INTRODUCTION. There are many factors which contribute to function after TKA. In this study we focus on the effect of varus-valgus (VV) balancing measured externally. A loose knee can show instability (Sharkey 2014) while too tight, flexion can be limited. Equal lateral-medial balancing at surgery leads to a better result (Unitt 2008; Gustke 2014), which is generally the surgical goal. Indeed similar varus and valgus laxity angles have been found in most studies in vitro (Markolf 2015; Boguszewski 2015) and in vivo (Schultz 2007; Clarke 2016; Heesterbeek 2008). The angular ranges have been 3–5 degrees at 10–15 Nm of knee moment, females having the higher angles. The goal of this study was to measure the varus and valgus laxity, as well as the functional outcome scores, of two cohorts; well-functioning total knees after at least one year follow-up, and subjects with healthy knees in a similar age group to the TKR's. Our hypothesis was that the results will be equal in the two groups. METHODS & MATERIALS. 50 normal subjects average age 66 (27 male, 23 female) and 50 TKA at 1 year follow-up minimum average age 68 years (16 male, 34 female) were recruited in this IRB study. The TKA's were performed by one surgeon (PAM) of one TKA design, balancing by gap equalization. Subjects completed a KSS evaluation form to determine functional, objective, and satisfaction scores. Varus and valgus measurements were made using the Smart Knee Fixture (Figure 1)(Borukhov 2016) at 20 deg flexion with a moment of 10 Nm. RESULTS. The statistical results are summarized in table 1. There was no significant difference in either varus or valgus laxity between the two groups (p= 0.9, 0.3 respectively). Pearson's correlation coefficient between varus and valgus laxity of the healthy group was 0.42, while for the TKA group was 0.55. In both cohorts varus laxity was significant higher than valgus laxity (p= 0.001 for healthy subjects and p=0.0001 for TKA). The healthy group had higher functional and objective KSS scores (p= 0.005, and p=0.004 respectively), but the same satisfaction scores as the TKA (p=0.3) (Table 2). No correlation was found between the total laxity of the TKA group and the KSS scores (functional, objective and satisfaction). Total laxity in females was significantly higher than in males in the healthy group, but no differences was found in the TKA group. DISCUSSION. The hypothesis of equal varus and valgus angles in the 2 groups was supported. The larger varus angle implied a less stiff lateral collateral compared with the medial collateral. If the TKA's were balanced equally at surgery, it is possible there was ligament remodeling over time. However the functional scores were inferior for the TKA compared with normal. This finding has not been highlighted in the literature so far. The causes could include weak musculature (Yoshida 2013), non-physiologic kinematics due to the TKA design, or the use of rigid materials in the TKA. The result presents a challenge to improve outcomes after TKA. For figures/tables, please contact authors directly.

There are many factors which contribute to function after TKA. In this study we focus on the effect of varus-valgus (VV) balancing measured externally. A loose knee can show instability (Sharkey 2014) while too tight, flexion can be limited. Equal lateral-medial balancing at surgery leads to a better result (Unitt 2008; Gustke 2014), which is generally the surgical goal. Indeed similar varus and valgus laxity angles have been found in most studies in vitro (Markolf 2015; Boguszewski 2015) and in vivo (Schultz 2007; Clarke 2016; Heesterbeek 2008). The angular ranges have been 3–5 degrees at 10–15 Nm of knee moment, females having the higher angles. The goal of this study was to measure the varus and valgus laxity, as well as the functional outcome scores, of two cohorts; well-functioning total knees after at least one year follow-up, and subjects with healthy knees in a similar age group to the TKR's. Our hypothesis was that the results will be equal in the two groups. 50 normal subjects average age 66 (27 male, 23 female) and 50 TKA at 1 year follow-up minimum average age 68 years (16 male, 34 female) were recruited in this IRB study. The TKA's were performed by one surgeon (PAM) of one TKA design, balancing by gap equalization. Subjects completed a KSS evaluation form to determine functional, objective, and satisfaction scores. Varus and valgus measurements were made using the Smart Knee Fixture (Borukhov 2016) at 20 deg flexion with a moment of 10 Nm. The statistical results demonstrated that there was no significant difference in either varus or valgus laxity between the two groups (p= 0.9, 0.3 respectively). Pearson's correlation coefficient between varus and valgus laxity of the healthy group was 0.42, while for the TKA group was 0.55. In both cohorts varus laxity was significant higher than valgus laxity (p= 0.001. e. −5. for healthy subjects and p=0.0001 for TKA). The healthy group had higher functional and objective KSS scores (p= 0.005. e. −4. , and p=0.004. e. −5. respectively), but the same satisfaction scores as the TKA (p=0.3). No correlation was found between the total laxity of the TKA group and the KSS scores (functional, objective and satisfaction). Total laxity in females was significantly higher than in males in the healthy group, but no differences was found in the TKA group. The hypothesis of equal varus and valgus angles in the 2 groups was supported. The larger varus angle implied a less stiff lateral collateral compared with the medial collateral. If the TKA's were balanced equally at surgery, it is possible there was ligament remodeling over time. However the functional scores were inferior for the TKA compared with normal. This finding has not been highlighted in the literature so far. The causes could include weak musculature (Yoshida 2013), non-physiologic kinematics due to the TKA design, or the use of rigid materials in the TKA. The result presents a challenge to improve outcomes after TKA

Background

Although thigh pain is an annoying problem after total hip arthroplasty (THA), little information has been known about its natural course.

It is recognised that as the severity of hallux valgus (HV) worsens, so do the clinical and radiological signs of arthritis in the first metatarsophalangeal joint.

However, few studies specifically document the degenerate changes. The purpose of this study is to determine if intraoperative mapping of articular erosive lesions of the first MTP joint can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity.

Aims. The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR). Methods. We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale. Results. We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001). Conclusion. Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected. Cite this article: Bone Jt Open 2023;4(1):46–52

Aims. The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD). Methods. In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. Results. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). Conclusion. OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data. Cite this article: Bone Jt Open 2023;4(3):138–145

Aims. The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA. Methods. A randomized controlled trial was undertaken, and patients were randomized to either mTKA or rTKA. The primary objective was functional improvement at six months. Overall, 100 patients were randomized, 50 to each group, of whom 46 rTKA and 41 mTKA patients were available for review at six months following surgery. There were no differences between the two groups. Results. There was no difference between rTKA and mTKA groups at six months according to the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) functional score (mean difference (MD) 3.8 (95% confidence interval (CI) -5.6 to 13.1); p = 0.425). There was a greater improvement in the WOMAC pain score at two months (MD 9.5 (95% CI 0.6 to 18.3); p = 0.037) in the rTKA group, although by six months no significant difference was observed (MD 6.7 (95% CI -3.6 to 17.1); p = 0.198). The rTKA group were more likely to achieve a minimal important change in their WOMAC pain score when compared to the mTKA group at two months (n = 36 (78.3%) vs n = 24 (58.5%); p = 0.047) and at six months (n = 40 (87.0%) vs n = 29 (68.3%); p = 0.036). There was no difference in satisfaction between the rTKA group (97.8%; n = 45/46) and the mTKA group (87.8%; n = 36/41) at six months (p = 0.096). There were no differences in EuroQol five-dimension questionnaire (EQ-5D) utility gain (p ≥ 0.389) or fulfilment of patient expectation (p ≥ 0.054) between the groups. Conclusion. There were no statistically significant or clinically meaningful differences in the change in WOMAC function between mTKA and rTKA at six months. rTKA was associated with a higher likelihood of achieving a clinically important change in knee pain at two and six months, but no differences in knee-specific function, patient satisfaction, health-related quality of life, or expectation fulfilment were observed. Cite this article: Bone Joint J 2023;105-B(9):961–970

Aims. To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. Methods. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. Results. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Conclusion. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis. Cite this article: Bone Jt Open 2023;4(5):338–356

Aims. This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes’ disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system. Methods. A total of 136 individuals aged 12 years or older who had Perthes’ disease in childhood completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility score (function), Nonarthritic Hip Score (NAHS) (function), EuroQol five-dimension five-level questionnaire (EQ-5D-5L) score (quality of life), and the numeric rating scale for pain (NRS). The Stulberg class of the participants’ hip radiographs were evaluated by three fellowship-trained paediatric orthopaedic surgeons. Hip shape and Stulberg class were compared to PROM scores. Results. A spherical hip was associated with the highest function and quality of life, and lowest pain. Conversely, aspherical hips exhibited the lowest functional scores and highest pain. The association between worsening Stulberg class (i.e. greater deviation from sphericity) and worse outcome persisted after adjustment for age and sex in relation to PROMIS (predicted mean difference -1.77 (95% confidence interval (CI) -2.70 to -0.83)), NAHS (-5.68 (95% CI -8.45 to -2.90)), and NRS (0.61 (95% CI 0.14 to 1.08)), but not EQ-5D-5L (-0.03 (95% CI -0.72 to 0.11)). Conclusion. Patient-reported outcomes identify lower function, quality of life, and higher pain in aspherical hips. The magnitude of symptoms deteriorated with time. Hip sphericity (i.e. the modified three-group classification of spherical, oval, and aspherical) appeared to offer similar levels of detail to the five-group Stulberg classification. Cite this article: Bone Joint J 2023;105-B(6):711–716

Aims. Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon. Methods. This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores. Results. In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend. Conclusion. Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA. Cite this article: Bone Jt Open 2022;3(1):29–34

Aims. The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing. Methods. A literature search was performed in PubMed, Embase, and Web of Science databases. The keywords used for the search criteria were ((3d print*) OR (rapid prototyp*) OR (additive manufactur*)) AND (orthopaedic). The inclusion criteria were: 1) use of 3D printing in orthopaedics, 2) randomized controlled trials, and 3) studies with participants/patients. Risk of bias was assessed with Cochrane Collaboration Tool and PEDro Score. Pooled analysis was performed. Results. Overall, 21 studies were included in our study with a pooled total of 932 participants. Pooled analysis showed that operating time (p < 0.001), blood loss (p < 0.001), fluoroscopy times (p < 0.001), bone union time (p < 0.001), pain (p = 0.040), accuracy (p < 0.001), and functional scores (p < 0.001) were significantly improved with 3D printing compared to the control group. There were no significant differences in complications. Conclusion. 3D printing is a rapidly developing field in orthopaedics. Our findings show that 3D printing is advantageous in terms of operating time, blood loss, fluoroscopy times, bone union time, pain, accuracy, and function. The use of 3D printing did not increase the risk of complications. Cite this article: Bone Joint Res 2021;10(12):807–819

Aims. The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures. Methods. A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype. Results. The one-year mortality rate of the stable and unstable subtype of Vancouver type B was 9.4% and 16.4%. Patient demographic factors, including residential status and pre-injury mobility were associated with mortality. There was no significant difference in mortality between patients treated with ORIF and Revision in either Vancouver B subtype. Patients treated with revision had significantly higher Parker Mobility Score (PMS) values (5.48 vs 3.43; p = 0.00461) and a significantly lower visual analogue scale (VAS) values (1.06 vs 1.94; p = 0.0399) for pain than ORIF in the unstable subtype. Conclusion. Among patients with Vancouver type B fractures, frail patients, such as those with worse scores for residential status and pre-injury mobility, had a high mortality rate. There was no significant difference in mortality between patients treated with ORIF and those treated with revision. However, in the unstable subtype, the PMS and VAS values at the final follow-up examination were significantly better in patients who received revision. Based on postoperative activities of daily life, we therefore recommend evision in instances when either treatment option is feasible. Cite this article: Bone Jt Open 2023;4(1):38–46

Aims. Golf is a popular pursuit among those requiring total hip arthroplasty (THA). The aim of this study was to determine if participating in golf is associated with greater functional outcomes, satisfaction, or improvement in quality of life (QoL) compared to non-golfers. Methods. All patients undergoing primary THA over a one-year period at a single institution were included with one-year postoperative outcomes. Patients were retrospectively followed up to assess if they had been golfers at the time of their surgery. Multivariate linear regression analysis was performed to assess the independent association of preoperative golfing status on outcomes. Results. The study cohort consisted of a total of 308 patients undergoing THA, of whom 44 were golfers (14%). This included 120 male patients (39%) and 188 female patients (61%), with an overall mean age of 67.8 years (SD 11.6). Golfers had a greater mean postoperative Oxford Hip Score (OHS) (3.7 (95% confidence interval (CI) 1.9 to 5.5); p < 0.001) and EuroQol visual analogue scale (5.5 (95% CI 0.1 to 11.9); p = 0.039). However, there were no differences in EuroQoL five-dimension score (p = 0.124), pain visual analogue scale (p = 0.505), or Forgotten Joint Score (p = 0.215). When adjusting for confounders, golfers had a greater improvement in their Oxford Hip Score (2.7 (95% CI 0.2 to 5.3); p < 0.001) compared to non-golfers. Of the 44 patients who reported being golfers at the time of their surgery, 32 (72.7%) returned to golf and 84.4% of those were satisfied with their involvement in golf following surgery. Those who returned to golf were more likely to be male (p = 0.039) and had higher (better) preoperative health-related QoL (p = 0.040) and hip-related functional scores (p = 0.026). Conclusion. Golfers had a greater improvement in their hip-specific function compared to non-golfers after THA. However, less than three-quarters of patients return to golf, with male patients and those who had greater preoperative QoL or hip-related function being more likely to return to play. Cite this article: Bone Jt Open 2022;3(2):145–151

Background. Patient satisfaction after total knee arthroplasty (TKA) has been lower than after a similar procedure, total hip arthroplasty. Poor subjective outcomes after TKA may be partially explained by abnormal kinematics patterns after TKA. The purpose of this study was to analyse rotational kinematics patterns in knees that had undergone posterior stabilized (PS)-TKA, and to clarify the relationships between rotational kinematics patterns and patient satisfaction, as well as between rotational kinematics patterns and knee function. Materials & Methods. A total of 49 osteoarthritis knees after primary PS-TKA (NexGen LPS-Flex fixed bearing knee system) were included in this study; deformed valgus, severe flexion contractures, and highly unstable knees were excluded. We used a computer navigation system and measured knee kinematics after each surgery was completed. A single investigator gently applied a manual range of motion from full extension to flexion. The angle of the internal rotation of the tibia was measured automatically at 0º, 30º, 45º, 60º, and 90º, along with maximum extension and flexion. We categorized the post-operative rotational kinematics patterns for individual cases, focusing on the initial knee flexion from 0–30º. Type A corresponded to an increased internal rotation angle of the tibia during the initial knee flexion (screw home-like movement). Type B corresponded to an increased external or an unchanged rotation angle of the tibia. We examined the range of motion (ROM) at 6 months after surgery and assessed the 2011 Knee Society Score (2011 KSS) at ≥1 year following surgery. Statistical analysis. The difference between the two groups was compared using a Wilcoxon rank sum test. Analyses were performed with JMP statistical software v8.0 (SAS Institute). A p-value of <0.05 was regarded as significant. Results. The tibia exhibited an average of 5º of internal rotation at initial knee flexion. The type A kinematics pattern achieved a better ROM and functional activity score (2011 KSS) than the type B kinematics pattern. Discussion. Modern TKA implants have been designed to reproduce normal knee kinematics to achieve better patient satisfaction and knee function. However, few reports have described the relationship between the rotational kinematics patterns at initial knee flexion and patient satisfaction. In our study, the type A postoperative rotational kinematics pattern (screw home-like movement) had better ROM and functional activity score than the type B kinematics pattern. The movement toward the internal rotation of the tibia during initial knee flexion might be important in achieving better clinical results after PS-TKA

