Extracted data included: number of patients discussed, Consultant, reason for discussion, and outcome (surgical listing or other). Data was analysed by two ASPPs using pivot tables in Microsoft Excel and was reported using counts and percentages across month and year. Results. The majority of MDT discussions were for a surgical opinion (n=293, 25% clinician led, n=351, 30% patient led). Of these, 46% (n=135) of clinician surgical opinions were directly listed compared to 20% (n=70) of patient led discussions. Similar rates of consultant clinic review were seen between the two groups (22% and 32%), suggesting that the majority of patients discussed for surgical consideration were appropriate. 517 (45%) were discussed for management opinion. Conclusions. This evaluation demonstrates that a majority of cases (68%) identified by ASPPs for surgical opinion were either directly listed or had consultant clinic surgical review. The results and trends identified will guide future patient pathway development and ASPP training. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

The principal of “function priority, early rehabilitation, and return to sports” is now the goal for sports injury rehabilitation. Neuromuscular electrical stimulation for anterior cruciate ligament (ACL) reconstruction is a rising procedure for early rehabilitation. This paper systematically assessed the effects of neuromuscular electrical stimulation on postoperative ACL reconstruction to provide guidance for physiotherapist and patient when designing a suitable rehabilitation protocol. To evaluate the interventional outcomes of neuromuscular electrical stimulation following ACL reconstruction, we searched PubMed, EMbase, the Cochrane Library, Web of Science and CNKI to collect all randomized controlled trials (RCTs) comparing the effects with neuromuscular electrical stimulation and without intervention on rehabilitation after ACL reconstruction up to January 30, 2022. Two investigators independently performed literature screening, data extraction, bias assessment of risk, and used RevMan 5.3 software to conduct a meta-analysis. A total of six RCTs were included, and the results showed that the use of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction significantly improved the International Knee Documentation Committee (IKDC) scores (MD 6.33, 95% CI [-0.43, 12.22]; I2 = 66%; p = 0.040), the Lysholm score (MD 7.94, 95% CI [6.49, 9.39]; I2 = 89%; p < 0.001), and the range of motion (ROM) (MD 9.99, 95% CI [7.97, 12.02]; I2 = 81%; p < 0.001) in the knees when compared to the control group without using neuromuscular electrical stimulation. Existing evidence show that neuromuscular electrical stimulation is beneficial for early rehabilitation after ACL reconstruction. The use of neuromuscular electrical stimulation is encouraged in the design of rehabilitation protocol. However, due to the limited number of RCT studies and the small sample size, further multi-center RCTs with more participants are needed for a higher-level evidence

Aims. To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up. Methods. We reviewed 155 patients (155 knees) who underwent MOHTO from January 2008 to December 2016 followed by second-look arthroscopy with a mean 5.3-year follow-up (2.0 to 11.7). Arthroscopic findings were assessed according to the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) grading system. Patients were divided into two groups based on the presence of normal or nearly normal quality cartilage in the medial femoral condyle: good (second-look arthroscopic) status (ICRS grade I or II; n = 70), and poor (second-look arthroscopic) status (ICRS grade III or IV; n = 85) groups at the time of second-look arthroscopy. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form survey. Results. Significant improvements in all clinical outcome categories were found between the preoperative and second-look arthroscopic assessments in both groups (p < 0.001). At the latest follow-up, the mean IKDC and WOMAC scores in the good status group further improved compared with those at the time of second-look arthroscopic surgery (p < 0.001), which was not shown in the poor status group. The mean IKDC (good status, 72.8 (SD 12.5); poor status, 64.7 (SD 12.1); p = 0.002) and mean WOMAC scores (good status, 15.7 (SD 10.8); poor status, 21.8 (SD 13.6); p = 0.004) significantly differed between both groups at the latest follow-up. Moreover, significant correlations were observed between ICRS CRA grades and IKDC scores (negative correlation; p < 0.001) and WOMAC scores (positive correlation; p < 0.001) at the latest follow-up. Good cartilage status was found more frequently in knees with the desired range of 2° to 6° valgus correction than in those with corrections outside this range (p = 0.019). Conclusion. Second-look arthroscopic cartilage status correlated with clinical outcomes after MOHTO at intermediate-term follow-up, despite the relatively small clinical differences between groups. Cite this article: Bone Joint J 2021;103-B(11):1686–1694

There has been extensive research into neck of femur fractures in the elderly. Fragility non-hip femoral fractures share many of the same challenges [1]. Surgical management is complex, patients are frail and mortality rates have been reported as high as 38% [2]. Despite this, relatively little data is available evaluating the level of MDT care provided to non-hip femoral fractures. This audit aimed to evaluate the standard of MDT care provided for patients with non-hip femoral fractures according to the NHFD key performance indicators. The following fractures were included in the dataset: distal femoral, femoral shaft and peri-prosthetic femoral. Patients under 65 were excluded. Data was retrospectively collected using post-operative and medical documentation. Performance was assessed according to five key performance indicators:. Did orthogeriatrics review the patient within 72-hours?. Was surgery performed within 36-hours?. Was the patient weight bearing post-operatively?. Was a confusion assessment completed?. Was the patient discharged home?. 38 patients met the inclusion criteria. 84% of patients were seen by orthogeriatrics within 72 hours of admission. 32% of patients were operated on within 36-hours of admission, with time to theatre exceeding 36-hours in 92% of peri-prosthetic fractures. 37% of patients were not advised to full weight bear post operatively. 84% of patients received a confusion assessment whilst 61% of patients were discharged to their prior place of living. Our results suggest that non-hip femoral fractures do not receive the same standard of MDT care as neck of femur fractures. Greater prioritisation of resources should be given to this patient subset so that care is equivalent to hip-fracture patients. Time to surgery is a particular area for improvement, particularly in peri-prosthetic fractures, a trend that is mirrored nationally. Greater emphasis should be placed on encouraging full-weight bearing post-operatively to prevent post-surgical complications

One assumed function of Total Ankle Replacement (TAR) is that by maintaining ankle joint motion we can protect the other hind foot joints from further degredation. 1. However, there is no work to our knowledge that compares hindfoot outcomes between TAR and arthrodesis. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion. 2. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. We performed a retrospective review of all patients at our centre who had had a TAR or ankle arthrodesis since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patients were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. 214 arthrodesis cases and 302 TAR were eligible. The average age was 57. Average time to follow up was 13 years (4–21). At the time of abstract submission 107 sets of notes had been reviewed fully. Full analysis will be performed by conference. 14% of TAR patients went on to have further procedures to the hindfoot joints while 35% of arthrodesis patients had further procedures (p=0.014). There was also a significant difference in the number of patients progressing to fusion of a further hindfoot joint between groups (TAR- 4%, arthrodesis- 20%, p=0.01). These data suggest that TAR are protective of symptomatic change of hindfoot joints. Patients with TAR had fewer hindfoot fusions than those with arthrodesis and also fewer procedures of any form, including injections

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41. Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this

Aims. The aim of this prospective study was to assess the long-term clinical, radiological, functional, and quality of life (QoL)-related outcome of patients treated with the synthetic Ligament Advanced Reinforcement System (LARS) device for anterior cruciate ligament (ACL) rupture. Methods. A total of 41 patients who underwent ACL reconstruction with the LARS device (mean age 39.8 years (SD 12.1 ); 32% females (n = 13)) were prospectively included between August 2001 and March 2005. MRI scans and radiographs were performed at a median follow-up of 2.0 years (interquartile range (IQR) 1.3 to 3.0; n = 40) and 12.8 years (IQR 12.1 to 13.8; n = 22). Functional and QoL-related outcome was assessed in 29 patients at a median follow-up of 12.8 years (IQR 12.0 to 14.0) and clinically reconfirmed at latest median follow-up of 16.5 years (IQR 15.5 to 17.9). International Knee Documentation Committee (IKDC) and Tegner scores were obtained pre- and postoperatively, and Lysholm score postoperatively only. At latest follow-up, range of motion, knee stability tests, 36-Item Short Form Health Survey (SF-36), and IKDC scores were ascertained. Complications and reoperations during follow-up were documented. Results. Cumulative complication rate was 66% (n = 27), with 11 developing within one year from surgery and 16 after one year (including five patients with both early and late complications). Ten graft failures (24%) and eight cases of reactive synovitis were observed (20%). All 11 patients with early complications and ten with late complications underwent reoperation (including five with another surgical procedure for early complications), amounting to a cumulative reoperation rate of 51% (n = 21). Revision ACL reconstruction was performed in one patient (2.4%). Median IKDC at latest follow-up was 89.7 (IQR 78.2 to 93.1), being significantly worse in the event of previous complications. Lachman test was positive in 56% (n = 15) of reconstructed knees. All norm-based SF-36 items were at or above median at latest follow-up, and did not differ depending on development of complications. Conclusion. Despite good functional and QoL-related results in the long term, the cumulative complication rate of 66%, including graft failures and reactive synovitis, has to be viewed with great concern. Cite this article: Bone Joint J 2022;104-B(2):242–248

To describe clinical situations for use of modified VAC in POC based on: diagnosis, comorbidities, BMI, wound size in cm, days following trauma when VAC was first applied, total duration of uninterrupted use, frequency of change, settings, bacterial growth, outcomes. To report the outcomes of mVAC use in POC within 6 months to help improve and standardize its application in the institution. This study involves data gathering from inpatients handled by orthopedic surgeons in training and subspecialty rotations in POC. The data collected are highly dependent on the doctors-in-charge's complete charting, thorough reporting and accurate documentation. Modified Vacuum Assisted Closure (mVAC) is used frequently in this study and is defined as a form of revised, adapted and reformed use of VAC based on available materials in the involved institution. The materials that are included are, but not limited to the following: sterile Uratex™ blue foam, nasogastric or suction tubing, phlegm suction machine, Bactigras™ and Opsite™ or Ioban™. A total of 58 patients were included in the study. The average age of the population was 35 and are predominantly male. The most common mechanism of injury was motorcycle accident and 37 of the patients were diagnosed with an open fracture of the lower extremity with open tibia fractures (22) being the most common. Average wound area measured was 24.12 cm. 3. All patients yield a bacteria growth with e. coli being the most frequent. Average during of uninterrupted use was 39 days. Of the 58 included in the study, 8 patients underwent STSG, 2 had a flap coverage surgery, 4 patients eventually underwent amputation and 33 with complete resolution of soft tissue defect after conversion to biologic dressing post-mVAC. The rest of the population were still ongoing mVAC at the end of the study. mVAC is an alternative temporary medium for soft tissue coverage for cases with or without concomitant fractures. mVAC promotes removal of exudate from the wound, supports wound apposition and granulation bed proliferation. Usage mVAC helps prepare for skin coverage procedure and on some cases leads to full resolution of defect