Objective: The purpose of this study was to determine how changes in functional shoulder score (Constant Score) affected the values of the SF-36 score, to determine the amount of functional score change to be considered relevant. Material and Method: 427 patients were included. All of them were assessed with a functional shoulder score (Constant Score) and fulfilled SF-36 score. Mean age was of 50,61(18–85), 200 of them were male and 227 female. 280 were considered to be active while 147 were retired as far as working status is concerned. There were 191 patients with university studies and 236 with primary studies. Primary diagnosis was cuff disorders in 265 patients, old-fracture in 43, degenerative in 72 and instability in 34. Correlations were performed with Spearman’s rho and regression models were evaluated. Results: There was a moderate but significant correlation between the total Constant Score and PF_NORM (0,511) and US standardized physical component (US STPH) (0,491) of the SF-36. For every point of increase in the Constant score the SF-36 increases 0,235 points. Looking into the different items of the Constant Score, Activities of daily living (ADL) and strength presented the stronger correlation with SF-36 (0,428, 0,411). In the regression model, every point of increase of pain, ADL, forward elevation, external rotation and internal rotation means an increase of 0,472, 0,39, 0,84, 0,82 and 0,86 of the US STPH of the SF-36. Conclusions: Whenever the outcome of any shoulder treatment is analyzed it has to be taken into account that for every point of increase of the Total Constant Score just 0,235 points of the US SPTH of the SF-36 increase. Depending on the mean value of the US SPTH of the SF-36 of the population studied, the relevant increase of Constant Score can be calculated. Mobility improvements seem to have more influence that pain changes as far as increasing the US SPTH of the SF-36 is concerned

Due to shorter hospital stays and faster patient rehabilitation Unicompartmental Knee Replacements (UKR) are now considered more cost effective than Total Knee Joint Replacements (TKJR). Obesity however, has long been thought of as a relative contraindication to UKR due to an unproven theoretical concern of early loosening. This study is a retrospective review of patient reported outcome scores and revision rates of all UKR with recorded BMI performed by the Canterbury District Health Board (CDHB) from January 2011 and September 2021. Patient reported outcome scores were taken preoperatively, at 6 months, 1 year, 5 years and 10 years post operatively. These included WOMAC, Oxford, HAAS, UCLA, WHOQOL, normality, pain and patient satisfaction. 873 patients had functional scores recorded at 5 years and 164 patients had scores recorded at 10 years. Further sub-group analysis was performed based on patient BMI of <25, 25–30, 30–35 and >35. Revision data was available for 2377 UKRs performed in Christchurch during this period. Both obese (BMI >30) and non-obese (BMI <30) patients had significantly improved post-operative scores compared to preoperative. Pre-operatively obese patients had significantly lower functional scores except for pain and UCLA. All functional scores were lower in obese patients at 5 years but this did not meet minimum clinical difference. At 10 years, there was significantly lower HAAS, satisfaction and WOMAC scores for obese patients but no difference in Oxford, normality, WHOQOL, UCLA and pain scores. There was no significant difference in the improvement from pre-operative scores between obese and non-obese patients. All cause revision rate for obese patients at 10 years was 0.69 per 100 observed component years compared to 0.76 in non-obese. This was not statistically significant. Our study proves that UKR is an excellent option in obese patients with post-operative improvement in functional scores and 10 year survivorship equivalent to non-obese patients

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

Higher levels of socioeconomic deprivation have been associated with worse health outcomes. The influence of socioeconomic deprivation on patients undergoing periacetabular osteotomy (PAO) has not previously been investigated. A total of 217 patients (171 female, 46 male; median age 23.4 years) who underwent PAO by a single surgeon were identified. Patients were categorised into three groups according to their New Zealand Deprivation (NZDep) Index: minimal deprivation (NZDep Index 1–3, n=89), moderate deprivation (NZDep Index 4–6, n=94), and maximal deprivation (NZDep Index 7–10, n=34). The three groups were compared with respect to baseline variables, surgical details, complications, and pre-operative and two-year post-operative functional scores (including International Hip Outcome Tool (iHOT-12), EQ-5D quality of life score, and University of California Los Angeles (UCLA) activity score). Multivariate regression was undertaken to assess for the effect of NZDep Index on patient outcomes. Patients in the maximal deprivation group were more likely to be Māori (p<0.001) and have surgery in a public rather than a private hospital (p=0.004), while the minimal deprivation group demonstrated a lower BMI (p=0.005). There were otherwise no other significant differences in baseline variables, surgical details, complications, nor pre-operative or two-year post-operative functional scores between the three groups (all p>0.05). Multivariate analysis identified a higher NZDep Index to be independently predictive of a lower pre-operative UCLA activity score (p=0.014) and a higher two-year iHOT-12 score (p<0.001). Our results demonstrate an inequality in access to PAO, with patients exposed to higher levels of socioeconomic deprivation under-represented in our study population. When provided access to PAO, these vulnerable patients achieve significant functional improvement at least as great as patients with less socioeconomic deprivation. Initiatives to improve access to hip preservation care in socioeconomically deprived populations appear warranted

Distal interphalangeal joint (DIPJ) fusion using a k-wire has been the gold standard treatment for DIPJ arthritis. Recent studies have shown similar patient outcomes with the headless compression screws (HCS), however there has been no cost analysis to compare the two. Therefore, this study aims to 1) review the cost of DIPJ fusion between k-wire and HCS 2) compare functional outcome and patient satisfaction between the two groups. A retrospective review was performed over a nine-year period from 2012-2021 in Counties Manukau. Cost analysis was performed between patients who underwent DIPJ fusion with either HCS or k-wire. Costs included were surgical cost, repeat operations and follow-up clinic costs. The difference in pre-operative and post-operative functional and pain scores were also compared using the patient rate wrist/hand evaluation (PRWHE). Of the 85 eligible patients, 49 underwent fusion with k-wires and 36 had HCS. The overall cost was significantly lower in the HCS group which was 6554 New Zealand Dollars (NZD), whereas this was 10408 NZD in the k-wire group (p<0.0001). The adjusted relative risk of 1.3 indicate that the cost of k-wires is 1.3 times more than HCS (P=0.0053). The patients’ post-operative PRWHE pain (−22 vs −18, p<0.0001) and functional scores (−38 vs −36, p<0.0001) improved significantly in HCS group compared to the k-wire group. Literatures have shown similar DIPJ fusion outcomes between k-wire and HCS. K-wires often need to be removed post-operatively due to the metalware irritation. This leads to more surgical procedures and clinic follow-ups, which overall increases the cost of DIPJ fusion with k-wires. DIPJ fusion with HCS is a more cost-effective with a lower surgical and follow-up costs compared to the k-wiring technique. Patients with HCS also tend to have a significant improvement in post-operative pain and functional scores

Abstract. Purpose. This study aims to compare the clinical and functional outcomes and donor site morbidity of anterior cruciate ligament reconstruction with hamstring tendon autograft and peroneus longus tendon autograft in patients with complete anterior cruciate ligament rupture. Methods. Patients who underwent ACL reconstruction from February 2018 to July 2019 were randomly allocated into two groups (hamstring and peroneus longus). Functional scores (IKDC and Lysholm scores) and pain intensity by visual analogue score were recorded preoperatively, 3, 6months, 1, and 2 years postoperatively. Donor site morbidities were assessed with thigh circumference measurements in hamstring group and ankle scoring with the American foot and ankle score in peroneus longus group. Results. Sixty patients (hamstring n = 30, peroneus n = 30) met the inclusion criteria. The functional scores (IKDC and Lysholm) did not show statistical difference among the two groups at two years follow-up (P- value>0.05). The means values for visual analogue score after two years in the hamstring and Peroneus longus group was 1±0.74 and 1.03± 1.06, respectively. In peroneus longus group, the mean foot and ankle score was 98.63±3.88 (range= 85–100). A significant difference was found in the hamstring group between operated and non-operated thigh circumferences with p- value <0.001. Conclusions. Peroneus longus tendon autograft is an easily accessible tendon for ACL reconstruction and gives comparable functional outcomes as hamstring tendon with no additional donor site morbidity in our study

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Aims. The aim of this study was to compare the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) using small and standard baseplates in Asian patients, and to investigate the impact of a mismatch in the sizes of the glenoid and the baseplate on the outcomes. Methods. This was retrospective analysis of 50 and 33 RSAs using a standard (33.8 mm, ST group) and a small (29.5 mm, SM group) baseplate of the Equinoxe reverse shoulder system, which were undertaken between January 2017 and March 2021. Radiological evaluations included the size of the glenoid, the β-angle, the inclination of the glenoid component, inferior overhang, scapular notching, the location of the central cage in the baseplate within the vault and the mismatch in size between the glenoid and baseplate. Clinical evaluations included the range of motion (ROM) and functional scores. In subgroup analysis, comparisons were performed between those in whom the vault of the glenoid was perforated (VP group) and those in whom it was not perforated (VNP group). Results. Perforation of the vault of the glenoid (p = 0.018) and size mismatch in height (p < 0.001) and width (p = 0.013) were significantly more frequent in the ST group than in the SM group. There was no significant difference in the clinical scores and ROM in the two groups, two years postoperatively (all p > 0.05). In subgroup analysis, the VP group had significantly less inferior overhang (p = 0.009), more scapular notching (p = 0.018), and more size mismatch in height (p < 0.001) and width (p = 0.025) than the VNP group. Conclusion. In Asian patients with a small glenoid, using a 29.5 mm small baseplate at the time of RSA was more effective in reducing size mismatch between the glenoid and the baseplate, decreasing the incidence of perforation of the glenoid vault, and achieving optimal positioning of the baseplate compared with the use of a 33.8 mm standard baseplate. However, longer follow-up is required to assess the impact of these findings on the clinical outcomes. Cite this article: Bone Joint J 2023;105-B(11):1189–1195

Abstract. Background. Rotator cuff injuries have traditionally been managed by either single-row or double-row arthroscopic repair techniques. Novel and more complex single-row methodologies have recently been proposed as a biomechanically stronger alternative. However, no rigorous meta-analysis has evaluated the effectiveness of complex single-row against double-row repair. This meta-analysis aims to evaluate clinical outcomes in patients with full-thickness rotator cuff injuries treated with both simple and complex single-row, as well as transosseous-equivalent double-row procedures. Methods. An up-to-date literature search was performed using the pre-defined search strategy. All studies that met the inclusion criteria were assessed for methodological quality and included in the meta-analysis. Pain score, functional score, range-of-motion and Re-tear rate were all considered in the study. Conclusion. The results of this meta-analysis suggest the there is no significant difference between simple single-row and TOE double-row in any of the observed outcomes. However, there are significantly improved ASES functional scores and lower re-tear rates with TOE DR when compared to sSR. The available data in the literature would therefore advocate the use of transosseous-equivalent double-row fixation for the treatment of full thickness cuff tears. This paper has highlighted other significant limitations in the included studies where further, more extensive literature is required on the subject to draw more robust conclusions

Aims. Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm. Methods. An independent retrospective review was conducted of a consecutive series of 21 patients with longitudinal instability injuries treated with anatomical central band reconstruction between February 2011 and July 2019. Patients with less than 12 months’ follow-up or who were treated acutely were excluded, leaving 18 patients in total. Preoperative clinical and radiological assessments were compared with prospectively gathered data using range of motion and the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) functional outcome score. Results. Of the 18 patients (nine male, nine female) who met the inclusion criteria, the median follow-up was 8.5 years (interquartile range (IQR) 5.6 to 10). Their mean age was 49 years (SD 11). The mean extension improved significantly from 38° (SD 15°) to 24° (SD 9°) (p = 0.027), with a mean flexion-extension arc change from 81° (SD 27°) to 93° (SD 30°) (p = 0.172) but with no forearm rotational improvement (p = 0.233) at latest follow-up. The QuickDASH functional score improved significantly from 80 (SD 14) to 52 (SD 26) following reconstruction (p = 0.031), but generally the level of disability remains high. Radiological assessment showed no progression of proximal migration of the radius, with a stable interbutton distance and ulnar variance from immediate postoperative radiograph to the latest follow-up. Conclusion. Central band interosseus membrane reconstruction using a synthetic braided cross-linked graft can improve patient-rated arm function and range of motion, but significant functional deficits remain in patients with chronic injuries. Cite this article: Bone Joint J 2024;106-B(2):182–188

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

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients

Abstract. Background. The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft failure is the concern and ensuring a durable initial graft with rapid integration is crucial. Graft augmentation with implantable devices (internal brace reinforcement) is a technique purported to reduce the risk of rupture and hasten recovery. We aim to compare the short-term outcome of ACL-R using augmented hamstring tendon autografts (internally braced with neoligament) and non-augmented hamstring autografts. Methods. This was a retrospective cohort study comparing augmented and non-augmented ACL-R. All procedures were performed in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes. Results. There were 70 patients in the augmented and 111 patients in the control group. Mean graft diameter in the augmented group was 8.82mm versus 8.44mm in the non-augmented. Six strand graft was achievable in 73.5% of the augmented group compared to 33% in the non-augmented group. Two graft failures were reported in the non-augmented group and none in the augmented group. Patient satisfaction rates were higher in the augmented group. There was a statistically insignificant improvement in the postoperative KOOS in the augmented group compared to the non-augmented group (p 0.6). Irrespective of augmentation status, no correlation was found between the functional score and age, or femoral tunnel width. Conclusion. Augmented ACL-R may achieve superior graft diameters, lower failure rates and better patient reported outcomes when compared to nonaugmented ACL-R. Prospective trials are needed to examine this further

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Aims. Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. Methods. We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman’s correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. Results. The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. Conclusion. The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26–32