The documentation of deep infection rates in joint replacement is fraught with multiple difficulties. Deep infections acquired in theatre may present late, but some later presenting deep infections are clearly haematogenous, and not related to surgical management. The effect of Ultra Clean Air on infection rates was published by Charnley in 1972 (CORR,87:167–187). The data is valuable because large numbers of THRs were performed in standard and Ultra Clean theatres, and detailed microbiology of the air was also recorded. No IV antibiotics were used, so only the effect of air quality was studied. We extracted the data on theatre type and numbers from Table 3, and numbers and intervals from surgery of deep infections from Table 7. Theatre types with 300 air changes per hour and 3.5 CFU/M. 3. were classified as Ultra Clean. A logistic regression model was used to examine the effect of theatre type and time elapsed after procedure on the probability of becoming infected. The model suggests that, controlling for time period, Ultra Clean Air is associated with a significantly lower probability of infection, with an OR of 0.30, p = 2.74 × 10. −6. The effect is larger earlier post-surgery, but it does persist. The results are best reviewed as a graphic, which shows that Ultra Clean Air clearly affects the deep infection rate for up to four years post-surgery. Ultra Clean Air reduces infection rates for up to four years post-surgery, so it is safe to assume that infections presenting after this are haematogenous. Ultra Clean Air does not eliminate early deep infection, so some early infections are not related to air quality. It is not practical to undertake widespread detailed retrospective analyses of cases. When monitoring infection rates there needs to be a balance between failing to record infections related to surgical technique and waiting many years to record low numbers of very late presenting problems. We suggest that registries should regard infections documented within three years of surgery as treatment complications. For any figures or tables, please contact the authors directly

To examine whether Natural Language Processing (NLP) using a state-of-the-art clinically based Large Language Model (LLM) could predict patient selection for Total Hip Arthroplasty (THA), across a range of routinely available clinical text sources. Data pre-processing and analyses were conducted according to the Ai to Revolutionise the patient Care pathway in Hip and Knee arthroplasty (ARCHERY) project protocol (. https://www.researchprotocols.org/2022/5/e37092/. ). Three types of deidentified Scottish regional clinical free text data were assessed: Referral letters, radiology reports and clinic letters. NLP algorithms were based on the GatorTron model, a Bidirectional Encoder Representations from Transformers (BERT) based LLM trained on 82 billion words of de-identified clinical text. Three specific inference tasks were performed: assessment of the base GatorTron model, assessment after model-fine tuning, and external validation. There were 3911, 1621 and 1503 patient text documents included from the sources of referral letters, radiology reports and clinic letters respectively. All letter sources displayed significant class imbalance, with only 15.8%, 24.9%, and 5.9% of patients linked to the respective text source documentation having undergone surgery. Untrained model performance was poor, with F1 scores (harmonic mean of precision and recall) of 0.02, 0.38 and 0.09 respectively. This did however improve with model training, with mean scores (range) of 0.39 (0.31–0.47), 0.57 (0.48–0.63) and 0.32 (0.28–0.39) across the 5 folds of cross-validation. Performance deteriorated on external validation across all three groups but remained highest for the radiology report cohort. Even with further training on a large cohort of routinely collected free-text data a clinical LLM fails to adequately perform clinical inference in NLP tasks regarding identification of those selected to undergo THA. This likely relates to the complexity and heterogeneity of free-text information and the way that patients are determined to be surgical candidates

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

Anterior cruciate ligament (ACL) injuries have been increasing, especially amongst adolescents. These injuries can increase the risk for early-onset knee osteoarthritis (OA). The consequences of late-stage knee OA include structural joint change, functional limitations and persistent pain. Interleukin-6 (IL-6) is a pro-inflammatory biomarker reflecting knee joint healing, and increasing evidence suggests that IL-6 may play a critical role in the development of pathological pain. The purpose of this study was to determine the relationship between subjective knee joint pain and function, and synovial fluid concentrations of the pro-inflammatory cytokine IL-6, in adolescents undergoing anterior cruciate ligament reconstruction surgery. Seven youth (12-17 yrs.) undergoing anterior cruciate ligament (ACL) reconstruction surgery participated in this study. They completed the Pedi International Knee Documentation Committee (Pedi-IKDC) questionnaire on knee joint pain and function. At the time of their ACL reconstruction surgery, synovial fluid samples were collected through aspiration to dryness with a syringe without saline flushing. IL-6 levels in synovial fluid (sf) were measured using enzyme linked immunosorbent assay. Spearman's rho correlation coefficient was used to determine the correlation between IL-6 levels and scores from the Pedi-IKDC questionnaire. There was a statistically significant correlation between sfIL-6 levels and the Pedi-IKDC Symptoms score (-.929, p=0.003). The correlations between sfIL-6 and Pedi-IKDC activity score (.546, p = .234) and between sfIL-6 and total Pedi-IKDC score (-.536, p = .215) were not statistically significant. This is the first study to evaluate IL-6 as a biomarker of knee joint healing in an adolescent population, reported a very strong correlation (-.929, p=0.003) between IL-6 in knee joint synovial fluid and a subjective questionnaire on knee joint pain. These findings provide preliminary scientific evidence regarding the relationship between knee joint pain, as determined by a validated questionnaire and the inflammatory and healing status of the patient's knee. This study provides a basis and justification for future longitudinal research on biomarkers of knee joint healing in patients throughout their recovery and rehabilitation process. Incorporating physiological and psychosocial variables to current return-to-activity (RTA) criteria has the potential to improve decision making for adolescents following ACL reconstruction to reduce premature RTA thereby reducing the risk of re-injury and risk of early-onset knee OA in adolescents

Abstract. Objectives. Epiphysiodesis is a commonly used treatment for lower limb angular deformities. However, in recent years, distal tibial growth modulation using ‘eight plates’ or screws has emerged as an alternative treatment for paediatric foot and ankle disorders, such as CTEV. Our objective was to assess the efficacy of distal tibial modulation in correcting various paediatric foot and ankle disorders. Methods. This retrospective study analysed 205 cases of paediatric foot and ankle disorders treated between 2003 and 2022, including only cases where the eight plate or screw was fixed on the anterior surface of the distal tibia. Our aim was to measure post-operative changes in dorsiflexion, the distal tibial angle, and the tibiocalcaneal angle by examining clinical records and radiology reports. Results. We identified nine cases (nine feet) meeting the full inclusion criteria, comprising seven cases of CTEV, one case of arthrogryposis, and one case of cavovarus foot. The cohort consisted of five male and four female patients, with a mean age of 10 years and 9 months at the time of surgery. Seven cases involved the left tibia, and two cases involved the right tibia. The mean time between pre-operative X-ray to surgery was 168 days, and the mean turnaround time between surgery and post-operative X-ray was 588 days. A mean change in the distal tibial angle of 4.33 degrees was noted. However, changes in dorsiflexion were documented in only one case, which showed a change of 13 degrees. Notably, our average distal tibial angle was significantly lower than reported in the literature, at 4.33 degrees. Additionally, some studies in the literature used the Oxford Ankle Foot Questionnaire for Children to assess pre- and post-operative outcomes, but it is important to note that it is validated only for children aged 5 to 16. Furthermore, most cases reported an improved tibiocalcaneal angle except for an anomaly of 105 degrees. We assessed satisfactory patient outcomes using patient notes. Out of the 6 procured notes, one has been discharged. The rest are still under yearly or 6-monthly review and are at various stages, such as physiotherapy, removing the eight plate, or requiring further surgery. The most common presentations at review are plantaris deformity and pain. Conclusions. Our study suggests that distal tibial growth modulation can be an effective treatment option for selected paediatric foot and ankle disorders. However, due to the limited number of cases in our study, the lack of documentation of changes in dorsiflexion, and a lack of pre- and post-operative outcomes using a standardised method, further research is needed to investigate this procedure's long-term outcomes and potential complications. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Scoliosis correction surgery is one of the longest and most complex procedures of all orthopedic surgery. The complication rate is therefore not negligible and is particularly high when the surgery is performed in patients with neuromuscular or connective tissue disease or complex genetic syndromes. In fact, these patients have various comorbidities and organ deficits (respiratory capacity, swallowing / nutrition, heart function, etc.), which can compromise the outcome of the surgery. In these cases, an accurate assessment and preparation for surgery is essential, also making use of external consultants. To make this phase simpler, more effective and homogeneous, a multidisciplinary path of peri-operative optimization is being developed in our Institute, which also includes the possibility of post-operative hospitalization for rehabilitation and recovery. The goal is to improve the basic functional status as much as possible, in order to ensure faster functional recovery and minimize the incidence of peri-operative complications, to be assessed by clinical audit. The path model and the preliminary results on the first patients managed according to the new modality are presented here. The multidisciplinary path involves the execution of the following assessments / interventions: • Pediatric visit with particular attention to the state of the upper airways and the evaluation of chronic or frequent inflammatory states • Cardiological Consultation with Echocardiogram. • Respiratory Function Tests, Blood Gas Analysis and Pneumological Consultation to evaluate indications for preoperative respiratory physiotherapy cycles, Non-Invasive Ventilation (NIV) cycles, Cough Machine. Possible Polysomnography. • Nutrition consultancy to assess the need for nutritional preparation in order to improve muscle trophism. • Consultation of the speech therapist in cases of dysphagia for liquids and / or solids. • Electroencephalogram and Neurological Consultation in epileptic patients. • Physiological consultation in patients already being treated with a cough machine and / or NIV. • Availability of postoperative hospitalization in the rehabilitation center (with skills in respiratory and neurological rehabilitation) for the most complex cases. When all the appropriate assessments have been completed, the anesthetist in charge at our Institute examines the clinical documentation and establishes whether the path can be considered complete and whether the patient is ready for surgery. At the end of the surgery, the patient is admitted to the Post-operative Intensive Care Unit of the Institute. If necessary, a new program of postoperative rehabilitation (respiratory, neuromotor, etc.) is programmed in a specialist reference center. To date, two patients have been referred to the preoperative optimization path: one with Ullrich Congenital Muscular Dystrophy, and one with 6q25 Microdeletion Syndrome. In the first case, the surgery was performed successfully, and the patient was discharged at home. In the second case, after completing the optimization process, the surgery was postponed due to the finding of urethral malformation with the impossibility of bladder catheterization, which made it necessary to proceed with urological surgery first. The preliminary case series presented here is still very limited and does not allow evaluations on the impact of the program on the clinical practice and the complication rate. However, these first experiences made it possible to demonstrate the feasibility of this complex multidisciplinary path in which a network of specialists takes part

Aims. Anterior cruciate ligament (ACL) rupture commonly leads to post-traumatic osteoarthritis, regardless of surgical reconstruction. This study uses standing MRI to investigate changes in contact area, contact centroid location, and tibiofemoral alignment between ACL-injured knees and healthy controls, to examine the effect of ACL reconstruction on these parameters. Methods. An upright, open MRI was used to directly measure tibiofemoral contact area, centroid location, and alignment in 18 individuals with unilateral ACL rupture within the last five years. Eight participants had been treated nonoperatively and ten had ACL reconstruction performed within one year of injury. All participants were high-functioning and had returned to sport or recreational activities. Healthy contralateral knees served as controls. Participants were imaged in a standing posture with knees fully extended. Results. Participants’ mean age was 28.4 years (SD 7.3), the mean time since injury was 2.7 years (SD 1.6), and the mean International Knee Documentation Subjective Knee Form score was 84.4 (SD 13.5). ACL injury was associated with a 10% increase (p = 0.001) in contact area, controlling for compartment, sex, posture, age, body mass, and time since injury. ACL injury was associated with a 5.2% more posteriorly translated medial centroid (p = 0.001), equivalent to a 2.6 mm posterior translation on a representative tibia with mean posteroanterior width of 49.4 mm. Relative to the femur, the tibiae of ACL ruptured knees were 2.3 mm more anteriorly translated (p = 0.003) and 2.6° less externally rotated (p = 0.010) than healthy controls. ACL reconstruction was not associated with an improvement in any measure. Conclusion. ACL rupture was associated with an increased contact area, posteriorly translated medial centroid, anterior tibial translation, and reduced tibial external rotation in full extension. These changes were present 2.7 years post-injury regardless of ACL reconstruction status. Cite this article: Bone Joint J 2021;103-B(9):1505–1513

Aims. Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study aims to analyze which classification system correlates best with FTCL and to assess their reliability. Methods. A prospective study of 300 consecutive patients undergoing unilateral total knee arthroplasty (TKA) for OA (mean age 69 years (44 to 91; standard deviation (SD) 9.5), 178 (59%) female). Two blinded examiners independently graded preoperative radiographs using five common systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlbäck. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Intraoperatively, anterior cruciate ligament (ACL) status and the presence of FTCL in 16 regions of interest were recorded. Radiological classification and FTCL were correlated using the Spearman correlation coefficient. Results. Knees had a mean of 6.8 regions of FTCL (SD 3.1), most common medially. The commonest patterns of FTCL were medial ± patellofemoral (143/300, 48%) and tricompartmental (89/300, 30%). ACL status was associated with pattern of FTCL (p = 0.023). All radiological classification systems demonstrated moderate ICC, but this was highest for the IKDC: whole knee 0.68 (95% confidence interval (CI) 0.60 to 0.74); medial compartment 0.84 (95% CI 0.80 to 0.87); and lateral compartment 0.79 (95% CI 0.73 to 0.83). Correlation with actual FTCL was strongest for Ahlbäck (Spearman rho 0.27 to 0.39) and KL (0.30 to 0.33) systems, although all systems demonstrated medium correlation. The Ahlbäck score was the most discriminating in severe knee OA. Osteophyte presence in the medial compartment had high positive predictive value (PPV) for FTCL, but not in the lateral compartment. Conclusion. The Ahlbäck and KL systems had the highest correlation with confirmed cartilage loss at TKA. However, the IKDC system displayed the best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, although it was less discriminating in more severe disease. Cite this article: Bone Joint J 2020;102-B(3):301–309

Dedication to quality has a longstanding tradition within the Schulthess Clinic. Pioneering documentation Maurice E. Müller initiated an International Documentation & Evaluation System (IDES) in the era of hip replacement becoming an increasingly wide spread and standardized procedure. Starting in 1984, IDES was used to document each and every hip replacement and as of 1995 also for every knee arthroplasty performed. Norbert Gschwend became the driving authority in the clinic for standardizing documentation and regular long term follow-up intervals for all patients. With increasing interest in patient reported outcomes (PROMs) a shift took place in the basic conception and electronic means (iPads) were introduced in 2012 to let patients complete their part of questionnaires, i.e. EQ-5D, OHS, OKS, UCLA & WOMAC while the clinical part was addressed in the same manner using HHS & KSS. Optimizing user experience while answering routine questions and allowing for the physician to quickly enter required data without the numbing experience of ever same paper forms largely increased the return on information. This approach also guarantees for complete data sets, often a problem when using pen and paper. Using these modern tools in combination with a refined recall procedure, we today show follow-up rates of well over 90% in the first post-operative years vs rates of 80% or less prior to introduction. As of late 2012 the Swiss implant registry for knees & hips was introduced and here again we today use iPads with an app specifically designed to quickly document and register all operations on a daily base, reducing the chore of using paper or web based on line options from 3 to 10 minutes per operation to a mere 20 seconds, fully plausibilized and in this way never returned for corrections. Pooling this data allows not only for generalized and stringent quality control but also facilitates spotting aberrant trends in the sense of an early warning system within our clinic with regard to procedures and implants. Pioneering this approach to facilitate & perfect all documentation related procedures we aspire towards an elevated quality level in reporting to help sustain & guarantee patient satisfaction despite the high day-by-day volume

The accurate and detailed documentation of surgical procedures is essential, forming part of good clinical practice set out by the General Medical Council (GMC). In the case of knee arthroscopy, it is vital for planning further management when referring to a soft tissue knee specialist. This study assesses the quality of documentation of knee arthroscopy and evaluates the implementation of a novel operative template. A retrospective study of 50 operative-notes of patients undergoing knee arthroscopy was completed. A 41-point assessment was made based on guidelines from the GMC, Royal College of Surgeons of England (RCSE), British Orthopaedic Association (BOA) and British Association for Surgery of the Knee (BASK). An operative-note template was devised to address the criteria important for further interventions and then assessed for its efficacy in providing appropriately detailed findings. Detailed documentation deemed essential by current guidelines were lacking the minimum standards expected. Criteria that were considered necessary for an arthroscopic procedure were as low as 4%. After instigating the new operative template, there was a statistically significant increase (p < 0.001) in documentation accuracy throughout the necessary criteria set out by the GMC, RCSE, BOA and BASK. We have devised an operative template for knee arthroscopy that improves the quality of documentation and allows for optimal further surgical planning. Clear documentation is important for patient safety, adequate referral to a specialist, research and coding purposes. This will ideally reduce the number of repeat knee arthroscopies performed and optimise patient care from the outset

Background of study. Following the Montgomery ruling, consent is now a matter of law. The medical professionals have to show proof that risks and implications and material risks are explained to the patient and that they have accepted to go ahead with surgery. Materials and Methods. We devised a free web based programme (. www.consentplus.com. ) which introduces a documented checkpoint to the consent process in hip and knee replacement surgery. It enables reproducible high-quality bite-sized information delivery to patients and their families in an optimal environment. It utilises the flip classroom principle to facilitate dialogue between doctors and patients. It generates physical documentation to show patients’ knowledge and understanding of the risks; to produce a truly informed consent. Results. 1567 users completed the Consent PLUS process over 28 hospitals across the UK. 98.1% of users were satisfied with Consent PLUS in terms of quality of service and information delivered. Users’ self-rated knowledge increased by 29%, independent of age group, prior knowledge or check-point scores. Supportive documentation for 100% of the users, which facilitated the consent process but did not replace the consultation. 60% of users accessed the system via desktop computers, 23% via tablet and 17% via mobile phone. 55 consultant surgeons and 28 hospitals have been registered into the system by the users. 96.9% of users found Consent PLUS useful and 96.3% would recommend it to their friends. 92.6% would use it again. Conclusion. Consent PLUS can facilitate information delivery and improve patients’ understanding of the risks of surgery and its implications subjectively and objectively. Consent PLUS is a tool designed to enhance and facilitate the consent process, not to replace the current consent forms

The British Orthopedic Association recommends that patients referred to fracture clinic are reviewed within 72 hours. With the increase in referrals and limited clinic capacity it is becoming increasingly difficult to see every referral with in a 72 hour time frame. Some patients are waiting 2 weeks or more before they can be seen in a fracture clinic. With the aim of improving care by seeking to meet BOAST 7 target, waiting times for fracture clinic appointments at the Homerton University Hospital were audited prospectively against this national guideline, before virtual fracture clinic was implemented and 6 weeks after the implementation of virtual fracture clinic at our hospital. Virtual fracture clinic is where an Orthopedic consultant reviews a patients x-rays and A&E documentation and decides if that patients needs to be seen in a face to face fracture clinic to discuss operative vs. non-operative management of their injury or if a treatment plan can be delivered without the patient having to come back to hospital. The study was conducted as a prospective closed-loop audit in which the second cycle took place after the implementation of the new virtual fracture clinic service. The first cycle showed a non-compliant waiting time with only 18% of patients being seen within 72 hours. Following the implementation of virtual fracture clinic, 84% of all patients were reviewed within 72 hours. Virtual fracture clinic delivered a significant reduction in waiting times. Virtual fracture clinic has only just been implemented at the Homerton University Hospital and hopefully at the next audit we will be 100% compliant with the BOA BOAST 7 Guideline. We would recommend that virtual fracture clinics being rolled out in Orthopedic departments in all hospitals which have Orthopedic services

There is increasing evidence that patients with ACL reconstruction using ipsilateral graft harvest are at greater risk of rupture (12.5%) on their contralateral compared to their surgical side (7.9%). The purpose of this study is to re-evaluate patients from a previous study comparing ipsi- versus contralateral graft harvest to compare ACL rupture rate at a minimum 10 year follow-up. An attempt to contact all participants from a previously published study was made to invite them to return for a follow-up. The assessment included an International Knee Documentation Committee Knee Clinical Assessment (IKDC), isokinetic concentric knee flexion and extension strength testing, as well as the ACL-Quality of life (ACL-QOL). A chart review was conducted to identify or confirm subsequent ipsi- or contralateral knee surgeries. In patients with ipsilateral graft, 3/34 (8.8%) re-ruptured and 3/34 (8.8%) had contralateral rupture. In the contralateral group, 1/28 (3.6%) re-ruptured and 2/28 (7.1%) had contralateral rupture. The relative risk (RR) of re-rupture with ipsilateral graft was 2.47 compared to using the contralateral site (p=0.42). RR of rupture on the contralateral side when ipsilateral graft was used was 1.23 compared to the alternate approach. Current contact information was unavailable for 21 patients. Of the 47 remaining, 37 were consented (79%). No difference in the ACL-QOL between groups (ipsilateral 68.4±24.4, contralateral 80.1±16.0, p=0.17) was observed. There were no differences in knee flexion strength between groups (peak torque flexion affected leg: ipsilateral 77.8nm/kg±27.4, contralateral: 90.0 nm/kg±35.1; p=0.32; Unaffected leg: ipsilateral: 83.3 nm/kg±30.2 contralateral 81.7 nm/kg±24.4; p= 0.89). This study suggests that using the contralateral hamstring in ACL rupture is not associated with an increase in ACL rupture on either side. The risk of ACL injury was low in all limbs; therefore, a larger study would be required to definitively state that graft side had no impact

All skeletally immature patients who presented with a supracondylar fracture between 01/09/2013 and 24/11/2015 (n = 50) were used to compare the current management of supra-condylar fractures of the humerus in children to the standards set by the BOAST 11 guidelines. 8.1% did not have full documentation of their neurovascular assessment. 93.9% underwent surgery within 24 hours of presentation. Average time to theatre for neurovascularly compromised patients was 4 hours 46 minutes. 81.8% were managed with 2 K-wires as recommended. Only 39.4% of the patients had their wires removed within 3 – 4 weeks. Only 6.1% had the recommended 2 mm wires. AO recommends the use of 2mm wires if 2 lateral wires are used whereas the BOAST 11 guideline recommends 2mm wires where possible. The results clearly demonstrate a need for further education and awareness of the BOAST 11 guidelines. Of particular interest is the documentation of patients' neurovascular status for appropriate management and for medico-legal purposes. Long term outcome comparison of surgical fixation with 2mm and 1.6mm wires would be useful to support the use of 2mm wires as recommended by the professional consensus in the BOAST 11 guidelines