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

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

Multiple studies have shown that the symptomatology of knee osteoarthritis weakly correlate to radiographic severity of disease. Current literature however does not have much in the way of comparing functional outcomes of those with OA knees with radiographic severity. Our objective was to compare radiographic measurements of OA knees with self-reported functional outcomes and determine if radiographic severity of OA knees correlated with loss of functional ability. A retrospective review of prospectively collected registry data of 305 patients with osteoarthritis of the knee was collected. The patient's x-rays were reviewed, and radiographic measurements were taken to include medial, lateral and patellofemoral joint space distance measured in millimetres. The Kellgren and Lawrence, and Ahlback classifications of radiographic knee OA were computed. These were correlated with severity of functional limitations was measured using the SF36, Knee society score (KSS) and Oxford knee scores. Statistical analysis were conducted with SPSS V22.0 statistical software. Demographic characteristics and functional assessments were analysed using one way ANOVA test. Post-hoc test using Tukey HSD and effect size (partial-eta squared η. 2. ) was performed if one-way ANOVA was found to be statistically significant. A p-value of 0.05 or less was considered statistically significant. Pre-operative patient demographics are shown in table 1. Patients in with Grade 2 osteoarthritis were significantly younger than Grade 4 patients (post-hoc p=0.003). There were no statistically significant differences in age between the other Grades, and there were no differences in BMI or gender or operative site between all grades. There were significant differences in KSS Function scores between Grade 2 and Grade 3 patients (post-hoc p=0.017) and Grade 2 and 4 patients (post-hoc p < 0 .001). Statistically significant differences were also found between Grade 1 and Grade 4 patients for the KSS Knee score (post-hoc p=0.016). There were significant differences in Oxford knee score (post-hoc p=0.026) and SF- Physical Function (post-hoc p < 0 .001) between Grade 2 and Grade 4 patients too. The effect size η. 2. for KSS Function, KSS Knee and Oxford knee score was 0.05, 0.06 and 0.33 respectively. When comparing the loss of joint space with the functional scores, there were no statistically significant correlations. Our study show that the radiological severity of knee osteoarthritis based on the two scoring methods was able to correlate with worsening functional scores. Most notably, the differences in KSS function scores correlated strongly between Grade 2 and Grade 3 patients. Of note, there was no correlation between the loss of joint space and the severity of functional limitations across any of the scoring systems. Our study showed that although both the Kellgren and Lawrence and Ahlback radiological grading of Osteoarthritis were able to correlate with worsening functional scores, this was not due to loss of joint space alone and further studies need to be conducted on the other contributors to the scoring system such as osteophytes and subchondral sclerosis. Our study show that the radiological severity of knee osteoarthritis based on the two scoring methods was able to correlate with worsening functional scores. Most notably, the differences in KSS function scores correlated strongly between Grade 2 and Grade 3 patients. Of note, there was no correlation between the loss of joint space and the severity of functional limitations across any of the scoring systems. Our study showed that although both the Kellgren and Lawrence and Ahlback radiological grading of Osteoarthritis were able to correlate with worsening functional scores, this was not due to loss of joint space alone and further studies need to be conducted on the other contributors to the scoring system such as osteophytes and subchondral sclerosis. For any figures or tables, please contact authors directly

Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

Abstract. Introduction. Surgery in patients with high body mass index (BMI) is more technically challenging and associated with increased complications post-operatively. Inferior clinical and functional mid-term results for high BMI patients undergoing high tibial osteotomy (HTO) relative to normal weight patients have been reported. This study discusses the clinical, radiological and functional outcomes of HTO surgery in patients with a high BMI. Method. This is a retrospective study on patients undergoing HTO surgery using the Tomofix anatomical MHT plate between 2017 and 2022, with follow-up period of up to 5 years. The cohort was divided: non-obese (BMI <30 kg/m2) and obese (BMI>30 kg/m2). Pre and post operative functional scores were collected: Oxford Knee Score (OKS), EuroQol-5D and Tegner. Complications, plate survivorship and Mikulicz point recorded. Results. 32 HTO procedures; 19 patients BMI <30 (average 27.0) and 14 patients BMI >30 (average 36.1). In BMI<30 cohort, one readmission for investigation of venous thromboembolism, doppler negative; two complications: hinge fracture and stitch abscess. The five year survivorship of the plate was 100%. In BMI>30 cohort, one readmission for pulmonary embolism; one complication: hinge fracture. The 5 year survivorship of the plate was 93%, 1 conversion to unicompartmental knee replacement. The average OKS improvement was 17 and 18 for BMI <30 and >30 respectively. Mikulicz point change was identical. Conclusion. The Tomofix anatomical MHT plate achieves good outcomes and minimal complications irrespective of BMI. Reduced plate survivorship, thus earlier conversion may be required in the obese, however higher cohort numbers are needed to confirm this

To analyse the efficacy and safety of cellular therapy utilizing Mesenchymal Stromal Cells (MSCs) in the management of rotator cuff(RC) tears from clinical studies available in the literature. We conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science, and Cochrane Library on August 2021 for studies analyzing the efficacy and safety of cellular therapy (CT) utilizing MSCs in the management of RC tears. VAS for pain, ASES Score, DASH Score, Constant Score, radiological assessment of healing and complications and adverse events were the outcomes analyzed. Analysis was performed in R-platform using OpenMeta [Analyst] software. RESULTS:. 6 studies involving 238 patients were included for analysis. We noted a significant reduction in VAS score for pain at 3 months (WMD=-2.234,p<0.001) and 6 months (WMD=-3.078,p<0.001) with the use of CT. Concerning functional outcomes, utilization of CT produced a significant short-term improvement in the ASES score (WMD=17.090,p<0.001) and significant benefit in functional scores such as Constant score (WMD=0.833,p=0.760) at long-term. Moreover, we also observed a significantly improved radiological tendon healing during the long-term follow-up (OR=3.252,p=0.059). We also noted a significant reduction in the retear rate upon utilization of CT in RC tears both at short- (OR=0.079,p=0.032) and long-term (OR=0.434,p=0.027). We did not observe any significant increase in the adverse events as compared with the control group (OR=0.876,p=0.869). Utilization of CT in RC tear is safe and it significantly reduced pain severity, improved functional outcome, enhanced radiological tendon healing, and mitigated retear rates at short- and long-term follow-up

Total hip arthroplasty (THA) has proved to be an effective treatment modality for sickle-cell hip arthropathy (mosaic-like dense bone due to infarcts). However, mode of failure, survival rates and challenges associated with revision hip arthroplasty in sickle-cell disease patients are mostly unknown. We retrospectively evaluated prospectively collected data from all patients with sickle-cell disease who underwent revision hip arthroplasty from 2016. Patient, surgery, medical and surgical complications related data were collected. The pinnacle and reclaim revision system with gription augments (JJ) was used in all patients. Pre-op and post-op clinical outcome data (both objective and subjective, HOOS Jr and OHS) were recorded. Cumulative success rates were recorded with re-revision surgery as an end point. We performed fifteen revision THAs on 13 patients (mean follow up of 6.6 years). The mean age of the patients was 48 years (range, 30–59). At final follow-up, a statistically significant improvement of mean OHS and HOOS JR scores eas found in all patients. reported (OHS: 34.0 and HOOS JR: 77.7). Cumulative success rate was 100% for re-revision for all reasons at 6 years. Five intensive care unit (ITU) admissions, two vaso-occlusive sickle cell crises, one transfusion-related complication and one acute chest syndrome (ACS) were recorded. On admission, the mean percentage of HbS was 75.25% (64.6–86.4%). Revision arthroplasty in sickle-cell disease patients poses increased risks, with medical and surgical challenges. However, with careful preparation, planning and a multi-disciplinary team approach, revision arthroplasty can result in excellent clinical outcomes and excellent functional scores in the majority of patients in the short and mid-term

Abstract. Unicompartment knee replacement (UKR) has been an effective treatment of isolated medial compartment osteoarthritis (OA). There has been several studies which suggest that patellofemoral (PFJ) wear may not be a relative contraindication for UKR with no statistical difference in failure rates. There is currently conflicting evidence on the role of BMI. We will review if BMI and PFJ wear impacts on the post operative functional scores following UKR. A retrospective review of a prospectively collected database was performed. Data was collected between 26/6/2014 and 25/8/2022. 159 UKR procedures were identified. BMI and PFJ cartilage wear were collected. Oxford knee scores (OKS) were collected at > 2 years. PFJ wear was split into International Cartilage Research Society (ICRS) grades I&II and III&IV. 159 UKR procedures were identified, of these 115 had 2 year follow up. There were 77 who had OKS recorded at 2 years. For PFJ wear there was no statistical difference in the median OKS at 2 years 45 vs 43.5 (p=0.408). Assessing the BMI the median was 29kg/m. 2. , range 20–43kg/m. 2. Spearman's rank was performed to assess the correlation between BMI and >2 year OKS, this demonstrated a moderately negative correlation p(df)=−0.339 (CI 95% −0.538, −0.104) p=0.004. There is no statistically significant difference in >2 year OKS following UKR regardless of PFJ wear. There is a moderately negative correlation between BMI and >2 year OKS which was significant p=0.004. Therefore BMI is a more important consideration when counselling patients for UKR

In this study, we examined the impact of dual-mobility (DM) versus fixed-bearing (FB) implants on outcomes following total hip arthroplasty (THA), a common and successful operation. We examined all-cause revision, revision due to dislocation, postoperative complications and functional scores in patients undergoing primary and revision THA. A systematic review was performed according to PRISMA guidelines, and was registered in PROSPERO (ID CRD42023403736). The Cochrane Library, Embase, MEDLINE, Web of Science, and Scopus were searched from inception to 12th March 2023. Eligible studies underwent meta-analysis and methodological assessment using the ROBINS-I tool. Data were pooled using a random-effects maximum-likelihood model. Eight comparative, non-randomised studies involving 2,810 DM implants and 3,188 FB implants were included. In primary THA, the difference in all-cause revision was imprecise (OR 0.82, 95% CI 0.25–2.72), whilst the DM cohort had a statistically significant benefit in revision due to dislocation (OR 0.08, 95% CI 0.02–0.28). In revision THA, the DM cohort showed significant benefit in all-cause revision (OR 0.57, 95% CI 0.31–1.05) and revision due to dislocation (OR 0.14, 95% CI 0.04–0.53). DM implants were associated with a lower incidence of implant dislocation and infection. Functional outcome analysis was limited due to underreporting. No intraprosthetic dislocations were observed. The results suggest that contemporary DM designs may be advantageous in reducing the risk of all-cause revision, revision due to dislocation, and postoperative complication incidence at mid-term follow-up. Further high-quality prospective studies are needed to evaluate the long-term performance of this design, especially in revision cases

Aims. To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps. Methods. In a retrospective cohort study, 98 TKAs (91 patients) with a preoperative ROM of ≤ 80° were examined. Mean follow-up time was 53 months (24 to 112). All TKAs in stiff knees were performed with a 2 mm increased flexion gap. Data were compared to a matched control group of 98 TKAs (86 patients) with a mean follow-up of 43 months (24 to 89). Knees in the control group had a preoperative ROM of at least 100° and balanced flexion and extension gaps. In all stiff and non-stiff knees posterior stabilized (PS) TKAs with patellar resurfacing in combination with adequate soft tissue balancing were used. Results. Overall mean ROM in stiff knees increased preoperatively from 67° (0° to 80°) to 114° postoperatively (65° to 135°) (p < 0.001). Mean knee flexion improved from 82° (0° to 110°) to 115° (65° to 135°) and mean flexion contracture decreased from 14° (0° to 50°) to 1° (0° to 10°) (p < 0.001). The mean Knee Society Score (KSS) improved from 34 (0 to 71) to 88 (38 to 100) (p < 0.001) and the KSS Functional Score from 43 (0 to 70) to 86 (0 to 100). Seven knees (7%) required manipulations under anaesthesia (MUA) and none of the knees had flexion instability. The mean overall ROM in the control group improved from 117° (100° to 140°) to 123° (100° to 130°) (p < 0.001). Mean knee flexion improved from 119° (100° to 140°) to 123° (100° to 130°) (p < 0.001) and mean flexion contracture decreased from 2° (0° to 15°) to 0° (0° to 5°) (p < 0.001). None of the knees in the control group had flexion instability or required MUA. The mean KSS Knee Score improved from 48 (0 to 80) to 94 (79 to 100) (p < 0.001) and the KSS Functional Score from 52 (5 to 100) to 95 (60 to 100) (p < 0.001). Mean improvement in ROM (p < 0.001) and KSS Knee Score (p = 0.017) were greater in knees with preoperative stiffness compared with the control group, but the KSS Functional Score improvement was comparable (p = 0.885). Conclusion. TKA with a 2 mm increased flexion gap provided a significant improvement of ROM in knees with preoperative stiffness. While the improvement in ROM was greater, the absolute postoperative ROM was less than in matched non-stiff knees. PS TKA with patellar resurfacing and a 2 mm increased flexion gap, in combination with adequate soft tissue balancing, provides excellent ROM and knee function when stiffness of the knee had been present preoperatively. Cite this article: Bone Joint J 2020;102-B(4):426–433

Stratification is required to ensure that only those patients likely to benefit, receive Autologous Chondrocyte Implantation (ACI); ideally by assessing a biomarker in the blood. This study aimed to assess differences in the plasma proteome of individuals who respond well or poorly to ACI. Isobaric tag for relative and absolute quantitation (ITRAQ) mass spectrometry and label-free proteomics analyses were performed in tandem as described previously by our group (Hulme et al., 2017; 2018; 2021) using plasma collected from ACI responders (n=10) compared with non-responders (n=10) at each stage of surgery (Stage I, cartilage harvest and Stage II, cell implantation). iTRAQ using pooled plasma detected 16 proteins that were differentially abundant at baseline in ACI responders compared with non-responders (n=10) (≥±2.0 fold; p<0.05). Responders demonstrated a mean Lysholm (patient reported functional score from 0–100) improvement of 33±13 and non-responders a mean worsening of −13±13 points. The most pronounced plasma proteome shift was seen in response to Stage I surgery in ACI non-responders, with 48 proteins being differentially abundant between the two surgical procedures. We have previously noted this marked shift in response to initial surgery in the SF of ACI non-responders, several of these proteins were associated with the Acute Phase Response. One of these proteins, clusterin, could be confirmed in patients’ plasma using an independent immunoassay using individual samples. Label-free proteomic data from individual samples identified only cartilage acidic protein-1 (known to associate with osteoarthritis progression) to be significantly more abundant at Stage I in the plasma of non-responders. This study indicates that proteins can be identified within the plasma that have potential use in ACI patient stratification. Further work is required to validate the findings of this discovery-phase work in larger ACI cohorts