The modified Hedgehog technique was previously used to reattach pure chondral shear-off fragments in the pediatric knee. In the modified Hedgehog technique, the calcified side of chondral fragments is multiple times incised and trimmed obliquely for an interlocking fit in the defect site. Fibrin glue with or without sutures is subsequently applied to fix the fragment to the defect. This preliminary report further elucidates the potential of the technique by evaluation of its application in young adults using patient reported outcome measures (PROMs) and high-field Magnetic Resonance Imaging (MRI) as outcome measures. Three patients with a femoral cartilage defect (2 medial, 1 lateral), and a concomitant pure chondral corpus liberum were operatively treated by the modified Hedgehog technique. Age at surgery ranged from 20.6–21.2 years, defect size ranged from 3.8–6.0 cm2. Patients were evaluated at three months and one year after surgery by PROMs and 7.0T MRI. PROMs included the Internation Knee Documentation (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale (VAS) questionnaires. 7.0T MRI (Magnetom, Siemens Healthcare, Erlangen, Germany) using a 28-channel proton knee coil (QED, Electrodynamics LLC, Cleveland, OH) included a proton density weighted turbo spin-echo sequence with fat suppression to assess morphological tissue structure andgagCEST imaging to measure the biochemical tissue composition in terms of glycosaminoglycans (GAG). Twelve months after surgery all patients reported no pain and showed full range of motion. While PROMs at three months showed large variability between patients, one year after surgery the scores were consistently improved. Over time, morphological MRI visualized improvements in integration of the cartilage fragment with the surrounding cartilage, which was supported by biochemical MRI showing increased GAG values at the defect edges. Statistics were not applied to the results because of the small sample size. The modified Hedgehog technique in young adults with an acute onset caused by a pure chondral corpus liberum can be considered promising. The improved PROM results over time were supported by 7.0T MRI that visualized improvements in tissue structure and biochemical composition. Inclusion of more patients in future studies would allow statistical analysis and more conclusive results. The etiology of loosening and time between onset of symptoms and surgery for successful graft integration may differ between pediatric and young adult patients and is subject for future studies

Shortening of patellar tendon after total knee arthroplasty (TKA) was previously reported by several studies. Its etiology still remains controversial. Patellar tendon shortening, a direct cause of patella baja, has a dramatic negative impact in terms of clinical outcomes after TKA. Main objective of this study is to assess the feasibility of utilizing a different technique with Ultrasound that is easy to use, cost-effective and able to eliminate the problem of differential magnification occurring in other techniques which count on standard x-rays and to establish the correlation between clinical outcomes and changes in patellar tendon length and thickness after TKA. The study was designed as prospective cohort and, after a minimum of 4-year-follow up period, 47 knees of 24 patients who had undergone primary TKA without patellar resurfacing were included in the study. All patients were scored with Kujala and HSS scores and all patellar tendons were evaluated with USG regarding their length and thickness. We used conventional grey-scale ultrasound imaging (US) to determine any changes in patellar tendon morphology. All cases were evaluated by the same radiologist. The patellar tendon was examined with the knee in 30° flexion. The flexion angle helped to stretch the extensor mechanism and avoid anisotropy (concavity) of the patellar tendon. The transducer was placed along the long axis of the tendon. The patellar tendon was initially examined in the longitudinal plane in order to measure the total length. Then, total length was divided into three parts and sagittal thickness was calculated at the proximal, median, and distal thirds of the patellar tendon. Both the length and thickness of the tendon were measured before surgery and at the 4th year of follow-up. Of the 47 knees that were included in our study, the mean pre-operative and postoperative length of the patellar tendon was 40.78±6.15 mm and 35.93±4.52 mm. Our results suggested significant shortening of the patellar tendon after primary TKA surgery (p<0.05). Intergroup analysis suggested that reduced sagittal thickness in the proximal third of the tendon was more strongly correlated with an increase in functional outcomes (p<0.05). Our results suggested no significant difference in clinical outcome scores between patients with increased or decreased length of the patellar tendon after TKA (p>0.05). We suggest that determining morphologic changes in sagittal thickness as well as length is important in explaining some of the ambiguous causes of anterior knee pain and impaired clinical outcomes after TKA. More accurate documentation of morphologic changes in the patellar tendon after TKA will certainly help to develop new techniques by surgeons or avoid some existing routines that may harm the tendon. USG is a feasible method for evaluating patellar tendon morphology after TKA but more future studies are needed

Background. Return to sports after anterior cruciate ligament reconstruction (ACLR) is multifactorial and rotational stability is one of the main concerns. Anterolateral ligament reconstruction (ALLR) has been recommended to enhance rotational stability. Purpose. To assess the effect of ALLR on return to sports. Study Design. Retrospective comparative cohort study;. Level of evidence: III. Methods. A total of 68 patients who underwent ACLR after acute ACL injury between 2015 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients with isolated ACLR (group ALL(-), n=41) were compared to patients with ACLR+ALLR (group ALL(+), n=27) in regard to subjective knee assessment via Tegner activity scale, Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, Knee Documentation Committee (IKDC) form and Lysholm score. All tests were performed before the surgery, at 6 months and 24 months postoperatively. Results. Mean follow-up was 29.7±2.9 months for group ALL(-) and 31.6±3.0 for ALL(+) (p=0.587). Tegner, ACL-RSI and IKDC scores at last follow-up were significantly better in ALL(+) compared to ALL(-). There were no significant differences in isokinetic extensor strength and single-leg hop test results between the groups. 40 (97.6%) patients in ALL(-) and 27 (100%) in ALL(+) had a grade 2 or 3 pivot shift (p=0.812) preoperatively. Postoperatively, 28 (68.3%) patients in ALL(-) and 25 (92.6%) patients in ALL(+) had a negative pivot shift (p<0.001). 2 (5.9%) patients in ALL(-) and 1 (3.7%) patient in ALL(+) needed ACLR revision due to traumatic re-injury (p=0.165). There was no significant difference in the rate of return to any sports activity (87.8% in ALL(-) vs 88.9% in ALL(+); p=0.532), but ALL(+) showed a higher rate of return to the same level of sports activity (55.6%) than group ALL(-) (31.7%) (p=0.012). Conclusion. ACLR combined with ALLR provided a significantly higher rate of return to the same level sports activity than ACLR alone, probably due to enhanced rotational stability

Introduction. Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening. Method. A retrospective review of documentation for all femoral Precice nails in our centre inserted between 2012 and 2017. This involved 98 nails (68 antegrade, 30 retrograde) in 88 patients (59 males, 29 females) with a mean age of 32 years (range 12–69 yrs). We excluded cases where there was no documentation regarding Range of Movement (ROM). Bilateral lengthenings were recorded as separate cases. This left 50 antegrade, 16 retrograde cases with hip ROM data and 55 antegrade, 26 retrograde cases with Knee ROM data. Results. Hip. In the antegrade group 20 cases (39%) developed no stiffness throughout treatment. ROM decreased in 61% (n=30) of cases and the median length at which this occurred was 3cm. Where a retrograde nail was inserted 62.5% of cases (n=10) maintained normal range of motion. The median length at which ROM decreased was 3.25cm, this occurred in 6 cases (37.5%). . Knee. Where the antegrade nail was inserted, 22 cases (40%) did not develop stiffness. There was reduced ROM in 33 cases (60%), occurring at a median distance of 2cm. The median distance at which reduced ROM occurred with the retrograde nails was 1.5cm, this occurred in 23 cases (88.5%). 3 cases did not develop stiffness. All cases regained full ROM. Conclusion. Although there was no permanent loss, Joint Stiffness still occurs with intramedullary limb lengthening and there remains the need for regular physiotherapy. There are no data from other institutions for comparison. Rehabilitation guidelines and a proforma to accurately monitor patients ROM throughout treatment have been developed

Background. Patients who undergo elective hip and knee arthroplasty often have multiple risk factors increasing their likelihood of suffering from hyponatraemia post operatively. Consequently suffering from hyponatraemia post elective hip and knee arthroplasty is common. Consequently we wanted to assess the occurrence of hyponatraemia in our elective arthroplasty unit, assess our effectiveness in managing this and importantly assess how its occurrence impacted on length of patient stay. Method. Retrospective analysis of elective hip and knee arthroplasty patients over a five month period. Pre-operative and post-operative sodium levels analysed and their grade measured using NICE reference ranges. In post-operative hyponatraemic patients blood results were analysed up until discharge. Discharge summaries were reviewed to assess communication between primary and secondary care. Length of admission calculated. Formal action plan developed in partnership with the anaesthetic department to improve future management. Results. 103 patients assessed. 24 (23%) suffered from post-operative hyponatraemia. 11 (48%) were discharged with a normalised sodium. 7 (29%) had documentation regarding their hyponatraemia in the discharge summary. 101 (98%) had a sodium drop post-operatively and 2 patients were hyponatraemic pre-operatively. Average length of stay for hyponatraemic hip patients was 5.00 days compared to 4.20 days for patients with normal sodium levels. Hyponatraemic post op knee patients had an average in hospital stay of 5.09 days compared to 4.13 days in knee patients with a normal post-operative sodium level. Conclusion. Hyponatraemia is common in the post-operative arthroplasty patient. In our unit it led to an increase in length of hospital stay. We believe the introduction of a structured post-operative oral rehydration regime with isotonic fluid would be a simple method to reduce occurrence post operatively. We feel standardising intra-operative fluid prescribing will reduce the likelihood of pushing patients into a post-operative hyponatraemic state. Finally we have introduced a hyponatraemia management flowchart to the department so ward based doctors can recognise and effectively manage hyponatraemic patients. If these measures are implemented length of stay in hospital can potentially be reduced

Introduction. Recent literature has sought to quantify pre-operative work associated with total joint arthroplasty. These studies have utilized surveys or self-reported time logs to estimate the Pre-op Optimization Work (POW) completed by the surgical team. The purpose of this study was to objectively quantify POW associated with total hip arthroplasty (THA) using electronic medical record (EMR) activity audit logs. Methods. Retrospective analysis of EMR activity for 4 arthroplasty surgeons and their clinical staff was collected for 100 consecutive THA cases (25 per surgeon). Clinical informatics data was generated using EMR activity audit logs for pre-THA activity. Every action and mouse-click within a patient's chart was recorded for each team member. The time between mouse-clicks was calculated and summed for each user. Times exceeding five minutes without activity were assumed to reflect inactivity and excluded. Descriptive statistics were used to estimate the POW associated with THA preparation. Results. The mean number of days for pre-THA time period was70.7 (SD43.9; range: 8–175days). During this period, the mean time spent in each patient's chart was 75.5 minutes (SD50.75) minutes. Surgeon's POW in the medical record accounted for 7.3(SD6.7) of these minutes. Much of the work was conducted by nurses (47.0 minutes, SD43.4), physician extenders (10.8 minutes, SD 13.1), and qualified office staff/technicians (10.4 minutes, SD14.9). The majority of work captured in the EMR activity log was associated with medication review, patient optimization, documentation of necessary medical clearances, ordersets, patient communication, and prior authorization requests. Conclusion. A considerable amount of preoperative work is required between the clinic date a patient decides to pursue THA and the day prior to surgery. These retrospective electronic time stamp measurements should represent the absolute minimum time required for surgical preparation