Background. Total Ankle Replacement (TAR) is an established treatment option for end-stage ankle arthritis. We analysed at minimum, 10-year patient-reported and clinical outcomes of 156 TARs from a single centre. We specifically compared outcomes between patients under 60 and over 60 at time of surgery. Methods. Data was collected retrospectively from our departmental patient database. It included all patients who underwent a TAR by a single surgeon between 2006 and 2010 and patients were divided into those under 60 and those over 60 at the time of surgery. Patient reported outcomes (PROMs), including WOMAC, SF-36 and patient satisfaction scores and complications were analysed preoperatively and at one, two, five and over 10 years postoperatively. Results. There were 156 patients included in this analysis, 61 were under 60 (mean age 50.29) and 95 were over 60 (mean age 69.12). A total of 12 patients had revision surgery, (nine in the under 60 group) and 52 patients were deceased at the time of analysis (10 in the under 60 group). At one year the over 60 group had less pain and better functional scores (p=0.02, p=0.017). At two, five and ten years there was no statistical difference in pain and function between groups. At two years the over 60s reported less stiffness and quicker return to activities of daily living (p=0.007, p=0.001). However, at five and 10 years there was no statistical difference in any domain. Conclusions. This study demonstrates that age does not correlate with a significant difference in pain or functional outcomes in patients who have TAR, at over 10 years follow up. The higher revision rates in the younger group may correlate with higher functional demand and lower mortality rate

Introduction. Ankle fractures represent approximately 10% of the fracture workload and are projected to increase due to ageing population. We present our 5 years outcome review post-surgical management of ankle fractures in a large UK Trauma unit. Methods. A total of 111 consecutive patients treated for an unstable ankle fracture were entered into a database and prospectively followed up. Baseline patient characteristics, complications, further intervention including additional surgery, functional status were recorded during five-year follow-up. Pre-injury and post-fixation functional outcome measures at 2-years were assessed using Olerud-Molander Ankle Scores (OMAS) and Lower Extremity Functional Scales (LEFS). A p value < 0.05 was considered significant. Results. The mean age was 46 with a male:female ratio of 1:1.1. The distribution of comorbidities was BMI >30 (25%), diabetes (5%), alcohol consumption >20U/week (15%) and smoking (26%). Higher BMI was predictive of worse post-op LEFS score (p = 0.02). Between pre-injury and post fixation functional scores at 2 years, there was a mean reduction of 26.8 (OMAS) and 20.5(LEFS). Using very strict radiological criteria, 31 (28%) had less than anatomical reduction of fracture fragments intra-operatively. This was, however, not predictive of patients' functional outcome in this cohort. Within 5-year period, 22 (20%) patients had removal of metalwork from their ankle, with majority 13 (59%) requiring syndesmotic screw removal. Further interventions included: joint injection (3), deltoid reconstruction (1), arthroscopic debridement (1), superficial sinus excision (2), and conversion to hindfoot nail due to failure of fixation (1). Reduction in OMAS was predictive of patients' ongoing symptoms (p=0.01). Conclusion. There is a significant reduction in functional outcome after ankle fracture fixation and patients should be counselled appropriately. Need for removal of metalwork is higher in patients who require syndesmosis stabilisation with screw(s)

There is some evidence to suggest that outcomes of THA in patients with minimal radiographic osteoarthritis may not be associated with predictable outcomes. The aim of this study was to:. Assess the outcome of patients with hip pain who underwent THA with no or minimal radiographic signs of osteoarthritis,. Identify patient comorbidities and multiplanar imaging findings which are predictive of outcome,. Compare the outcome in these patients to the expected outcome of THA in hip OA. A retrospective review of 107 hips (102 patients, 90F:12M, median age 40.6, IQR 35.1–45.8 years, range 18–73) were included for analysis. Plain radiographs were evaluated using the Tonnis grading scale of hip OA. Outcome measures were all-cause revision; iHOT12; EQ-5D; Oxford Hip Score; UCLA Activity Scale; and whether THA had resulted in the patient's hip pain and function being Better/Same/Worse. The median Oxford Hip Score was 33.3 (IQR 13.9, range 13–48), and 36/107 (33.6%) hips achieved an OHS≥42. There was no association between primary hip diagnosis and post-operative PROMs. A total of 91 of the 102 patients (89.2%, 93 hips) reported that their hip pain and function was Better than prior to THA and would have the surgery again, 7 patients (6.8%, 10 hips) felt the Same, and 4 patients (3.9%, 4 hips) felt Worse and would not have the surgery again. Younger patients undergoing total hip arthroplasty with no or minimal radiographic osteoarthritis had lower postoperative Oxford Hip Scores than the general population; though most felt symptomatically better and knowing what they know now, would have surgery again. Those with chronic pain syndrome or hypermobility were likely to benefit less. Those with subchondral cysts or joint space narrowing on CT imaging were more likely to achieve higher functional scores and satisfaction

Introduction. Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail. Materials & Methods. A retrospective cohort study was performed based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiological and clinical outcomes, and adverse events. Factors influencing radiological and clinical outcomes were analysed. Results. 47 patients were included, with a mean follow-up of three years. The mean age at time of surgery was 63.6 years. Patients had a median of two previous surgeries. The median LOS was 8.5 days, and median EFT was 237 days. Where simultaneous limb lengthening was performed, the average lengthening was 2.9cm, increasing the EFT by an average of 4 months. Primary and final union rates were 91.5% and 95.7% respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and re-operations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. Conclusions. Complex ankle fusion using circular frames can achieve good outcomes in complicated clinical scenarios, however patients can expect a prolonged time in the frame and high rates of adverse events. Multiple risk factors were identified for poorer outcomes, which should be considered in patient counselling and prognostication

Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia. We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test. A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals. On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity

Abstract. Purpose. Unicompartmental knee arthroplasty (UKA) is an effective treatment for late knee osteoarthritis (OA). However, its indications remain controversial. Young age (< 60 years) has been associated with worse outcomes. The goal of this systematic review and meta-analysis is to study the effect of age on UKA outcomes. Methods. The primary objective was to compare the UKA revision rate in young patients with that of old patients, using the age thresholds of 60 and 55 years. Secondary objectives were patient-reported outcome measures (PROMs) and implant design. PubMed, Ovid, Web of Science, Google Scholar, and Cochrane library were searched in June 2021. This review was conducted in accordance with the PRISMA guidelines (PROSPERO registration number: CRD42021248322). Results. A total of 12 observational studies with 6,448 knees were included. A mean MINORS score of 19 was assigned to the review. The mean age of patients was 64.32 years, with follow-up ranging from 0.2 to 15 years. There was no significant difference in revision rate, incident or PROMs between young and old patients in the analysis for each age threshold. Further sub-analysis adjusting for implant type in mobile- and fixed-bearing prostheses also showed similar results between those above and under 60 and 55 years. Conclusion. Young age was not associated with a higher revision rate or lower functional scores. Thus, this review provides evidence that performing UKA at a younger age (< 60 years) should not be considered suboptimal. However, this finding should be applied in context, as other confounding factors need to be explored

Abstract. Introduction. Articular cartilage degradation is a defining feature of osteoarthritis. Synovium is a reactive tissue with synovial villae, neoangiogenesis and intimal hyperplasia common to many joint pathologies. The consequences of cartilage debris in osteoarthritis impacting the synovial intima is not well understood. We analysed the immunohistology of synovium from 16 patients with osteoarthritis and 17 patients undergoing knee surgery for non-arthritic pathologies. This data was integrated with imaging and functional scores to correlate synovitis in osteoarthritis. Methodology. Formalin-fixed paraffin embedded synovial biopsy sections were cut in serial sequence and processed for routine staining (H&E or CD3, CD68, CD20, Vimentin, vWF and PCNA IHC) using standardised Dako monoclonal mouse anti-human antibodies. Digital images scanned at x20 were evaluated for fragments of cartilage and aggregates of inflammatory cells. Clinical data (gender, BMI, KL grade, WOMAC & SF-12 scores) was aligned with histopathological data. Results. Cartilage fragments were seen in the synovial intimal layer from end-stage osteoarthritis especially those with BMI<30kg/m2. Macrophages, T-cells and B-cells were identified surrounding cartilage inclusions. Inflammatory aggregates of T-cells, B-cells and macrophages were located peri-cartilage in the intima and peri-vascular in the sub-intimal layer of the synovium. Worse synovitis and function scores were significantly associated with both cartilage inclusions and inflammatory aggregates. X-ray features linked to longer duration of symptoms were associated with inflammatory aggregates. Conclusion. The histological features of the synovium clearly reflect deteriorating joint structures and compromised clinical function

Recent studies on animal models focused on the effect of preserving tendon remnant of rotator cuff on tendon healing. A positive effect by combining tendon remnant preservation and small bone vents on the greater tuberosity in comparison with standard tendon-to-bone repair has been shown. The purpose of the present clinical study was to evaluate the efficacy of biologic augmentation of arthroscopic rotator cuff repair by maintaining tendon remnant on rotator cuff footprint combined with small bone vents of the greater tuberosity. A retrospective study was conducted. All patients who underwent arthroscopic rotator cuff repair associated with small bone vents (nanofractures) and tendon footprint preservation were considered eligible for the study. Inclusion criteria were: diagnosis of full-thickness rotator cuff tear as diagnosed at preoperative magnetic resonance imaging (MRI) and confirmed at the time of surgery; minimum 24-month of follow-up and availability of post-operative MRI performed not earlier than 6 months after surgery. Exclusion criteria were: partial thickness tears, irreparable tears, capsulo-labral pathologies, calcific tendonitis, gleno-humeral osteoarthritis and/or previous surgery. Primary outcome was the ASES score. Secondary outcomes were: Quick-DASH and WORC scores, and structural integrity of repaired tendons by magnetic resonance imaging (MRI) performed six months after surgery. A paired t-test was used to compare pre- and postoperative clinical outcomes. Subgroup analysis was performed according to tear size. Significance was set at p < 0.05. The study included 29 patients (M:F = 15:14). Mean age (+ SD) of patients was 61.7 + 8.9 years. Mean follow-up was 27.4 ± 2.3 months. Comparison between pre- and postoperative functional scores showed significant clinical improvement (p < 0.001). Subgroup analysis for tear size showed significant differences in the QuickDASH score (0.04). Particularly, a significant difference in the QuickDASH score could be detected between medium and large tears (p=0.008) as well as medium and massive lesions (p=0.04). No differences could be detected between large and massive tears (p= 0.35). Postoperative imaging showed healed tendons in 21 out of 29 (72%) cases. Preservation of tendon remnant combined with small bone vents in the repair of medium-to-massive full-thickness rotator cuff tears provided significant improvement in clinical outcome compared to baseline conditions with complete structural integrity in 72% of the cases

As the field of hip arthroscopy continues to develop, functional measures and testing become increasingly important in patient selection, managing patient expectations prior to surgery, and physical readiness for return to athletic participation. The Hip Sport Test (HST) was developed to assess strength, coordination, agility, and range of motion prior to and following hip arthroscopy as a functional assessment. However, the relationship between HST and hip strength, range of motion, and hip-specific patient reported outcome (PRO) measures have not been investigated. The purpose of this study was to evaluate the correlation between the HST scores and measurements of hip strength and range of motion prior to undergoing hip arthroscopy. Between September 2009 and January 2017, patients aged 18-40 who underwent primary hip arthroscopy for the treatment of femoroacetabular impingement with available pre-operative HST, dynamometry, range of motion, and functional scores (mHHS, WOMAC, HOS-SSS) were identified. Patients were excluded if they were 40 years old, had a Tegner activity score < 7, or did not have HST and dynamometry evaluations within one week of each other. Muscle strength scores were compared between affected and unaffected side to establish a percent difference with a positive score indicating a weaker affected limb and a negative score indicating a stronger affected limb. Correlations were made between HST and strength testing, range of motion, and PROs. A total of 350 patients met inclusion criteria. The average age was 26.9 ± 6.5 years, with 34% females and 36% professional athletes. Total and component HST scores were significantly associated with measure of strength most strongly for flexion (rs = −0.20, p < 0 .001), extension (rs = −0.24, p<.001) and external rotation (rs = −0.20, p < 0 .001). Lateral and diagonal agility, components of HST, were also significantly associated with muscle strength imbalances between internal rotation versus external rotation (rs = −0.18, p=0.01) and flexion versus extension (rs = 0.12, p=0.03). In terms of range of motion, a significant correlation was detected between HST and internal rotation (rs = −0.19, p < 0 .001). Both the total and component HST scores were positively correlated with pre-operative mHHS, WOMAC, and HOS-SSS (p<.001 for all rs). The Hip Sport Test correlates with strength, range of motion, and PROs in the preoperative setting of hip arthroscopy. This test alone and in combination with other diagnostic examinations can provide valuable information about initial hip function and patient prognosis

Meniscal tears commonly co-occur with ACL tears, and many studies address their side, pattern, and distribution. Few studies assess the patient's short-term functional outcome concerning tear radial and circumferential distribution based on the Cooper et al. classification. Meniscal tears require primary adequate treatment to restore knee function. Our hypothesis is to preserve the meniscal rim as much as possible to maintain the load-bearing capacity of the menisci after meniscectomy. The purpose of this study is to document the location and type of meniscal tears that accompany anterior cruciate ligament (ACL) tears and their effect on patient functional outcomes following arthroscopic ACL reconstruction and meniscectomy. This prospective cross-sectional observational study was conducted at AL-BASRA Teaching Hospital in Iraq between July 2018 and January 2020 among patients with combined ipsilateral ACL injury and meniscal tears. A total of 28 active young male patients, aged 18 to 42 years, were included. All patients were subjected to our questionnaire, full history, systemic and regional examination, laboratory investigations, imaging studies, preoperative rehabilitation, and were followed by Lysholm score 6 months postoperatively. All 28 patients were males, with a mean age of 27 ± 0.14 years. The right knee was the most commonly affected in 20/28 patients (71.4%). The medial meniscus was most commonly injured in 11 patients, 7 patients had lateral meniscal tears, and 10 patients had tears in both menisci. The most common tear pattern of the medial meniscus was a bucket handle tear (36.4%), while longitudinal tears were the most frequent in the lateral meniscus (71.4%) (P-value = 0.04). The most common radial tear location was zone E-F (5/28, 17.8%), and the most common circumferential zone affected was the middle and inner third, reported in 50% of tears. Good and excellent outcomes using the Lysholm score after 6 months were obtained in 42.9% and 17.9% of patients, respectively. Better functional scores were associated with lateral meniscal tears, bucket handle tears, tears extending to a more peripheral vascular area, and if no more than one-third of the meniscus was resected (P-value = 0.002). Less favourable outcomes were reported in smokers, posterior horn tears, and when surgery was delayed more than 1 year (P-value = 0.03). We conclude that there is a negative correlation between the amount of meniscus resected and functional outcome. Delayed ACL reconstruction increases the risk of bimeniscal tears. Bucket handle tears are the most common tears, mostly in the medial meniscus, while longitudinal tears are most common in the lateral meniscus. We recommend performing early ACL reconstruction within 12 months to reduce the risk of bimeniscal injuries

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

Aims. The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. Methods. This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs. Results. Overall, 712/991 (71.8%) responded at ≤ three months for THA (n = 164) and TKA (n = 199), and ≥ three years for THA (n = 88) and TKA (n = 261). The median EQ-5D-5L score in those waiting ≤ three months was 0.155 (interquartile range (IQR) -0.118 to 0.375) and 0.189 (IQR -0.130 to 0.377) for ≥ three years. Matched controls had a median EQ-5D-5L 0.837 (IQR 0.728 to 1.000). Compared to matched controls, EQ-5D-5L scores were significantly lower in both waiting cohorts (p < 0.001) with significant differences found in every domain. Negative scores, indicating a state “worse than death”, were present in 40% at ≤ three months and 38% at ≥ three years. Patients waiting ≥ three years had significantly more opioid (28.4% vs 15.2%; p < 0.001) and antidepressant prescriptions (15.2% vs 9.9%; p = 0.034) and significantly more joint-related attendances at unscheduled care (11.7% vs 0% with ≥ one ED attendance (p < 0.001) and (25.5% vs 2.5% ≥ one OOH GP attendance (p < 0.001)). Conclusion. Patients on waiting lists in Northern Ireland are severely disabled with the worst HRQoL and functional scores studied. The lack of deterioration in EQ-5D-5L and joint-specific scores between patients waiting ≤ three months and ≥ three years likely reflects floor effects of these scores. Prolonged waits were associated with increased dependence on strong opiates, depression, and attendances at unscheduled care. Cite this article: Bone Joint J 2023;105-B(7):783–794

Aims. Avulsion of the proximal hamstring tendon origin can result in significant functional impairment, with surgical re-attachment of the tendons becoming an increasingly recognized treatment. The aim of this study was to assess the outcomes of surgical management of proximal hamstring tendon avulsions, and to compare the results between acute and chronic repairs, as well as between partial and complete injuries. Methods. PubMed, CINAHL, SPORTdiscuss, Cochrane Library, EMBASE, and Web of Science were searched. Studies were screened and quality assessed. Results. In all, 35 studies (1,530 surgically-repaired hamstrings) were included. Mean age at time of repair was 44.7 years (12 to 78). A total of 846 tears were acute, and 684 were chronic, with 520 tears being defined as partial, and 916 as complete. Overall, 92.6% of patients were satisfied with the outcome of their surgery. Mean Lower Extremity Functional Score was 74.7, and was significantly higher in the partial injury group. Mean postoperative hamstring strength was 87.0% of the uninjured limb, and was higher in the partial group. The return to sport (RTS) rate was 84.5%, averaging at a return of 6.5 months. RTS was quicker in the acute group. Re-rupture rate was 1.2% overall, and was lower in the acute group. Sciatic nerve dysfunction rate was 3.5% overall, and lower in the acute group (p < 0.05 in all cases). Conclusion. Surgical treatment results in high satisfaction rates, with good functional outcomes, restoration of muscle strength, and RTS. Partial injuries could expect a higher functional outcome and muscle strength return. Acute repairs result in a quicker RTS with a reduced rate of re-rupture and sciatic nerve dysfunction. Cite this article: Bone Jt Open 2022;3(5):415–422

Aims. The primary objective of this study was to compare the postoperative infection rate between negative pressure wound therapy (NPWT) and conventional dressings for closed incisions following soft-tissue sarcoma (STS) surgery. Secondary objectives were to compare rates of adverse wound events and functional scores. Methods. In this prospective, single-centre, randomized controlled trial (RCT), patients were randomized to either NPWT or conventional sterile occlusive dressings. A total of 17 patients, with a mean age of 54 years (21 to 81), were successfully recruited and none were lost to follow-up. Wound reviews were undertaken to identify any surgical site infection (SSI) or adverse wound events within 30 days. The Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) score were recorded as patient-reported outcome measures (PROMs). Results. There were two out of seven patients in the control group (28.6%), and two out of ten patients in the intervention group (20%) who were diagnosed with a SSI (p > 0.999), while one additional adverse wound event was identified in the control group (p = 0.593). No significant differences in PROMs were identified between the groups at either 30 days (TESS, p = 0.987; MSTS, p = 0.951) or six-month (TESS, p = 0.400) follow-up. However, neoadjuvant radiotherapy was significantly associated with a SSI within 30 days of surgery, across all patients (p = 0.029). The mean preoperative modified Glasgow Prognostic Score (mGPS) was also significantly higher among patients who developed a postoperative adverse wound event (p = 0.028), including a SSI (p = 0.008), across both groups. Conclusion. This is the first RCT comparing NPWT with conventional dressings following musculoskeletal tumour surgery. Postoperative wound complications are common in this group of patients and we observed an overall SSI rate of 23.5%. We propose proceeding to a multicentre trial, which will help more clearly define the role of closed incision NPWT in STS surgery. Cite this article: Bone Jt Open 2021;2(12):1049–1056

Introduction. Hip arthrodiastasis for paediatric hip conditions such as Perthes disease is growing in popularity. Intended merits include halting the collapse of the femoral head and maintaining sphericity by minimising the joint reaction force. This can also be applied to protecting hip reconstruction following treatment of hip dysplasia. Our aim was to assess functional outcomes and complications in a cohort of paediatric patients. Materials and Methods. A retrospective single-surgeon cohort study was performed in a University teaching hospital from 2018–2021. Follow-up was performed via telephone interview and review of patient records. Complications, time in frame and functional scores using the WOMAC hip score were recorded. Results. Following review, 26 procedures were identified in 24 patients. Indications included 16 cases of Perthes disease, 4 following slipper upper femoral epiphysis, 3 avascular necrosis, and single cases following infection, dysplasia and a bone cyst. Pre-treatment WOMAC scores averaged 53.9, improving to 88.5 post-removal. Pin site infections were encountered in 11 patients, all treated with oral antibiotics. Two patients required early removal of frame due to pin loosening. Average time in frame was 3.9 months. Conclusions. This series displays how hip arthrodiastasis can be used to manage paediatric hip conditions. Complex reconstructions may be required in patients with severe deformity following perthes disease, DDH or SUFE. The use of arthrodiastasis in these patients aims to protect the reconstruction and potentially improve outcomes. A dedicated team of specialist nurses, physiotherapists and psychologists are crucial to the treatment program

A tourniquet is usually used during ankle arthroscopy to allow for improved visibility and reduced operation time. However, clinical studies on knee arthroscopy have not demonstrated this to be true. In addition, Zengerink and van Dijk emphasized a limited tourniquet time in ankle arthroscopy as a possible factor to lower the complication rate even more. The purpose of this prospective randomized controlled trial was to examine the effect of tourniquet use on arthroscopic visualization, operative time, postoperative intra-articular bleeding, postoperative pain scores and outcome of anterior ankle arthroscopy. A consecutive series of 50 patients who were scheduled for anterior ankle arthroscopy were randomized to have the surgery done either without the tourniquet inflated (25 patients) or with the tourniquet inflated (25 patients). The patients were evaluated by the course of the surgery, postoperative intra-articular bleeding, pain during the early postoperative period and by using the subjective and objective functional scores to evaluate the condition of the ankle before and 3 and 6 months after the surgery. The statistical analysis was performed with the normality of distribution tested by both Kolmogorov-Smirnov and Shapiro-Wilk tests. Appropriate parametric or non-parametric methods were then used to test statistical hypotheses, while the statistical significance (alpha, Type I error) was set at .05. Fourty-nine patients were present at the final follow-up, 6 months after the surgery. The results between the groups were comparable regarding the duration of the operative procedure, consumption of sterile saline, visualisation and functional scores. Notable difference between the groups in favour of the non-tourniquet group was present regarding postoperative bleeding, but was not statistically significant. Statistically significant difference in favour of the non-tourniquet group was found regarding postoperative pain during several days in the early postoperative period. Our study has shown that anterior ankle arthroscopy may be performed adequately without the use of a tourniquet and that it has the same operative course as in cases in which the tourniquet is used and functional outcomes which are not worse than in cases in which the tourniquet is used

The jackaling position within rugby has not been previously described as a mechanism for proximal hamstring injuries. This prospective single surgeon study included 54 professional rugby players (mean age 26 ± 4.8 years) undergoing acute primary surgical repair of complete, proximal hamstring avulsion injuries confirmed on preoperative magnetic resonance imaging. All study patients underwent a standardised postoperative rehabilitation programme. Predefined outcomes were recorded at regular intervals. Mean follow-up time was 17 months (range, 12 months to 24 months) from date of surgery. 51 patients (94.4%) returned to their pre-injury level of sporting activity. Mean time from surgical repair to full sporting activity was 7 months (range, 4 months to 12 months). Zero patients had recurrence of the primary injury. At 1 year after surgery compared to 3 months after surgery, patients had increased mean isometric hamstring muscle strength at 0° (98.4 ± 2.8% vs 88.1% ± 5.4%, p<0.001), 15° (95.9 ± 2.9 vs 88.2 ± 8.1%, p<0.001) and 45° (92.9% ± 4.1% vs 76.8% ± 9.7%, p<0.001), higher mean lower extremity functional scores (77.0 ± 2.3 vs 64.5 ± 4.5, p<0.001), and improved Marx activity rating scores (14.3 ± 1.5 vs 10.7 ± 2.6, p<0.001). Acute surgical repair of proximal hamstring avulsion injuries caused by the contact jackaling position produces high patient satisfaction, high return to preinjury level of sporting activity, with low risk of recurrence at short-term follow-up

Background. Traditional teaching recommends against arthroplasty in the index finger, due to concerns over failure with pinch stress, and prefers arthrodesis is for its stability. We aim to allay these fears and present the results of our series of index finger silastic PIPJ arthroplasties. Methods: Between 2007 & 2018 48 silastic index finger PIPJ arthroplasties were undertaken in 37 patients at our Hand Unit. All were performed under local anaesthetic ring block. Eleven patients underwent PIPJ arthroplasty in both Index fingers. Thirty-five women and two men made up the cohort with a mean age of 69 years. A retrospective analysis of all patients has been undertaken to determine the clinical results including patient satisfaction, grip and pinch strength and reoperation rates. Mean follow up was 5.1 years. Results. Six index fingers developed ulnar deviation greater than 10 degrees and there were five reoperations (10.2%). There was an excellent arc of movement of mean 44 degrees with high patient satisfaction and functional scores (mean VAS pain score 1.1, Quickdash 34, PEM 44). 90% of patients would undergo the procedure again and no patient would prefer a fusion. Conclusions: Silastic Interposition arthroplasty of the PIPJ of the Index finger is a durable procedure with excellent clinical outcomes. Our large study refutes the established technique of arthrodesis for Index finger OA, with low incidence of ulnar deviation and excellent patient satisfaction

Aims. To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes. Methods. A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using β-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups. Results. There were ten and 25 defects in the femur and tibia, respectively. Median LEFS improved significantly from 8 (IQR 1.5 to 19.3) preoperatively to 63.5 (IQR 57 to 73.3) at final follow-up (p < 0.001). Bone healing was achieved in all limbs, and median time from the second stage to bone healing was six months (IQR 5 to 10). Median time to bone healing, preoperative LEFS, or postoperative LEFS did not differ significantly between the defect size groups or among the treatment groups. Conclusion. IMT using β-TCP provided satisfactory clinical and radiological outcomes for segmental bone defects in the lower limbs; surgical outcomes were not influenced by bone defect size or operated part. Cite this article: Bone Joint J 2021;103-B(3):456–461

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

Aims. The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures. Patients and Methods. Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86). Results. Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals. Conclusion. Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009–1014

Introduction and Objective. Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR. Materials and Methods. A primary search was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials. Results. All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r=0.20 p<0.05, R=0.317 p=0.001, and correlation coefficient 0.197 p=0.005). TSK score significantly correlated with mean active range of motion (ROM) at six months (105.33 (SD=12.34) vs 85.53 (SD=14.77) p=0.000) post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme (TSK −14.30 (SD=0.80) vs −2.10 (SD=0.80) p<0.001)), an outpatient CBT programme (TSK 27.76 (SD=4.56) vs 36.54 (SD=3.58), and video-based psychological treatment (TSK 24 (SD=5) vs 29 (SD=5) p<0.01). Conclusions. Kinesiophobia negatively affects functional outcomes up until one year post-operatively, while active ROM is reduced up to six months post procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR

Introduction and Objective. TKA have shown both excellent long-term survival rate and symptoms and knee function improvement. Despite the good results, the literature reports dissatisfaction rates around 20%. This rate of dissatisfaction could be due to the overstuff that mechanically aligned prostheses could produce during the range of motion. Either size discrepancy between bone resection and prosthetic component and constitutional mechanical tibiofemoral alignment (MTFA) alteration might increase soft tissue tension within the joint, inducing pain and functional limitation. Materials and Methods. Total knee arthroplasties performed between July 2019 and September 2020 were examined and then divided into two groups based on the presence (Group A) or absence (Group B) of patellofemoral overstuff, defined as a thickness difference of more than 2 mm between chosen component and bone resection performed, taking into account at least one of the following: femoral medial and lateral condyle, medial or lateral trochlea and patella. Based on pre and post-operative MTFA measurements, Group A was further divided into two subgroups whether the considered alignment was modified or not. Patients were assessed pre-operatively and at 6 months post-op using the Knee Society Score (KSS), Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Visual Analogue Scale (VAS) and Range of Motion (ROM). Results. One hundred total knee arthroplasties were included in the present study, 69 in Group A and 31 in group B. Mean age and BMI of patients was respectively 71 and 29.2. The greatest percentage of Patellofemoral Overstuff was found at the distal lateral femoral condyle. OKS, KSS functional score, and FJS were statistically significant higher in patients without Patellofemoral Overstuff. Therefore, Group A patients with a non-modified MTFA demonstrated statistically significant better KSS, ROM and FJS. Conclusions. Patellofemoral Overstuff decrease post-operative clinical scores in patients treated with TKA. The conventional mechanically aligned positioning of TKA components might be the primary cause of prosthetic overstuffing leading to worsened clinical results. Level of evidence: III; Prospective Cohort Observational study;