Osteoporosis is a disease when bone mass and tissue is lost, with a consequent increase in bone fragility and increase susceptibility to develop fracture. The osteoporosis prevalence increases markedly with age, from 2% at 50 years to more than 25% at 80 years. 1. in women. The vast majority of distal radius fractures (DRFs) can be considered fragility fractures. The DRF is usually the first medical presentation of these fractures. With an aging population, all fracture clinics should have embedded screening for bone health and falls risk. DRF is the commonest type of fracture in perimenopausal women and is associated with an increased risk of later non-wrist fracture of up to one in five in the subsequent decade. 2. . According to the national guidelines in managing the fragility fractures of distal radius with regards the bone health review, we, as orthopedic surgeons, are responsible to detect the risky patients, refer them to the responsible team to perform the required investigations and offer the treatment. We reviewed our local database (E-trauma) all cases of fracture distal radius retrospectively during the period from 01/08/2019 to 29/09/2019. We included total of 45 patients who have been managed conservatively and followed up in fracture clinic. Our inclusion criteria was: women aged 65 years and over, men aged 75 years and over with risk factors, patients who are more than 50 years old and sustained low energy trauma whatever the sex is or any patient who has major risk factor (current or frequent recent use of oral or systemic glucocorticoids, untreated premature menopause or previous fragility fracture). We found that 96% of patients were 50 years old or more and 84% of the patients were females. 71% of patients were not referred to Osteoporosis clinic and 11% were already under the orthogeriatric care and 18% only were referred. Out of the 8 referred patients, 3 were referred on 1st appointment, 1 on the 3rd appointment, 1 on discharge from fracture clinic to GP again and 3 were without clear documentation of the time of referral. We concluded that we as trust are not compliant to the national guidelines with regards the osteoporosis review for the DRF as one of the first common presentations of fragility fractures. We also found that the reason for that is that there is no definitive clear pathway for the referral in our local guidelines. We recommended that the Osteoporosis clinic referral form needs to be available in the fracture clinic in an accessible place and needs to be filled by the doctor reviewing the patient in the fracture clinic in the 1st appointment. A liaison nurse also needs to ensure these forms have been filled and sent to the orthogeriatric team. Alternatively, we added a portal on our online database (e-trauma), therefore the patient who fulfils the criteria for bone health review should be referred to the orthogeriatric team to review

We sought to determine whether smoking affected the outcome of reconstruction of the anterior cruciate ligament. We analysed the results of 66 smokers (group 1 with a mean follow-up of 5.67 years (1.1 to 12.7)) and 238 non-smokers (group 2 with a mean follow-up of 6.61 years (1.2 to 11.5)), who were statistically similar in age, gender, graft type, fixation and associated meniscal and chondral pathology. The assessment was performed using the International Knee Documentation Committee form and serial cruciometer readings. Poor outcomes were reported in group 1 for the mean subjective International Knee Documentation Committee score (p < 0.001), the frequency (p = 0.005) and intensity (p = 0.005) of pain, a side-to-side difference in knee laxity (p = 0.001) and the use of a four-strand hamstring graft (p = 0.015). Patients in group 1 were also less likely to return to their original level of pre-injury sport (p = 0.003) and had an overall worse final 7 International Knee Documentation Committee grade score (p = 0.007). Despite the well-known negative effects of smoking on tissue healing, the association with an inferior outcome after reconstruction of the anterior cruciate ligament has not previously been described and should be included in the pre-operative counselling of patients undergoing the procedure

St Mary's Hospital, the major trauma centre for West London, treated 168 patients with lower limb open fractures in 2011 & 2012. This audit compared antibiotic administration in the emergency department against the current BOAST IV guidelines. The choice, timing, dose, and documentation of antibiotic administration was collected from the casualty cards and the transfer documentation for any patient initially seen at another hospital. The severity of the injury (as the Gusitollo-Anderson classification) after the initial debridement and any infectious complications that presented before discharge were also recorded. The results showed a higher compliance with the BOAST IV guidelines for those patients directly admitted rather than transferred to the major trauma centre. In direct admissions the recommended antibiotics were either not given or not adequately documented in 7% of cases. In those patients transferred from another emergency department the documentation was inadequate in 27% of cases. The likely causes of these results are discussed alongside the unit's bone infection rates

Aims. Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months. Patients and Methods. A single-centre assessor-blinded, comprehensive cohort study, incorporating a pilot randomized controlled trial (RCT) was performed on patients with a symptomatic compartment of the knee in which a (sub)total meniscectomy had previously been performed. They were randomized to be treated either with a meniscal allograft transplantation or personalized physiotherapy, and stratified for malalignment of the limb. They entered the preference groups if they were not willing to be randomized. The Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Lysholm score and complications were collected at baseline and at four, eight and 12 months following the interventions. Results. A total of 36 patients entered the study; 21 were randomized and 15 chose their treatments. Their mean age was 28 years (range 17 to 46). The outcomes were similar in the randomized and preference groups, allowing pooling of data. At 12 months, the KOOS. 4. composite score (mean difference 12, p = 0.03) and KOOS subscales of pain (mean difference 15, p = 0.02) and activities of daily living (mean difference 18, p = 0.005) were significantly superior in the meniscal transplantation group. Other PROMs also favoured this group without reaching statistical significance. There were five complications in the meniscal transplantation and one in the physiotherapy groups. Conclusion. This is the first study to compare meniscal allograft transplantation to non-operative treatment. The results provide the best quality evidence to date of the symptomatic benefits of meniscal allograft transplantation in the short term, but a multicentre RCT is required to investigate this question further. Cite this article: Bone Joint J 2018;100-B:56–63

Approximately 20% of patients with ankle fracture sustain syndesmosis injury. This is most common in trans-syndesmotic (type B) and supra-syndesmotic (type C) fibula fractures. Intra-operative assessment of syndesmosis integrity is important because failure to treat these injuries can result in ankle instability and pain. Our aim was to audit the documentation of intra-operative testing of syndesmosis during ankle fracture open reduction and internal fixation (ORIF). All patients who had ankle fracture ORIF between 1/1/2010 and 21/11/2011 were included. Pre-operative radiographs were reviewed and fractures were classified according to AO classification. Operation notes were reviewed for documentation of assessment of syndesmosis integrity. 153 patients, of mean age 50 years (15–93) were included. 60% (n=92) were female. In 78% of cases (n=119), an assessment of syndesmosis integrity was documented in the operation note. Of the patients with no documented syndesmosis assessment (n=35), the majority had type B fractures (n=34). One patient had a type C fracture. We have shown that 22% of patients undergoing ankle ORIF for fracture do not have documented assessment of syndesmosis integrity. We suggest that all patients who have ankle ORIF should have intra-operative assessment and documentation of syndesmosis integrity so these injuries are identified and treated accordingly

A total of 218 patients with unilateral anterior cruciate ligament deficiency were randomly assigned to one of four groups. In group A an anatomical double bundle anterior cruciate ligament reconstruction was performed; group B were treated by a single bundle using an Endobutton for femoral fixation; in group C by a single bundle using RigidFix cross pins for femoral fixation; and in group D by a single bundle using a bioabsorbable TransFix II screw for femoral fixation. For tibial fixation a bioabsorbable Intrafix interference screw was used for all the groups and the graft was fashioned from the semitendinosus and gracilis tendons in all patients. In all, 18 patients were lost to follow-up. The remaining 200 were subjected to a clinical evaluation, with assessment of the anterior drawer, Lachman’s and the pivot-shift tests, and KT-1000 arthrometer measurement. They also completed the International Knee Documentation Committee, Lysholm knee and Tegner activity scores. At a mean of 29 months (25 to 38) follow-up there were no significant differences concerning time between injury and range of movement and Lysholm knee scores among the four groups. However, the double bundle method showed significantly better results for the pivot-shift test (p = 0.002). The KT 1000 measurements showed a mean difference between the reconstructed knee and the patients’ normal knee of 1.4 mm in the double bundle group and 2.4 mm in the single bundle group; which was statistically significant. The Lachman and anterior drawer tests also showed superior results for the double bundle method. The International Knee Documentation Committee scale showed no significant difference among the groups (p < 0.001). On clinical evaluation the double bundle group showed less laxity than the single bundle groups. However, regardless of the technique, all knees were improved by anterior cruciate ligament reconstruction compared with their pre-operative status

Though knee osteoarthritis (OA) is diagnosed and monitored radiographically, full thickness cartilage loss (FTCL) has rarely been correlated with radiographic classification. This study aims to analyse which classification system correlates best with FTCL and assessing their reliability. Prospective study of 300 consecutive patients undergoing total knee arthroplasty (TKA) for OA. Two blinded examiners independently graded preoperative radiographs using 5 systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlback. Interobserver agreement was assessed using the intraclass correlation coefficient. Intraoperatively, anterior cruciate ligament (ACL) status and FTCL in 16 regions of interest were recorded. Radiographic classification and FTCL were correlated using the Spearman correlation coefficient. On average, each knee had 6.8±3.1 regions of FTCL, most common medially. The commonest patterns of FTCL were medial with patellofemoral (48%) and tricompartmental (30%). ACL status was associated with pattern of FTCL (p=0.02). All classification systems demonstrated moderate ICC, but this was highest for IKDC: whole knee 0.68 (95%CI 0.60–0.74); medial compartment 0.84 (0.80–0.87); and lateral compartment 0.79 (0.73–0.83). Correlation with FTCL was strongest for Ahlback (Spearman rho 0.27–0.39) and KL (0.30–0.33), though all systems demonstrated medium correlation. The Ahlback was the most discriminating in severe OA. Osteophyte presence in the medial compartment had high positive predictive value for FTCL, but not in the lateral compartment. The Ahlback and KL systems had the highest correlation with confirmed cartilage loss. However, the IKDC system displayed best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, though less discriminating in severe disease

Aims. Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft. Materials and Methods. A search was performed of Medline and Pubmed using the terms “Anterior Cruciate Ligament” and “ACL” combined with “revision”, “re-operation” and “failure”. Only studies that reported the outcome at a minimum follow-up of two years were included. Two authors reviewed the papers, and outcomes were subdivided into autograft and allograft. Autograft was subdivided into hamstring (HS) and bone-patellar tendon-bone (BPTB). Subjective and objective outcome measures were analysed and odds ratios with confidence intervals were calculated. Results. A total of 32 studies met the inclusion criteria. Five studies used HS autografts, eight reported using BPTB autografts, two used quadriceps tendon autografts and eight used various types. Seven studies reported using allografts, while the two remaining used both BPTB autografts and allografts. Overall, 1192 patients with a mean age of 28.7 years (22.5 to 39) and a mean follow-up of 5.4 years (2.0 to 9.6) were treated with autografts, while 269 patients with a mean age of 28.4 years (25 to 34.6) and a mean follow-up of 4.0 years (2.3 to 6.0) were treated with allografts. Regarding allografts, irradiation with 2.5 mrad was used in two studies while the graft was not irradiated in the seven remaining studies. Reconstructions following the use of autografts had better outcomes than those using allograft with respect to laxity, measured by KT-1000/2000 (MEDmetric Corporation) and the rates of complications and re-operations. Those following the use of allografts had better mean Lysholm and Tegner activity scores compared with autografts. If irradiated allografts were excluded from the analysis, outcomes no longer differed between the use of autografts and allografts. Comparing the types of autograft, all outcomes were similar except for HS grafts which had better International Knee Documentation Committee scores compared with BPTB grafts. Conclusion. Autografts had better outcomes than allografts in revision ACL reconstruction, with lower post-operative laxity and rates of complications and re-operations. However, after excluding irradiated allografts, outcomes were similar between autografts and allografts. Overall, the choice of graft at revision ACL reconstruction should be on an individual basis considering, for instance, the preferred technique of the surgeon, whether a combined reconstruction is required, the type of graft that was previously used, whether the tunnels are enlarged and the availability of allograft. Cite this article: Bone Joint J 2017;99-B:714–23