The management of prosthetic joint infection (PJI) has been widely performed for total hip arthroplasties (THA), but none has compared it with hip resurfacing arthroplasty (RSA). We also carried out a retrospective case-control study comparing the surgical treatment of PJI by surgical debridement and implant retention between RSA and THA in order to clarify whether there was a difference in terms of (1) successful healing of PJI (2) functional scores after recovery (3) risk factors for recurrence of PJI. Our hypothesis was that simple debridement with prosthesis retention regardless of the timeframe allowed to obtain a higher success rate for RSA compared to THA. From 2010 to 2018, a single-center case-control study based on 3056 RSA found 13 PJI were age-matched (based on the 139 THA PJI treated) with 15 THA PJI (mean age of 53 years old (47–58) for THA and 59 (45–66) for RSA (p=0.34)). We compared their survival (absence of infectious recurrence) and the means differences between the 2 groups (demographical, clinical and biological data). There was no difference between the 2 groups concerning: age (p=0.3), BMI (p=0.4), initial diagnosis (p=0.4), operating time for primary surgery (p=0.3), the presence of a postoperative hematoma (p=0.4), the type of bacteria (p=0.5), the total duration of antibiotic therapy (p=0.9) and the type of antibiotic therapy (p=0.6). Early postoperative infections (less than 6 weeks) occurred in 7/13 RSA cases (54%) compared to 11/15 THA cases (73%). At the mean follow-up of 5 years (2–7), the success rate without recurrence was significantly higher in the RSA group 100% versus 66.7% (10/15) for the THA group (p=0.044). At the last follow-up, the Oxford Hip Score was higher in the RSA versus THA group's (14 versus 22 p=0.004). Simple surgical debridement an RSA without changing implants after PJI can be done regardless of the time to onset of infection. This is secondary to the absence of metaphyseal bone invasion and the low content of joint fluid

Abstract. Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

The benefits of HXLPE in total knee arthroplasty (TKA) have not been as evident as total hip arthroplasty (THA). A systematic review and meta-analysis to assess the impact of highly-crosslinked polyethylene (HXLPE) on TKA outcomes compared to conventional polyethylene (CPE) is described. All studies comparing HXLPE with CPE for primary TKA were included for analysis. The minimum dataset included revision rates, indication for revision, aseptic component loosening and follow-up time. The primary outcome variables were all-cause revision, aseptic revision, revision for loosening, radiographic component loosening, osteolysis and incidence of radiolucent lines. Secondary outcome measures included postoperative functional knee scores. A random-effects meta-analysis allowing for all missing data was performed for all primary outcome variables. Six studies met the inclusion criteria. In total, there were 2,234 knees (1,105 HXLPE and 1,129 CPE). The combined mean follow-up for all studies was 6 years. The aseptic revision rate in the HXLPE group was 1.02% compared to 1.97% in the CPE group. There was no difference in the rate of all-cause revision (p = 0.131), aseptic revision (p = 0.298) or revision for component loosening (p = 0.206) between the two groups. Radiographic loosening (p = 0.200), radiolucent lines (p = 0.123) and osteolysis (p = 0.604) was similar between both groups. Functional outcomes were similar between groups. The use of HXLPE in TKA yields similar results for clinical and radiographic outcomes when compared to CPE at midterm follow-up. HXLPE does not confer the same advantages to TKA as seen in THA

To evaluate if clinical recovery following midshaft clavicle fracture is associated with nonunion and determine if this has superior predictive value compared to estimation at time of injury. A prospective study of all patients (≥16 years) who sustained a displaced midshaft clavicle fracture was performed. We assessed patient demographics, injury factors, functional scores and radiographic predictors with a standardized protocol at six-weeks. Conditional-stepwise regression was used to assess which factors independently predicted nonunion at six-months post-injury determined by CT. The nonunion predictor six-week model (NUP6) was compared against a previously validated model based on factors available at time of injury (NUP0-smoking, comminution and fracture displacement). 200 patients completed follow-up at six months. The nonunion rate was 14% (27/200). Of the functional scores, the QuickDASH had the highest accuracy on receiver-operator-characteristic (ROC) curve analysis with a 39.8 threshold, above which was associated with nonunion (Area Under Curve (AUC) 76.8%, p<0.001). On regression modelling QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort (n=80/200). Conversely if two or more were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The NUP6 model appeared to have superior accuracy when compared to the NUP0 model on ROC curve analysis (AUC 87.3% vs 64.8% respectively). Delayed assessment at six-weeks following displaced clavicle fracture enables a more accurate prediction of fracture healing

There has been growing interest in the literature regarding evaluation of functional outcomes in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) while suffering from depression and using selective serotonin reuptake inhibitors (SSRI). Previous literature has shown that these patients have lower post-operative functional scores compared to those without SSRI use and with multiple musculoskeletal co-morbidities. This might be the result of potentially suboptimal motivation and participation in the post-operative rehabilitation programs. One recent study from a single center has suggested a reduction in adverse events in patients undergoing arthroplasty while on SSRI. The purpose of this study is to evaluate the post operative functional scores of patients on SSRI and compare them with the patients not prescribed SSRIs. A retrospective data analysis was performed on patients who had primary TKA and primary THA between 1st June 2014 and 31st May 2017. The patients into two groups. In the first, patients received SSRI for at least one year before the surgery while in group two, patients did not receive SSRI. Outcome measures included Western Ontario and McMaster university osteoarthritis index (WOMAC) and EQ5D5L scores at pre surgery, three months and 12 months post surgery. Chi-square and t test was used to compare categorical variables and continuous variables respectively. Multivariate linear regression was conducted to compare the change of scores between the two groups and was adjusted for age, gender, and comorbidities. These outcome scores were analyzed separately for TKA and THA. In the TKA group, there were 1,452 patients using SSRI and 15,981 not using SSR. In the THA group there were 851 patients using SSRIs and 10,102 patients without SSRIs. The baseline WOMAC for TKA patients was 45.6 for the controls and 41.8 for those patients on SSRIs (p < 0 .001). The baseline EQ5DL was 0.53 and 0.46 in the same groups (p < 0 .001). The baseline WOMAC for THA patients was 39.1 for the controls and 36.2 for patients using SSRIs (p < 0 .001). The baseline EQ5DL scores were 0.43 and 0.37respectively, again indicating patients on SSRI therapy had lower baseline scores (p < 0 .001). There was improvement in WOMAC and EQ5DL scores in all patient groups at 3 months and 12 months. After adjusting for gender, age, comorbidities and baseline score, THA patients not using SSRI showed a greater improvement in their WOMAC and EQ5DL scores than those prescribed SSRIs, WOMAC (p=0.008), EQ5DL (p=0.001). TKA patients showed a similar outcome but only the EQ5DL was statistically significant, WOMAC (p=0.12), EQ5DL (p=0.036). Our results show that patients on SSRI have lower preoperative WOMAC and EQ5DL scores at baseline when compared to patients not undergoing treatment for depression or anxiety with SSRIs. After arthroplasty, patients using SSRIs show significant improvement at 12 months but the improvement is smaller than the group not using SSRIs

The function of the shoulder joint has traditionally been evaluated based on range of motion (ROM) in predefined anatomical planes and also by using functional scores, which assessed shoulder function based on the ability to conduct certain activities of daily living (ADLs). However, measuring ROM only in terms of flexion-extension, abduction-adduction and internal-external rotation may under-account for the 3-dimensional mobility of the shoulder joint. Furthermore, functional scores, such as the Oxford shoulder score or American shoulder and elbow surgeons (ASES) score, are subjective measures and are not an accurate assessment of shoulder joint function. In this study, we proposed the use of the globe model of the shoulder joint which can be used to provide an objective measure of the global ROM and also function of the shoulder joint – termed the Global and Functional arc of motion (GAM and FAM). Thirty-three young, healthy male patients (23.7 ± 1.5 years) were recruited and tasked to perform eight ADLs and a full humeral circumduction movement which represented their active global ROM. Reflective markers were placed in accordance to the International Society of Biomechanics (ISB) and optical-based motion capture cameras were used to track relative motion of the dominant humerus with respect to the thorax (i.e. thoracohumeral motion). The GAM and FAM were generated by plotting the thoracohumeral on a spherical coordinate system during global ROM and the eight ADLs respectively. Shoulder joint global ROM and function were quantified by calculating the area enclosed by the closed loop of GAM and FAM respectively. The spherical coordinate system, or more commonly referred to as the globe model, describes thoracohumeral movement using plane of elevation (POE), angle of elevation (AOE) and rotation. In our model, POE and AOE represents longitude and latitude of the globe respectively, and rotation is depicted using a red-green-blue (RGB) colour scale. Overall, subject's GAM of the shoulder joint covered an area of 4.64 ± 0.48 units2 compared to only 1.12 ± 0.26 units2 for the FAM. Subjects only required 24.4 ± 5.7 % of their global shoulder ROM for basic daily functioning. Studies that reduced shoulder joint movement into planar movements (i.e. sagittal, coronal and rotation) do not account for the 3-dimensional nature of the joint and doing so may overestimate the requirement of the shoulder joint for ADLs relative to its ROM in each plane. While others have attempted to use the globe model, such studies tend to reduce the globe into its descriptive angles (i.e. POE, AOE and rotation), reducing its intuitiveness. In contrast, by keeping an intact globe, the proposed globe model was more intuitive and yet capable of quantifying both shoulder joint global ROM and function. Doing so, we found that young healthy subjects only required approximately a quarter of their global ROM of the shoulder joint to complete the most common daily tasks, which was significantly less than what was previously reported

Aims. The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN). Methods. The study involved a retrospective analysis of 23 patients. All had a previous, operatively managed, femoral shaft fracture with malunion due to hardware failure. They were treated with a clamshell osteotomy between May 2015 and March 2020. The mean age was 42.6 years (26 to 62) and 15 (65.2%) were male. The mean follow-up was 2.3 years (1 to 5). Details from their medical records were analyzed. Clinical outcomes were assessed using the quality of correction of the deformity, functional recovery, the healing time of the fracture, and complications. Results. The mean length of time between the initial injury and surgery was 4.5 years (3 to 10). The mean operating time was 2.8 hours (2.05 to 4.4)), and the mean blood loss was 850 ml (650 to 1,020). Complications occurred in five patients (21.7%): two with wound necrosis, and three with deep vein thrombosis. The mean coronal deformity was significantly corrected from 17.78° (SD 4.62°) preoperatively to 1.35° (SD 1.72°) postoperatively (p < 0.001), and the mean sagittal deformity was significantly corrected from 20.65° (SD 5.88°) preoperatively to 1.61° (SD 1.95°; p < 0.001) postoperatively. The mean leg length discrepancy was significantly corrected from 3.57 cm (SD 1.27) preoperatively to 1.13 cm (SD 0.76) postoperatively (p < 0.001). All fractures healed at a mean of seven months (4 to 12) postoperatively. The mean Lower Extremity Functional Scale score improved significantly from 45.4 (SD 9.1) preoperatively to 66.2 (SD 5.5) postoperatively (p < 0.001). Partial cortical nonunion in the deformed segment occurred in eight patients (34.8%) and healed at a mean of 2.4 years (2 to 3) postoperatively. Conclusion. A clamshell osteotomy combined with IMN fixation in the treatment of patients with a femoral shaft fracture and a previous post-traumatic femoral malunion achieved excellent outcomes. Partial cortical nonunions in the deformed segment also healed satisfactorily. Cite this article: Bone Joint J 2023;105-B(4):449–454

Abstract. Introduction. Derby technique for posterolateral corner (PLC) reconstruction uses a doubled gracilis autograft to reconstruct the popliteo-fibular ligament (PFL) and a split biceps tendon transfer to reconstruct the lateral collateral ligament (LCL). We report midterm outcomes of a case series who underwent PLC reconstruction. Methodology. A retrospective review of 27 patients who underwent PLC reconstruction from 2012 until 2018 was performed (6 females, 21 males, median age 26). Median time interval from injury to primary procedure was 10 months. Outcomes were recorded as per clinical assessment and outcome scores. Results. All patients had no varus laxity in full knee extension. Similarly, at 30° of knee flexion, 25 patients (92.5%) had no varus laxity and 2 patients (7.5%) had grade 1 laxity. No patients demonstrated abnormal external rotation at final follow up. Outcome scores were obtained from 17 patients who underwent primary ligament reconstruction at a mean follow up of 72 months postoperatively. The mean Lysholm score was 94 +/-5.5 (72–100) and mean subjective IKDC score was 78/87 (89.6%) (51–87). 90% of our patients had gained normal or nearly normal IKDC scores on returning to routine activities of daily living and sports following surgery compared to their pre-injury status. Conclusion. Our technique enables an anatomical LCL & PFL reconstruction in isolation or in combination with ACL/PCL reconstruction or to augment an acute repair without contralateral graft harvest or allograft. The functional knee scores demonstrated in this cohort are comparable and in fact superior to previously published knee scores after PLC reconstruction

Background. Hip arthroscopy is a rapidly growing, evolving area within arthroscopic Orthopaedic Surgery, with annual rates increasing as much as 25-fold each year. Despite improvements in equipment and training, it remains a challenging procedure. Rates of revision surgery have been reported as 6.3% to 16.9%. Objectives. The primary objective was to determine the success of joint preservation after hip arthroscopy. The secondary objective was to determine whether patient characteristics or PROM functional score trends could predict revision hip arthroscopy or Total Hip Arthroplasty (THA). Study Design & Methods. We reviewed 1363 hip arthroscopies performed from January 2010 to December 2016 by a single high-volume surgeon at a single institution. Data was prospectively collected and retrospectively reviewed with a minimum 2-year follow-up. Functional outcomes were assessed with the International Hip Outcome Tool (IHOT-33). Hip arthroscopy failures were defined as Total Hip Arthroplasty or revision hip arthroscopy after index hip arthroscopy. Results. There were751 females and 612 males with an average age of 34.63 years (19 – 58 years). There were 199 cases (14.6%) of labrum repairs only, 286 (20.9%) cam and labrum repairs, 319 (23.4%) cam and pincer surgeries and 193 (14.1%) cam only surgeries. All pre-operative IHOT-33 patient-reported outcomes scores (27.42 ± 6.2) improved significantly at the 6 week-, 3 month- and 6-month follow-up visits (p<0.05). The best improvements were seen in symptoms and functional improvements (IHOT-SFL) (p<0.05) while the poorest amelioration of job-related concerns (IHOT-JRC) existed at all time points (p<0.05). There were 223 failures, 131 patients (9.61%) underwent revision hip arthroscopy and 92 required THA (6.75%) at 18.45 months ± 7.34 months. The 2-year survival rate was 89.2%. The THA conversion rate was 8.4% for patients > 50 years old and 3.72% for patients < 50 years old. Age (>50 years) and female sex were associated with increased risk of conversion to THA (p<0.05) while young (<25 years old) and female patients were most likely to undergo hip revision arthroscopy. Surgery involving repair of the labrum only are more likely to result in revision arthroscopy surgery and THA (70.7% at 10.6 years). CAM & pincer surgery have best longevity (90.9% at 10.6 years). Conclusions. Joint preservation and no subsequent surgery at 10.6 years is 83.64%. This study showed that predictors of revision hip arthroscopy or THA included poor pre-morbid functional score, female gender, age > 45, sudden functional score decrease at 3 months follow-up and cases in which only the labrum is surgically repaired

Aims. The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture. Methods. A comprehensive search on PubMed, MEDLINE, Scopus, and Cochrane Central databases was conducted to identify studies reporting comparative results of the SI versus the DI approach. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for search strategy. Of 606 titles, 13 studies met the inclusion criteria; methodological quality was assessed with the Newcastle-Ottawa scale. Random- and fixed-effects models were used to find differences in outcomes between the two surgical approaches. The range of motion (ROM) and the Disabilities of the Arm, Shoulder and Hand (DASH) scores, as well as neurological and non-neurological complications, were assessed. Results. A total of 2,622 patients were identified. No significant differences in DASH score were detected between the techniques. The SI approach showed significantly greater ROM in flexion (standardized mean difference (SMD) -0.508; 95% confidence interval (CI) -0.904 to -0.112) and pronation (SMD -0.325, 95% CI -0.637 to -0.012). The DI technique was associated with significantly less risk of lateral antebrachial cutaneous nerve damage (odds ratio (OR) 4.239, 95% CI 2.171 to 8.278), but no differences were found for other nerves evaluated. The SI group showed significantly fewer events of heterotopic ossification (OR 0.430, 95% CI 0.226 to 0.816) and a lower reoperation rate (OR 0.503, 95% CI 0.317 to 0.798). Conclusion. No significant differences in functional scores can be expected between the SI and DI approaches after distal biceps tendon repair. The SI approach showed greater flexion and pronation ROM and a lower risk of heterotopic ossification and reoperation. The DI approach was favourable in terms of lower risk of neurological complications. Cite this article: Bone Joint J 2020;102-B(12):1608–1617

Aims. For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy. Methods. We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment. Results. The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30). Conclusion. TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and young osteosarcoma patients with open physes when a good response to chemotherapy and no progression of the tumour to the epiphysis have been confirmed by MRI. Cite this article: Bone Joint J 2020;102-B(6):772–778

Aims. The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Methods. A total of 35 consecutive patients treated with extendable endoprosthetic replacement of the humerus in children were included. There were 17 boys and 18 girls in the series with a median age at the time of initial surgery of nine years (interquartile range (IQR) 7 to 11). Results. The median follow-up time was 10.6 years (IQR 3.9 to 20.4). The overall implant survival at ten years was 75%. Complications occurred in 13 patients (37%). Subluxation at the proximal humerus occurred in 19 patients (54%) but only six (17%) were symptomatic. Subluxation was seen more commonly in children under the age of nine years (86%) than in those aged nine years or more (33%) (p = 0.002). Implant failure occurred in nine patients (26%): the most common cause was aseptic loosening (four patients, 11%). Lengthening of the implant was carried out in 23 patients (66%). At final follow up, three patients had a limb that was shortened by 5 cm or more. The mean Musculoskeletal Tumor Society (MSTS) functional score was 79% (73% to 90%). Conclusion. Extendable endoprosthetic replacement is a reliable method of reconstructing humerus after excision of a bone sarcoma. Children who are less than nine years old have a high risk of subluxation. Cite this article: Bone Joint J 2020;102-B(1):64–71

Abstract. Objectives. We aimed to evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus detected by ultrasound. Methods. Adult patients who sustained a displaced midshaft clavicle were recruited prospectively. We assessed patient demographics, functional scores and radiographic predictors with a standardized protocol at six weeks. Ultrasound evaluation of the fracture site was undertaken to determine if sonographic bridging callus was present. Nonunion was determined by CT scanning at six months post-injury. Clinical features at six weeks were used to stratify patients at high risk of nonunion and a QuickDASH ≥40, fracture movement on examination or absence of callus on radiograph. Results. 112 patients completed follow-up at six months with a nonunion incidence of 17% (n=18/112). Sonographic bridging callus was detected in 62.5% (n=70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found failure to detect sonographic bridging callus at six weeks was associated with nonunion, older age, female sex, and greater overall fracture displacement (Nagelkerke R2=0.60). Of the cohort, 30.4% (n=34/112) had absent sonographic bridging callus at six weeks in combination with one or more of the ‘high risk’ clinical features. If one was present the nonunion rate was 47.1%, increasing to 60% with two risk factors and 100% when combined with all three. Conclusions. Ultrasound can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. When combined with poor clinical recovery this could be used to target patients for early operative intervention. 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

Aims. In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Methods. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. Results. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. Conclusion. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354–1358

Aim. The reconstruction of bone critical size defects of the tibia is one of the most complex therapeutic challenges in the orthopedic field. This study aims to describe and evaluate our three-staged surgical protocol of reconstruction of infected defects of the tibia emphasizing in limb salvage rate, resolution of infection, functional outcome and patient satisfaction. Method. A retrospective review was performed in all cases of complex infected tibia fracture with combined soft and bone tissue loss treated in a specialized limb reconstruction center between 2010 and 2018. In all cases, a three-stage protocol was performed: 1) Infected-limb damage control with radical debridement, 2) Soft tissue coverage with vascularized or local flap 3) Bone reconstruction procedure. The minimum follow-up required was 12 months after external fixator removal. Results. Twenty-eight patients with a mean age of 42 years were included. The mean soft tissue defect was 91.7 cm2 and the mean bone defect was 5.8 cm. 67.85% of the cases were classified as a type IV B-local osteomyelitis. The median global treatment time was 456 days. The External Fixator Time (EFT) was 419, 284, 235 for bone transport, shortening-lengthening and acute shortening groups respectively. The median Bone Healing Index (BHI) was 1.82 months/cm in bone transport group and 2.15 months/cm in shortening-lengthening group. The limb salvage rate was 92.85%. Infection resolution rate was 96,42%. We achieved bone union in 92,85% of the cases. Regarding ASAMI bone score, 92.8% of the cases were “good-or-excellent”. Two patients underwent a delayed amputation. Eight cases of non-progressive Docking Site (DS) healing were observed. Nineteen non-expected reinterventions were performed. Functional data: the mean VAS score was 1.0. The mean LEFS score was 55.88 (55.88/80). Regarding ASAMI functional score, 78,6% of the cases were “good-or-excellent”. More than 80% of the patients could return to work. 100% of the patients were “very satisfied” or “moderately satisfied” (75% and 25% respectively). Conclusions. Our results demonstrate that our three-stage surgical approach in infected tibial bone defects with soft tissue damage can result in high infection resolution, good functional outcome, good patient satisfaction and an acceptable limb salvage rate despite the large time of treatment and unexpected reinterventions

Background. Recently, a larger number of elderly individuals with osteoporosis has undergone total knee arthroplasty (TKA). Intuitively, such vulnerable bone condition should deteriorate post-TKA functional recovery compared to a non-osteoporotic condition, but this hypothesis has not been directly examined. Methods. To address this issue, we analysed prognosis of patients who underwent TKA in Toranomon Hospital in Japan between April 2016 and March 2017 (27 of 40 cases, age 75.0±8.2 years old, BMI 24.5±3.1), and evaluated effects of osteoporosis on the changes in functions of the knees three/six/twelve months after the operation. The knee functions were quantified based on Knee Society Score (KSS), and the severity of the pre-operative osteoporosis was evaluated by T-score. We examined the relationships between these scores using multiple regression analyses with age, BMI, and sex as covariates. We excluded patients with rheumatoid arthritis. Results. The multiple regression analyses revealed that the severity of osteoporosis (T-score) before TKA did not have sufficient explanatory powers for either type of KSS (for Knee Score, adjusted R2 ≤ 0.16; for Functional Score, adjusted R2 ≤ 0.15). In addition, Pearson correlation coefficients between the pre-operative osteoporosis severity and KSS were weak (for Knee Score, |r| < 0.07, P > 0.78; for Functional Score, |r| < 0.27, P > 0.21; Fig 1). This tendency was qualitatively preserved even when we repeated these analyses for each sex group. Conclusions. These analyses suggest that counterintuitively, pre-operative osteoporosis does not significantly deteriorate the functional outcome of TKA in the elderly population. Although longer observations of larger samples will be needed, the current findings indicate the possibility that we may not have to hesitate over TKA even for osteoporotic patients. For any figures or tables, please contact the authors directly

Thumb Carpometacarpal (CMC) arthritis is a common pathology of the hand. Surgical treatment with thumb reconstruction is well described. Retrospective outcomes have been described for multiple techniques, suggesting patient satisfaction with multiple different techniques. The Thompson technique uses a slip of Abductor Pollicis Longus for suspension and interposition as well as excision of the trapezium. Retrospective outcomes suggest good patient satisfaction. We describe the improvement in Patient rated outcomes scores (PROS) and changes in pinch and grip strength in a prospectively collected cohort of patients treated with a modification of the Thompson technique. To assess changes in Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder, and Hand (QDASH) scores, as well as to determine the percentage of patients that surpassed the Minimal Clinically Important Difference (MCID) figure that has been described in the literature for these tests. In addition, measurements for evaluation of pinch and grip strength prior to surgery, at six, and at twelve months follow-up were done. Between June 2016 and February 2019, a consecutive prospective series of Thirty-seven LRTI procedures with APL suspension arthroplasty (Thompson technique) were performed on 34 patients with osteoarthritis of the thumb CMC joint (24 women / 13 men; age 63±8.553). All surgeries were performed by the senior surgeon. Data was collected as part of a wrist pain database. Patients failing conservative treatment and electing surgical management of thumb arthritis were enrolled into the database. Patients were evaluated pre-operatively with the PRWE and QDASH questionnaires and grip and pinch strength measurements, and postoperatively at 6 and 12 months. The MCID for QDASH and PRWE is 14 and will be evaluated at the same time points for each patient. Paired student T-test was used to determine differences in the means. Data are presented as mean ± SD unless stated otherwise. Differences with p<.05 were considered significant. Compared to the pre-operative assessment, at six months, the means of PRWE pain score and PRWE functional score decreased significantly (32.824 SD±10.721 vs. 19.265 SD±12.268 and 30.262 SD±10.050 vs. 16.431 SD± 9.697 respectively, n=34,, p<0.05). 69% of the patients surpassed the MCID of 14 six months after the surgery. In addition, QDASH mean score also dropped from 56.108 to 32.219 (SD± 21.375 n=32. p<0.05) at six months. At one year, 76% of the patients were above the MCID of 14. The mean scores of these three questionnaires did not show significant change between six and twelve months. Compared to the initial pre-operative assessment, we found no statistically significant difference in the means of grip strength, point pinch, and lateral key pinch at six and twelve months. Thumb reconstruction with APL suspension arthroplasty demonstrates significant improvement in pain and functionality. No significant improvement in grip and pinch strength is observed, even at one year postoperatively

Introduction. The purpose of this study was to determine if better outcomes occur with use of robotic-arm assistance by comparing consecutive series of non-robotic assisted (NR-TKA) and robotic-arm assisted (NR-TKA) total knee arthroplasties with the same implant. Methods. 80 NR-TKAs and then 101 RA-TKAs were performed consecutively. 70 knees in each group that had a minimum two-year follow-up were retrospectively reviewed. Range of motion, Knee Society (KS) scores, and forgotten joint scores (FJS) were compared using Mann-Whitney U tests. Tourniquets, used for all cases, had their inflation time recorded. Component realignment to minimize soft tissue releases was used in both groups with the goal to stay within a mechanical alignment of 3° of varus to 2° of valgus. The use of soft tissue releases for balance were compared. Results. There were no statistical differences in baseline characteristics including pre-operative Knee Society scores between cohorts. The two-year NR-TKA and RA-TKA median KS knee and functional scores were 99.0 and 90.0 and 100.0 and 100.0 respectively. Mann-Whitney U test indicated a statistically significant difference in KS-KS (p<.00001) and near statistically significant difference in KS-FS (p=0.075). The 10-point higher KS-FS is considered a minimal clinically important difference. The median FJS at two years for the NR-TKA was 61.5 and the RA-TKA was 75.0. Although not statistically significant (p=0.1556), the 13.5-point increase in the RA-TKA cohort also represents a minimal clinically important difference. RA-TKA patients had statistically significant 5° higher knee flexion (p<.00001). Desired post-operative coronal alignment was present in 92.9% of NR-TKAs and 94.3% of RA-TKAs. 28.6% more of the RA-TKA cases were able to be balanced without a soft tissue release. Median tourniquet time was only 3.9 minutes longer for the robotic-arm assisted cohort. Conclusion. This comparison study demonstrates potential benefits in use of robotic-arm assistance over manual instrumentation in TKA

Introduction. The use of intraoperative liposomal bupivacaine (LB) peri-articular injection has been highly debated for total knee arthroplasty (TKA). We evaluated the effect of an institutional-wide discontinuation of intraoperative LB on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Material and Methods. Between July 1, 2019 and November 30, 2019, an institutional policy discontinued use of intraoperative LB, while the volume of non-LB with epinephrine was increased from 40-ml to 60-ml. A historical cohort was derived from patients undergoing TKA between January 1, 2019 and June 30, 2019. All patients received the same opioid sparing protocol, minimizing variability in prescribing habits. No adductor canal blocks/pumps were utilized. Nursing documented verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Opiate administration events were derived as Morphine Milligram Equivalences (MMEs) per patient per 24-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) tool was utilized. All time events were calculated relative to TKA completion instant. Results. 789 primary TKAs did not receive intraoperative LB, while 888 patients acted as controls. Age was significantly greater in patients that did not receive intraoperative liposomal bupivacaine (66.80±8.97 vs 65.57±9.46; p<.01). Gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were similar between the two groups (p>.05). Compared to historical controls, discontinuation of LB demonstrated no significant difference in postoperative inpatient VRS pain scores up to 72 hours (p>.05), opioid administration up to 96 hours (p>.05), or AM-PAC scores within the first 24 hours (p>.05). Discussion. Subjective pain scores, opioid consumption, and functional scores were unchanged in the early postoperative period following the discontinuation of intraoperative liposomal delivery of bupivacaine in TKA