Purpose. Isolated fractures of femoral condyle in the coronal plane (Hoffa fracture) is rare and is surgically challenging to treat. 44 patients were operated between 2004–2014. The aim was to retrospectively assess the fracture patterns, fixation done and functional outcome. Methods. All injuries resulted from direct trauma to the knee out of which 36 were due to road traffic accidents.38 were closed injuries and the rest open.35 involved lateral condyle, 8 involved medial condyle and one was bicondylar type. All were anatomically reduced with fixation decided based on preoperative radiographs, CT scan and intra-op observation. Early passive motion and isometric exercises were started but kept non-weight bearing for 6–8 weeks. The mean follow up period was five years. Outcomes were measured using Neer's scoring system and International Knee Society Documentation Committee (IKDC) Functional Score. Results. 26 patients had excellent outcome, 14 had satisfactory and 4 had unsatisfactory outcome which corresponded with the specified fracture severity pattern. Uniformly excellent results were obtained in all simple pattern fractures, whereas comminuted fracture patterns were more challenging to treat with variable outcomes. Conclusion. In our retrospective observational study, we found that each fracture had specific pattern which dictated the treatment plan and the prognosis. Subsequently we grouped the fractures and proposed a classification system that would specify the pattern of fracture and dictate the type of fixation preferred. We conclude that therapeutic outcome is significantly affected by the amount of articular surface comminution, posterior cortex comminution, attainment of anatomical reduction and stable fixation

Aims

The primary aim of this study is to assess the survival of the uncemented hydroxyapatite (HA) coated Trident II acetabular component as part of a hybrid total hip arthroplasty (THA) using a cemented Exeter stem. The secondary aims are to assess the complications, joint-specific function, health-related quality of life, and radiological signs of loosening of the acetabular component.

Purpose. To establish if the subjective features of both bilateral leg pain and sexual dysfunction are presenting features in cauda equina syndrome (CES). Background. There appears to be conflicting expert opinion ‘red flag’ symptoms in the context of CES with many experts basing clinical decisions on the objective clinical findings only. Bilateral radiculopathy has been suggested as a possible sign of suspected CES, although a consensus statement by BASS and SBNS makes no reference to either this or sexual dysfunction. However, bilateral leg pain is included in the NICE clinical knowledge summary and sexual dysfunction is highlighted within CES guidance by the American Association of Neurological Surgeons. Methods. The clinical documentation of patients undergoing urgent magnetic resonance imaging (MR) due to clinical suspicion of cauda equina syndrome (CES) was reviewed over 12 months. Patients questioned regarding sexual function were included in this retrospective analysis (n=179), along with those with bilateral leg pain (n=294). Patients with confirmed cauda equina compression (CES +ve) were compared to those without (CES -ve). A logistic regression was applied to find the odds ratio. Results. In CES +ve 37.5% had sexual dysfunction, 48% had bilateral leg pain. CES –ve 14% had sexual dysfunction, 27% bilateral leg pain. Both significant to p=0.015 with an odds ratio of 3.6 and 2.5 respectively. Conclusions. Both sexual dysfunction and bilateral leg pain do appear to be ‘red flags’ for CES and should therefore be asked in the ED to aid clinical reasoning when suspecting this diagnosis. No conflicts of interest. No funding obtained

Patients admitted with spinal injuries following trauma require careful serial examinations to detect any neurological deficit that may develop. Thorough documentation of the findings is of paramount importance. Enforced working practice within the NHS means that these patients are often assessed by different members of staff with varying levels of experience, thus inconsistent documentation can be a cause for concern. The project aim was to design a human computer interface to standardise the performance and documentation of serial neurological examinations in patients with spinal injury, allowing the user to accurately detect any neurological deterioration. A prototype system was developed for ward based PC’s incorporating the essential requirements of the neurological examination. Usability testing was performed on the prototype by recruiting fifteen users who would be expected to routinely perform the neurological examination on spinal injury patients. Usability was defined by a number of well defined goals (impression, efficiency, learnability, memorability, safety and effectiveness) and methods used in the evaluation included direct observation during completion of tasks, a questionnaire and unstructured interview. Both quantitative and qualitative data was collected. This data was subsequently analysed using descriptive and inferential methods. The results of the analysis showed that the users responded favourably to the prototype in respects to the all usability goals except efficiency. This lack of efficiency was expected due to the rigid nature of computer based systems compared to paper based methods of recording data but this disadvantage was more than compensated for by the increased patient safety that the system would provide. It can be concluded from the usability testing that the prototype achieves the aims of the project but further work is required in developing the prototype into a final interface design before beta testing in a clinical environment can be considered

Introduction: Congenital clubfoot is a very common deformity in developing countries which leads to secondary socioeconomic problems. Clubfoot programs using the Ponseti method have been initiated in many third world countries in the last years. However, many treatment related, logistic, and structural problems are encountered during these efforts. We report our two-year experience with a clubfoot program in Mali. Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006. Further visits for advanced teaching, documentation, follow-up and implementation of a clinical structure were scheduled approximately every three months. Parallel to the Ponseti program a program to operate neglected or resistant clubfeet was initiated. Regular meetings with the government at different levels were attained and efforts were made to include the clubfoot program into the national RBC program. Results: During workshops in October 2006 and January and March 2007 seven health care workers have been intensively trained in the Ponseti method. A review of our documentation showed that up to now 235 patients had been seen and treated. Out of 105 children with idiopatic clubfoot who presented younger than one year of age 52 were available for follow-up after the end of Ponseti treatment. The outcome was “good” or “medium” in 40 patients (77%) and “poor” in 12 children (23 %). The late age at presentation, the low compliance and the rare use of the abduction orthosis are ongoing problems which could not have been solved yet. Additionally, the structural improvements in our treatment center as well as the direct government support are still insufficient. Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world. Nevertheless, many obstacles have to be overcome to implement a sustainable project, most of which are not so much treatment associated but of structural, organizational and political nature

Introduction In view of the legal claim for quality assurance in Germany, complete documentation and a professional evaluation of shoulder arthroplasty procedures are indispensable. Under the auspices of German AO International (DAOI), the German Society of Orthopeadics and Orthopeadic Surgery (DGOOC), the German Society of Trauma Surgery (DGU) and the German Society of Shoulder and Elbow Surgery (DVSE), and in collaboration with the MEM Institute for Evaluative Research in Orthopaedic Surgery, University of Bern, the nationwide online Shoulder Arthroplasty Register was implemented. Register setup The German Shoulder Arthroplasty Register consists of three online questionnaires, covering surgery for primary shoulder arthroplasty, follow-up examination, and revision surgery. Registered surgeons can access the questionnaires via Internet. For easier administration in clinics, paper copies of the questionnaires are also available. Online validation procedures check all entered data for completeness and plausibility. After passing these checks, data are sent to the central database. The centralization of the data collection is crucial for data unification and validity. Advantages Participating surgeons benefit from descriptive real-time statistics of their patients, and constant benchmarking of their performance in comparison with the whole register is possible. With the documentation of complications, implant failures and revision surgery, quality assurance reports can be easily produced. Furthermore, X-ray images of special cases can be uploaded. Perspective The German Shoulder Arthroplasty Register was launched in January 2006 and documentation is ongoing. First scientific results will be available in 2007

Aims

Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear.

Aims. Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients. Materials and Methods. We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This involved a comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the following combinations of keywords, “knee”, “anterior cruciate ligament”, “reconstruction”, “injury”, “children”, “adolescent”, “skeletally immature”, “open physis” and “surgery”. Results. A total of 53 studies met the inclusion criteria and were included for analysis. The overall rate of disturbance of growth after ACL reconstruction was 2.6%, with no statistical difference between transphyseal and physeal-sparing techniques. Physeal-sparing techniques had a lower rate of post-operative complications compared with transphyseal techniques (p = 0.0045). Outcomes assessed were Lysholm score, International Knee Documentation Committee (IKDC) score, the IKDC grade, the Tegner score and the KT-1000. Both techniques had similar clinical outcomes. Conclusions. This review reveals low rates of disturbance of growth after ACL reconstruction in skeletally immature patients. Although limited, the available evidence did not support any particular surgical technique when considering disturbance of growth or clinical outcome. Further randomised controlled trials are needed to investigate the efficacy of differing surgical techniques on outcomes in skeletally immature patients. Cite this article: Bone Joint J 2017;99-B:1053–60

Introduction. Total hip arthroplasty (THA) candidates have received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid administration documentation and are now implementing opioid-sparing protocols (OSP) into THA integrated care pathways (ICP). Here we evaluate the effectiveness of a novel OSP in primary THA at out institution. Methods. Between January 2019 to April 2019, all patients undergoing primary THA were placed under a novel OSP (Table 1). Patient demographics, inpatient/surgical factors, and inpatient opiate administration events were collected. A historical 2:1 cohort was subsequently derived from patients undergoing THA between January 2018 to August 2018. Opiate administration events collected from our EDW were converted into Morphine Milligram Equivalences (MMEs) and transformed into average MME's per patient per 24-hour interval. Nursing documented visual analog scale (VAS) pain scores were also queried and averaged per patient per 12-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) Short Forms tool was utilized. Results. 652 primary THAs had received our institution's OSP, and 1357 patients were utilized as our historical control. Age, gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were all similar between the two groups (Table 2). Compared to historical controls, OSP patients demonstrated significantly lower 24-hour interval opiate consumption at 0–24, 24–48 and 48–72 hours. Though VAS pain score variations reached statistical significance at various intervals, differences were not clinically relevant (Table 4). Lastly, OSP patients demonstrated significantly higher AM-PAC scores across all 6 functional domains (Table 5) and raw total scores within 24-hours of surgery completion. Discussion. Our OSP reduced opiate consumption by 26.50% while maintaining a comparable level of self-reported patient pain. Lower opiate utilization may also improve functional status in the immediate postoperative period. For any tables or figures, please contact the authors directly

Study background: The management of patients presenting in primary care with a “new episode of back pain” using the RCGP guidelines by a nurse practitioner (NP) compared to a control group given ‘usual care’ by the GP. Methods and Results: The evaluation includes sequential monitoring of LBOS, audit of documentation for both groups of patients to assess application of guidelines and patient recall of key information. Conclusion: The NHS Plan (2000) called for national standards for treating all major conditions in “Shifting the Balance of Power- the next steps” (2001) a clear criterion is that “service outcomes which provide better and better validated information” will form part of the performance rating. These two documents highlight the need for more user and client involvement in service development but this needs to be carefully monitored and linked to effective evidence. This study demonstrates that the NP documentation follows the guidelines identified by the RCGP, conversely it was not possible to assess from the GP documentation if all the steps had been followed. The mean average LBOS in the NP patients was slightly higher than those in the GP group, was this because these patients were having guideline applied care as opposed to “usual care”?. Evaluation of the patient recall of information shows the NP sent five patients for X-ray even though this did not occur and is not recommended in guidelines. Conversely twenty-three patients can remember being given the “Back Book” by the GP but this was only documented in three cases. We believe that patient recall demonstrates an ineffective way to measure outcome and funding allocation for back pain management and needs to more accurately reflect the evidence

Aims

This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data.

Introduction: In many developing countries clubfeet are not recognized at birth and usually remain untreated due to limited medical and financial recourses. With high births rates of up to 50 births per 1000 population in the poorest countries like Mali, Uganda or Niger the clubfoot deformity has become a socioeconomic problem. Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. During the project design and planning members from an already established Ponseti program, the Uganda Sustainable Clubfoot Care Project, gave valuable advice and guidance for the planning of the Mali program. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006. Results: During workshops in October 06 and January and March 07 a total of 31 health care workers have been trained using the Ponseti method. Documentation as of March 07 shows that 124 clubfeet in 80 Patients have been treated. There were 54 male and 26 female patients which resembles the male to female ratio described in literature. The mean age at presentation was 12.1 months (range: 9 days to 37 months). The Pirani score was evaluated at presentation in 93 of 124 feet and was 4.23 at the average. In March 07 follow-up for patients in whom treatment was initiated from October to January was available for 25 patients with 38 clubfeet. A medium result (plantigrade foot, DF at least neutral) was seen in 11 feet, a good result (plantigrade foot, DF possible) in 23 feet, an early recurrence with need for re-casting in 4 feet. A release operation was performed in 2 feet (2 patients), and 11 feet (7 patients) are awaiting operation. These patients presented at a mean age of 22 months (12–36 months) and included 3 patients with secondary clubfeet. Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world and gives these infants in the poorest countries the rare opportunity to receive the same state-of-the-art treatment as infants in the richest countries around the world. Nevertheless, many obstacles have to be overcome to implement a sustainable project. The lack of doctors and especially orthopaedic surgeons can only partly be compensated by highly motivated health care workers. The lack of documentation and follow-up impedes quality control and evaluation needed for funding. Awareness programs to ensure treatment within the first months of live are most important to increase the success-rate but imply fully operable Ponseti clinics which are able to take care of the increasing patient flow

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as ‘big data’, AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI’s limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction.

Cite this article: Bone Joint Res 2023;12(7):447–454.

Aims. The purpose of this study was to report the experience of dynamic intraligamentary stabilisation (DIS) using the Ligamys device for the treatment of acute ruptures of the anterior cruciate ligament (ACL). Patients and Methods. Between March 2011 and April 2012, 50 patients (34 men and 16 women) with an acute rupture of the ACL underwent primary repair using this device. The mean age of the patients was 30 years (18 to 50). Patients were evaluated for laxity, stability, range of movement (ROM), Tegner, Lysholm, International Knee Documentation Committee (IKDC) and visual analogue scale (VAS) scores over a follow-up period of two years. Results. At final follow-up, anteroposterior translation differed from the normal knee by a mean of 0.96 mm (-2 mm to 6 mm). Median (interquartile range) IKDC, Tegner, Lysholm and VAS scores were 98 (95 to 100), 6 (5 to 7), 100 (98 to 100) and 10 (9 to 10), respectively. Pre-injury Tegner activity levels were reached one year post-operatively. A total of nine patients (18%) required a secondary intervention; five developed instability, of whom four underwent secondary hamstring reconstructive surgery, and five required arthroscopic treatment for intra-articular impingement due to scar tissue which caused a fixed flexion deformity. In addition, 30 patients (60%) required removal of the tibial screw. Conclusion. While there was a high rate of secondary interventions, 45 patients (90%) retained their repaired ACL two years post-operatively, with good clinical scores and stability of the knee. Take home message: Dynamic intraligamentary stabilisation presents a promising treatment option for acute ACL ruptures, eliminating the need for ACL reconstruction. Cite this article: Bone Joint J 2016;98-B:793–8

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Literature surrounding artificial intelligence (AI)-related applications for hip and knee arthroplasty has proliferated. However, meaningful advances that fundamentally transform the practice and delivery of joint arthroplasty are yet to be realized, despite the broad range of applications as we continue to search for meaningful and appropriate use of AI. AI literature in hip and knee arthroplasty between 2018 and 2021 regarding image-based analyses, value-based care, remote patient monitoring, and augmented reality was reviewed. Concerns surrounding meaningful use and appropriate methodological approaches of AI in joint arthroplasty research are summarized. Of the 233 AI-related orthopaedics articles published, 178 (76%) constituted original research, while the rest consisted of editorials or reviews. A total of 52% of original AI-related research concerns hip and knee arthroplasty (n = 92), and a narrative review is described. Three studies were externally validated. Pitfalls surrounding present-day research include conflating vernacular (“AI/machine learning”), repackaging limited registry data, prematurely releasing internally validated prediction models, appraising model architecture instead of inputted data, withholding code, and evaluating studies using antiquated regression-based guidelines. While AI has been applied to a variety of hip and knee arthroplasty applications with limited clinical impact, the future remains promising if the question is meaningful, the methodology is rigorous and transparent, the data are rich, and the model is externally validated. Simple checkpoints for meaningful AI adoption include ensuring applications focus on: administrative support over clinical evaluation and management; necessity of the advanced model; and the novelty of the question being answered.

Cite this article: Bone Joint J 2022;104-B(12):1292–1303.

The December 2023 Research Roundup³⁶⁰ looks at: Tissue integration and chondroprotective potential of acetabular labral augmentation with autograft tendon: study of a porcine model; The Irish National Orthopaedic Register under cyberattack: what happened, and what were the consequences?; An overview of machine learning in orthopaedic surgery: an educational paper; Beware of the fungus…; New evidence for COVID-19 in patients undergoing joint replacement surgery.

Accurate documentation of operative findings is a fundamentally important part of any procedure and forms part of the Royal College of Surgeons of England's guidelines to good care, especially to “ensure that there are legible operative notes (typed if possible) for every operative procedure.” However, many hospitals fall short of this guideline when it comes to arthroscopic procedures because of the difficulty in reproducing visually representative and easy-to-understand images. There is an inability to properly record and archive findings of arthroscopic procedures. We, along with the British Orthopaedic Association, have developed an interactive, free Web-based operative note template that allows the surgeon to draw findings on diagrams of the joints commonly undergoing arthroscopy, type the findings, and then print as many copies as required. The use of the forms has allowed for quicker, easier, and more accurate documentation of arthroscopic procedures. The forms can then be saved to a database and used as a research tool

Aims

During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon’s decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing.

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The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery.

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Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury.

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The ‘pink, pulseless hand’ is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications.

Aims

The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades.

Acute multiligament knee injuries (MLKI) are rare, high energy traumatic injuries associated with an increased risk of lower limb complications. The objectives of this study were to investigate the adequacy of clinical assessment for neurovascular status, compartment syndrome, and deep vein thrombosis in the emergency department (ED) following acute MLKI. The authors conducted a retrospective case note review of 19 patients with MLKI presenting at the ED of a Major Trauma Centre during a 7.5-year period between June 2009 and December 2016. MLKIs were diagnosed by MRI or examination under anaesthesia and confirmed intraoperatively. Arterial assessment consisted of documented capillary refill time, dorsalis pedis and posterior tibial pulse assessment (through palpation or Doppler ultrasound), and ankle-brachial pressure index (ABPI) calculation. Neural assessment was adequate if there was documented assessment of both sensory and motor function of the superficial peroneal, deep peroneal and tibial nerves individually. Data was collected for 19 patients (17 male, 2 female). The mean age was 34 (range: 14–61). The most common injury mechanism was road traffic accident. Neurovascular assessment was suboptimal in all categories: only one patient received a satisfactory lower limb neurological assessment and no patients received complete vascular assessments. Neurovascular assessment of multiligament knee injuries was suboptimal. Reasons for this included poor documentation and lack of certain specific clinical assessments, such as ABPI calculation. We propose the introduction of an acute knee injury pro forma highlighting the components of a full lower limb neurovascular examination to rectify this problem

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

This paper considers the new financial infrastructure of the National Health Service and provides a resource for orthopaedic surgeons. We describe the importance of accurate documentation and data collection for National Health Service hospital Trust finances and league tables, and support our discussion with examples drawn from our local audit work

Introduction. Acromial and scapular fractures are a rare but difficult complication with reverse total shoulder arthroplasty (rTSA), with an incidence rate reported from 1–10%. The risk factors associated with these fractures types is largely unknown. The goal of this study is to analyze the clinical outcomes, demographic and comorbidity data, and implant sizing and surgical technique information from 4125 patients who received a primary rTSA with one specific prosthesis (Equinoxe, Exactech, Inc) and were sorted based on the radiographic documentation of an acromial and/or scapula fracture (ASF) to identify factors associated with this complication. Methods. 4125 patients (2652F/1441M/32 unspecified; mean age: 72.5yrs) were treated with primary rTSA by 23 orthopaedic surgeons. Revision and fracture reverse arthroplasty cases were excluded. The radiographic presence of each fracture was documented and classified using the Levy classification method. 61 patients were identified as having ASF, 10 patients had fractures of the Type 1, 32 patients had Type 2, and 18 patients had Type 3 fractures according to Levy's classification. One fracture was not classifiable. Pre-op and post-op outcome scoring, ROM as well as demographic, comorbidity, implant, and surgical technique information were evaluated for these 61 patients and compared to the larger cohort of patients to identify any associations. A two-tailed, unpaired t-test identified differences (p<0.05). Results. The overall rate of ASF was 1.48% with the average time after surgery occurring at 12.9 ± 17.9 months (range 1 day to 78 months). Men had an ASF rate of 0.69% (10 of 1441); whereas women had a rate of 1.92% (51 of 2652). Patients with ASF were observed to be significantly shorter than patients without ASF (65.1 in vs 63.3 in, p=0.0004). ASF were more common in females (p=0.0019), have Rheumatoid Arthritis (p=0.0051), Cuff Tear Arthropathy (p=0.0093), or previous shoulder surgery (p=0.0189). Patient's weight did not correlate, nor did BMI. No difference was observed in humeral stem size, glenosphere diameter, or the humeral tray offset, humeral liner offset, or combined humeral tray+liner offset. The average number of screws used in the fracture group was significantly more than in the non-fracture group (p=0.0327), and 93% of patients in the fracture group had a screw in the superior hole of the baseplate. Pre-operatively, patients who developed ASF had significantly worse ASES (p=0.0104) and SPADI (p=0.0136) scores and also had significantly worse forward elevation (p=0.0237) and internal rotation (p=0.0054) than those who did not develop ASF. At latest follow-up, patients with ASF had significantly worse SST, UCLA, ASES, Constant, and SPADI scores (all p<0.0001); significantly worse abduction, forward elevation, internal rotation, strength (all p<0.0001); and significantly less preop-to-postop improvement in all measured outcomes, except for external rotation (all p<0.0001). Finally, 24% of fractures were identified as being caused by a traumatic event, 28% of patients with fractures had a previous acromioplasty, and 53% of fractures were Levy type 2. Discussion. Acromial and scapular fractures after rTSA are a rare complication, with an incidence of 1.48% in this analysis of 4125 patients with a single rTSA prosthesis. These fractures were observed to occur at an average of 12.9 months after surgery, but were observed as early as 1 day and as late as 6.5 years. Female patients, Rheumatoid Arthritis, Cuff Tear Arthropathy, previous shoulder surgery, relatively worse pre-operative ASES or SPADI scores, relatively decreased pre-operative forward elevation and internal rotation as well as a larger number of screws placed in the baseplate all were significantly associated with the occurrence of ASF. Although 93% of patients with ASF had a screw placed in the superior hole of the baseplate, we cannot conclude that this is a driving factor at this time, as the superior screw number for the non-fracture group was not recorded. Future work should evaluate if usage of a superior glenoid baseplate screw and previous acromioplasty are also risk factors for these fracture types after rTSA. This study is the largest ever performed analysis of this rare complication and provides news insight into the predisposing risk factors to consider when evaluating patients for rTSA

Neurological examination in children presenting with upper limb fractures is often poorly performed. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our own hospital and performed a further 3 month clinical review to detect any resulting change in practice. In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination. Following introduction of the guideline, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. Introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Aims

Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

Introduction. ‘VTE disease is the new MRSA’, with much attention received in the media and the political world. Following the 2010 NICE guidelines all patients admitted to hospital should have VTE prophylaxis considered and a formal VTE risk assessment done with documentation and review in a 24 hour period. We carried out a completed audit cycle to identify our adherence to these guidelines and introduced a novel method to ensure compliance. Materials/Methods. An audit of 400 patients admitted to the orthopaedic department was carried out with review of case notes. Three key parameters were investigated: Firstly the compliance of carrying out a risk assessment for VTE disease with correct documentation, secondly investigating how many patients got re-assessed in 24 hours and finally if patients received appropriate VTE prophylaxis. The data was re-audited following the introduction of a new drug chart with a box section for VTE risk assessment and prophylaxis on the chart itself. Results. In the first cycle VTE risk assessments were carried out in 2.5% with 0% having a re-assessment in 24 hours and 93.5% of patients having correctly prescribed VTE prophylaxis. Following the new drug charts, the risk assessments were carried out in 79%, re-assessment in 50% and correct prescribed prophylaxis in 99% of the patients. Conclusions. We recommend all hospitals should have a section in the drug chart itself for VTE risk assessment and prophylaxis as this greatly improves compliance to the NICE guidelines. This ensures optimal patient care and protects the trust from litigations

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department. Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children. The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination. 30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function. While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children

Introduction. In November 2017, the Center for Medicare and Medicaid Services (CMS) finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty (TKA) procedures from the Medicare inpatient-only (IPO) list of procedures. This action had significant and unexpected consequences. For several years, CMS has utilized a rule called the “Two-Midnight Rule” to define outpatient status for all procedures not on the IPO list. CMS made TKA subject to the “Two-Midnight Rule” in conjunction with the decision to move TKA off the IPO list. According to the “Two-Midnight Rule,” a hospital admission should be expected to span at least two midnights in order to be covered as an inpatient procedure. If it can be reliably expected that the patient will not require at least two midnights in the hospital, the “Two-Midnight Rule” suggests that the patient is considered an outpatient and is therefore subject to outpatient payment policies. Under prior guidance related to the “Two-Midnight Rule;” however, CMS also states that Medicare may treat some admissions spanning less than two midnights as inpatient procedures if the patient record contains documentation of medical need. The final rule was clear in stating CMS's expectation was that the great majority of TKAs would continue to be provided in an inpatient setting. Methods. We looked at 3 different levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of fee for service (FFS) inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April of 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in inpatient classification of TKA patients over time, number of Quality Improvement Organization (QIO) audits, compliance solutions of organizations for the new rule and cost implications of those compliance solutions were evaluated. Results. Hospital reimbursement averages $10,122 in an outpatient facility (includes implant, other supplies, ancillary staff, etc.) but does NOT include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in reimbursement to hospitals varies widely however due to nuances in the CMS reimbursement formula (90. th. percentile decrease, $6,725 vs 10th percentile $2,048). Physician payments are the same in both settings (avg $1,403). TKA patients not designated for in-patient admissions are not eligible for bundle payment programs thus removing the healthiest, most predictable patients from the program. Patients designated as outpatients are subject to higher out of pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. A survey of AAHKS surgeons demonstrated that 44.74% were doing inpatient designation only, 17.89% were doing outpatient designation only, 25.53 % designated patients as necessary, and 10% were designated by the hospital. This survey showed that 66/374 (17.65%) of AAHKS responders had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of a large academic medical center demonstrated that since January 1, 2018, 470/690 (68.1%) of CMS TKA patients left the institution in less than 2 midnights. During this time period the institution was subjected to 2 QIO audits. All CMS patients had been designated as inpatients prior to May 2019. Conclusions. There are many unintended consequences to the IPO rule application to TKA. Clearly, more study is needed to provide better guidelines to knee replacement surgeons. A well-defined outpatient TKA bundle would allow CMS and TKA surgeons to better serve their patients. For figures, tables, or references, please contact authors directly

We have investigated whether shape of the knee can predict the clinical outcome of patients after an anterior cruciate ligament rupture. We used statistical shape modelling to measure the shape of the knee joint of 182 prospectively followed patients on lateral and Rosenberg view radiographs of the knee after a rupture of the anterior cruciate ligament. Subsequently, we associated knee shape with the International Knee Documentation Committee subjective score at two years follow-up. The mean age of patients was 31 years (21 to 51), the majority were male (n = 121) and treated operatively (n = 135). We found two modes (shape variations) that were significantly associated with the subjective score at two years: one for the operatively treated group (p = 0.002) and one for the non-operatively treated group (p = 0.003). Operatively treated patients who had higher subjective scores had a smaller intercondylar notch and a smaller width of the intercondylar eminence. Non-operatively treated patients who scored higher on the subjective score had a more pyramidal intercondylar notch as opposed to one that was more dome-shaped. We conclude that the shape of the femoral notch and the intercondylar eminence is predictive of clinical outcome two years after a rupture of the anterior cruciate ligament. Cite this article: Bone Joint J 2014;96-B:737–42

The aim of this study was to assess the effect of injecting genetically engineered chondrocytes expressing transforming growth factor beta 1 (TGF-β1) into the knees of patients with osteoarthritis. We assessed the resultant function, pain and quality of life. . A total of 54 patients (20 men, 34 women) who had a mean age of 58 years (50 to 66) were blinded and randomised (1:1) to receive a single injection of the active treatment or a placebo. We assessed post-treatment function, pain severity, physical function, quality of life and the incidence of treatment-associated adverse events. Patients were followed at four, 12 and 24 weeks after injection. At final follow-up the treatment group had a significantly greater improvement in the mean International Knee Documentation Committee score than the placebo group (16 points; -18 to 49, vs 8 points; -4 to 37, respectively; p = 0.03). The treatment group also had a significantly improved mean visual analogue score at final follow-up (-25; -85 to 34, vs -11 points; -51 to 25, respectively; p = 0.032). Both cohorts showed an improvement in Western Ontario and McMaster Osteoarthritis Index and Knee Injury and Osteoarthritis Outcome Scores, but these differences were not statistically significant. One patient had an anaphylactic reaction to the preservation medium, but recovered within 24 hours. All other adverse events were localised and resolved without further action. . This technique may result in improved clinical outcomes, with the aim of slowing the degenerative process, leading to improvements in pain and function. However, imaging and direct observational studies are needed to verify cartilage regeneration. Nevertheless, this study provided a sufficient basis to proceed to further clinical testing. Cite this article: Bone Joint J 2015;97-B:924–32

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice. In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment. Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

The December 2023 Spine Roundup³⁶⁰ looks at: Does size matter in adolescent pedicle screws?; Effect of lumbar fusion and pelvic fixation rigidity on hip joint stress: a finite element analysis; Utility of ultrasonography in the diagnosis of lumbar spondylolysis in adolescent patients; Rett syndrome-associated scoliosis a national picture.

Introduction. This community Arthroplasty Register is an individual initiative to document arthroplasty procedures performed from 2007 to date in a sample area in Cairo, Egypt. Currently, there is no published study or official documentation of the indications for arthroplasty, types of implants or the rate of total hip and knee arthroplasty (THA & TKA). Although the population of Egypt reached 80,394,000, the unofficial estimate of the rate of joint replacement is less than 10,000 per year. This rate is less than 10% of what is currently done in UK, a country with similar or even less population than Egypt. This indicates the unmet need for TKA in Egypt, where the knee OA is prevailing and there is a call for documentation and a registry. Methods. The registry sheet is 3 pages; pre-, intra- and post-operative. It is available in printed format and online as demonstrated below . www.knee-hip.com. During the registry period, there were 282 cases collected prospectively and 206 collected retrospectively. This initial analysis included only prospectively collected data of 157 TKA and 125 THA. Results. For THA, the mean age was 48 years ranging from (19–86). Female to male ratio was 1.15:1. The rate of uncemented THA was 84.8%, Cemented was 10.2% and hybrid THA was 5%. We have observed significant growth in the uncemented type of fixation. The rate of primary was 54.4 % (complex primary 26.4%), Conventional THA techniques were done for 56.15%, while computer assisted surgery was used in 43.85% of cases. For TKA, there was 71.33% primary and 19.7% complex primary, 8.97% revision arthroplasty. A female to male ratio was 2.92:1. The main indication for TKA was OA in 87.26%. Preoperative radiographic evaluation showed that 47% had severe varus and 15% had significant bone defect. Conventional TKA techniques were done for 73.2%, while computer assisted surgery was sued in 26.8 % of cases

Evaluation of transtibial aiming of the femoral tunnel at its anatomical position in arthroscopical ACL reconstruction. 43 ACL reconstructions with hamstrings’ graft were studied. First, the femoral tunnel was drilled through the anteromedial portal at 09.30–10.00 (14.00–14.30 resp.) and then the tibial tunnel (av. anteroposterior angle: 63,5°, sagittal: 64,2°) at the same diameter with simoultaneous radiological documentation. Then, with a femoral aiming device, we tried to put a K-wire at the center of the drilled femoral tunnel. Fotographic documentation took place. In 20 cases the diameter of the tunnels was 7mm, in 11, 7,5mm, in 7, 8mm, in 3, 8,5mm and in 1, 9mm. Evaluation of all radiological and photographic material from 2 observers followed, according to the deviation of the transtibial K-wire from the center of the femoral tunnel. 38 ACL reconstructions were evaluated. It was shown that in 11 cases the transtibial K-wire was in the femoral tunnel (28,9%) (in 7 with a diameter of 7mm., in 2 with 7,5mm. and in 2 with 8mm.). The K-wire was in 23 cases (60,5%) at the perimeter or out of the femoral tunnel (in 11, with a diameter of 7mm., in 8 with 7,5mm., in 4 with 8mm., in 3 with 8,5mm. and in 1 with 9mm.). There was no correlation with the angles of the tibial tunnel or the age of the patients. Transtibial aiming of the femoral tunnel at its anatomical position is very difficult and there is no correlation of the transtibial deviation with the diameter of the tibial tunnel

The December 2022 Knee Roundup³⁶⁰ looks at: Effect of physical therapy versus arthroscopic partial meniscectomy: the ESCAPE trial at five years; Patellofemoral arthroplasty or total knee arthroplasty: a randomized controlled trial; Rehabilitation versus surgical reconstruction for anterior cruciate ligament injury; End-stage knee osteoarthritis in Australia: the effect of obesity; Do poor patient-reported outcome measures at six months relate to knee revision?; What is the cost of nonoperative interventions for knee osteoarthritis?

Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.