Introduction and Objective. Several studies have described double and triple femoral neck lengthening osteotomies to correct coxa brevis deformity, however, no overview exists in literature. Our aim was to perform the first systematic review of the outcomes of double and triple femoral neck lengthening. Materials and Methods. After an extensive search in Pubmed, CINAHL and Embase libraries for published articles using the following search strategy: ‘(((proximal femoral deformity) OR hip dysplasia) OR coxa brevis) AND (((femoral neck lengthening) OR double proximal femoral osteotomy) OR triple proximal femoral osteotomy)’, we included studies reporting the results of double and triple femoral neck osteotomies. Clinical and radiological outcomes, and reported complications were extracted. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results. After evaluating 456 articles, we included 11 articles reporting 149 osteotomies in 143 patients (31% male, 64% female, 5% unspecified). Mean age of the patients was 20 years (range 7 years to 52 years). Indications were developmental hip dysplasia (51%), Perthes disease (27%), infection (6%), post-trauma (4%), congenital disorders (2%), slipped capital femoral epiphysis (1%), idiopathic (3%) and unknown (6%). The mean limb length discrepancy reduced by 12 mm (0 mm to 40 mm). In total, 65% of 101 positive Trendelenburg sign hips experienced improvement of abductor muscle strength. An 18% (9% to 36%) increase could be found in functional hip scores. Mean increase in articulo-trochanteric distance was 24 mm (10 mm to 34 mm). Five patients older than 30 years at the time of osteotomy and two younger patients with prior hip incongruency had disappointing results and required arthroplasty. In all, 12 complications occurred in 128 osteotomies, in which complications were reported. Conclusions. This first systematic review of double and triple femoral neck lengthening osteotomies shows that favorable outcomes and few complications can be expected in coxa brevis, however, excessive caution is required in older patients with incongruent hips

Aims. Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF. Methods. A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications. Results. In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications. Conclusion. The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: Bone Joint J 2020;102-B(3):293–300

Aims. Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction. Methods. Between 1989 and 2015, 32 patients underwent a Type I or Type I/IV pelvic resection without reconstruction for a primary bone tumour. There were 21 men and 11 women with a mean age of 35 years (15 to 85). The most common diagnosis was chondrosarcoma (50%, n = 16). Local recurrence-free, metastasis-free, and overall survival were assessed using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumour Society (MSTS) and Toronto Extremity Salvage Score (TESS). Results. At a mean follow-up of 159 months (1 to 207), 23 patients were alive without disease, one was alive with lung metastases, one was alive following local recurrence, four were dead of disease, and three had died from other causes. The overall ten-year survival was 77%. There was only one (3%) local recurrence, which occurred at 26 months. There were 18 complications in 17 patients; 13 wound healing complications/infections, three fractures, one pulmonary embolism, and one dislocation of the hip. Most complications occurred early. The mean functional scores were 21.1 (SD 8.1) for MSTS-87, 67.3 (SD 23.9) for MSTS-93 and 76.2 (SD 20.6) for TESS. Conclusion. Patients requiring Type I or Type I/IV pelvic resections can expect a good oncological outcome and a high rate of local control. Complications are generally acute in nature and are easily manageable. These patients achieved a good functional outcome without the need for bony reconstruction. Cite this article: Bone Joint J 2020;102-B(6):779–787

Background. This study aimed to investigate the effect of body mass index (BMI) on functional outcome following hip preservation surgery using the U.K. Non-Arthroplasty Hip Registry (NAHR). Methods. Data on adult patients who underwent hip arthroscopy or periacetabular osteotomy (PAO) between January 2012 and December 2018 was extracted from the UK Non-Arthroplasty Hip Registry dataset allowing a minimum of 12 months follow-up. Data is collected via an online clinician and patient portal. Outcomes comprised EuroQol-5 Dimensions (EQ-5D) index and the International Hip Outcome Tool 12 (iHOT-12), preoperatively and at 6 and 12 months. Results. A total of 6,666 patients were identified with BMI data available in 52%, comprising 3,220 arthroscopies and 277 PAO. Patients were divided into WHO groups: <25kg/m. 2. (n=1,745 (49.8%)), 25–30kg/m. 2. (n=1,199 (34.2%)), and ≥30kg/m. 2. (n=562 (16.0%)). Patients with higher BMI tended to be older. Pre-operative, 6 and 12-month follow-up were available for 91%, 49% and 45% of cases respectively. Higher BMI was associated with significantly poorer baseline, 6- and 12-month outcomes (12-month mean iHOT-12 score: <25kg/m. 2. = 62.3 (95%CI 60.4 to 64.3), 25–30kg/m. 2. = 57.3 (95%CI 55.0 to 59.7), ≥30kg/m. 2. = 54.7 (95%CI 51.1 to 58.2)). However, all groups saw similar and statistically significant improvement in pre- vs post-op scores (mean 12-month iHOT-12 gain: <25kg/m. 2. = +27.1 (95%CI 25.1 to 29.0), 25–30kg/m. 2. = +26.5 (95%CI 24.0 to 29.0), ≥30kg/m. 2. = +26.8 (95%CI 23.2 to 30.4), between-group p = 0.9). EQ-5D outcomes followed the same trend. Modelling for age, sex and procedure we found no significant difference in 12-month iHOT-12 gain between BMI groups. Conclusion. Whilst obese patients started from, and achieved lower post-operative raw functional scores, all BMI groups saw similar and significant degrees of improvement in functional outcome post-operatively. Obesity should not be considered a contraindication to hip preservation surgery

Aims. The aim of this study was to evaluate the efficacy of the surgical dislocation approach and modified trapdoor procedure for the treatment of chondroblastoma of the femoral head. Patients and Methods. A total of 17 patients (ten boys, seven girls; mean age 16.4 years (11 to 26)) diagnosed with chondroblastoma of the femoral head who underwent surgical dislocation of the hip joint, modified trapdoor procedure, curettage, and bone grafting were enrolled in this study and were followed-up for a mean of 35.9 months (12 to 76). Healing and any local recurrence were assessed via clinical and radiological tests. Functional outcome was evaluated using the Musculoskeletal Tumour Society scoring system (MSTS). Patterns of bone destruction were evaluated using the Lodwick classification. Secondary osteoarthritis was classified via radiological analysis following the Kellgren–Lawrence grading system. Steinberg classification was used to evaluate osteonecrosis of the femoral head. Results. The epiphyseal plate was open, closing, and closed in five, five, and seven patients, respectively. In total, eight, six, and three patients were classified as having Lodwick classification IA, IB, and IC, respectively. Allogeneic and autogenous bone grafting was used in 13 and four patients, respectively. All patients had good bone healing and no local recurrence was observed. One patient developed osteonecrosis of the femoral head (Steinberg IA) and one developed secondary osteoarthritis of the hip joint (Kellgren–Lawrence Grade II). The mean postoperative MSTS functional score was 27.7 (24 to 30). Conclusion. Surgical dislocation and modified trapdoor procedures are safe and effective techniques for treating chondroblastoma in the femoral head. Cite this article: Bone Joint J 2019;101-B:732–738

Fractures of the lateral clavicle with complete displacement have a high non-union rate and are associated with poor functional outcomes following non-operative treatment. Various operative techniques are available but preliminary studies of open reduction and tunnelled suspensory device (ORTSD) fixation report good early functional outcomes with a low rate of complications. This study assesses the functional outcomes in a large series of patients treated using ORTSD. After surgical reconstruction in 67 patients, outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Oxford score at six weeks, and three, six and twelve months post-operatively. 55 of 64 surviving patients were contacted at a mean of 69 (27–120) months to complete DASH and Oxford scores, evaluate overall satisfaction, and document any complications. At one year post-operatively, the mean Oxford score was 46.4 and mean DASH score was 2.4 points (59/67 patients assessed). At a mean of 69 months after surgery, the mean Oxford score was 46.5 and mean DASH score was 2.2 (55 surviving and contactable patients). There were no significant differences between the one-year functional scores and those at the latest follow-up. Two patients developed symptomatic non-union requiring re-operation, and two developed an asymptomatic fibrous union not requiring surgery. The five-year survival when considering only obligate revision for implant-related complications was 97.0%. ORTSD fixation for isolated displaced lateral-end clavicle fractures in medically-fit patients is associated with good functional outcomes, and a low rate of medium-term complications. Routine removal of the implant was not necessary

Reverse shoulder arthroplasty (RSA) has an increasing effective use in the treatment of patients with a variety of diagnoses, including rotator cuff deficiency, inflammatory arthritis, or failed shoulder prostheses. Glenoid bone loss is not uncommonly encountered in these cases due to the significant wear. Severe bone loss can compromise glenoid baseplate positioning and fixation, consequently increasing the risk for early component loosening, instability, and scapular notching. To manage severe glenoid bone deficiencies, bone grafts are commonly used. Although, many studies report outcome of bone grafting in revision RSA, the literature on humeral head autograft for glenoid bone loss in primary RSA is less robust. The purpose of this study is to evaluate the clinical and radiographic outcomes of primary RSA with humeral head autograft for glenoid bone loss at our institution. Institutional review board approval was obtained to retrospectively review the records of 22 consecutive primary RTSA surgeries in 21 patients with humeral head autograft for glenoid bone loss between January 2008 and December 2016. Five patients died during follow-up, three were unable to be contacted and one refused to participate, leaving a final study cohort of 12 patients with 13 shoulders that underwent RSA. All patients had a clinical evaluation including detailed ROM and clinical evaluation using the American Shoulder and Elbow Surgeons (ASES) Score, Constant Score, Western Ontario Osteoarthritis of the Shoulder Index (WOOS), and Short Form-12 (SF-12) questionnaires. Preoperative and postoperative plain radiographs and CT scans were assessed for component position, loosening, scapular notching, as well as graft incorporation, resorption, or collapse. There were 6 males and 6 females, with an average age of 74 ± 6.8 years. The average BMI was 31.7 ± 5.3, and the median ASA score was 3. Average follow-up was 3.4 ± 1.1 years. The average postoperative range of motion measurements for the operative arm are: flexion = 120 ± 37, abduction = 106 ± 23, external rotation = 14 ± 12, internal rotation at 90 degrees of abduction = 49 ± 7, external rotation at 90 degrees of abduction = 50 ± 28. Average functional scores are: ASES: 76.9 ± 19.2, WOOS: 456 ± 347, SF12 physical: 34.2 ± 8.2, SF12 mental: 54.1 ± 10.2, Constant Score: 64.6 ± 14. No evidence of hardware loosening or evidence of bone graft resorption were encountered. On CT, the average of pre operative B-angle was 79.3 ± 9.3 while the pre operative reverse shoulder angle was 101.4 ± 28. Glenoid retroversion average on CT was 13.3 ± 16.6. Post operative baseplate inclination average was 82 ± 7.4 while the baseplate version 7.8 ±10. The operative technique was able to achieve up to 30 degrees of inclination correction and up to 50 degrees of version correction. In conclusion, primary reverse shoulder arthroplasty with humeral head autograft for glenoid bone loss provides excellent ROM and functional outcomes at mid-term follow-up. This technique has a high rate of bone incorporation and small risk of bone resorption at mid term follow up

Introduction. Functional outcomes of mechanically aligned (MA) total knee arthroplasty have plateaued. The aim of this study is to find an alternative technique for implant positioning that improves functional outcomes of TKA. Methods. We prospectively randomized 100 consecutive patients undergoing TKA into two groups: in the group A an intramedullary femoral guide and an extramedullary tibial guide were used with aim to obtain a neutral traditional mechanical alignment; in the group B an extramedullary femoral guide set on distal femoral condyles and an extramedullary tibial guide neutrally aligned were used to obtain an adaptation of the conventional MA technique. Patients were followed-up clinically with the Short Form Health Survey (SF-12), Oxford Knee Score (OKS) and Visual Analogue Score (VAS) questionnaires pre-operatively and then at 1 year post-operatively. Mechanical alignment was calculated on standing weight bearing Xray pre- and post-operatively. T-test was used to compare the results between groups. Results. Both groups showed an improvement of clinical scores. At 1 year of follow-up OKS and SF-12 were significantly higher in group B: 47,6 ±0.75 and 46.5 ±0.76 respectively; VAS was similar in both groups. Values of mechanical alignment changed from 6.45 ±8.45 to 0.25 ±0.91 for group A and from 6.8 ±7.94 to 2.5 ±4.7 for group B. Conclusion. This study shows that adjusted mechanical alignment (AMA) with a small under-correction of frontal deformity lead to improved functional scores following total knee replacement compared to conventional technique of neutral alignment. These results are satisfactory at short follow-up but long-term studies are needed to evaluate the difference in the rate of wear of the prosthetic components

Recently, new metallurgical techniques allowed the creation of 3D metal matrices for cementless acetabular components. Among several different products now available on the market, the Biofoam Dynasty cup (MicroPort Orthopedics® Inc., Arlington, TN, USA) uses an ultraporous Titanium technology but has never been assessed in literature. Coping with this lack of information, our study aims to assess its radiological osteointegration at two years in a primary total hip arthroplasty and compares it to a successful contemporary cementless acetabular cup. This monocentric retrospective study includes 96 Dynasty Biofoam acetabular components implanted between March 2010 and August 2014 with a minimum 2 years radiographic follow-up. Previous acetabular surgery, any septic issue or re-operation for component malposition were exclusion criteria. They were compared to 96 THA using the Trident PSL matched for age, gender, BMI and follow-up. Presence of radiolucencies and sclerotic lines were described on AP pelvis views using the classification of DeLee and Charnley. There was no statistical difference between the two groups concerning demographics and mean follow-up (p> 0.05). Shell's anteversion was similar but inclination was greater in the biofoam group (p=0.006). 27,17% of the Biofoam shells presented radiolucencies in 2 zones or more and 0% of the Trident shells. 11,96% of Biofoam cups showed radiolucencies in the 3 zones of DeLee comparing to 0% of the Trident cups. There was no statistical difference between the Biofoam group (n=54/96) and the Trident PSL group (n=57/96) in pre-operative functional scores for both WOMAC subscales and SF-12. When evaluating last follow-up PROM's, no significant differences were found comparing the entirety of both groups, 56 Biofoam and 51 Trident PSL. No difference was found either when comparing Biofoam patients with ³ 2 zones of radiolucencies (n=15) to the whole Trident group (n=51). This study raises concerns about radiologic evidence of osteointegration of the Biofoam acetabular cup. Nevertheless, these radiological findings do not find any clinical correlation considering clinical scores. Thus, it may question the real meaning of these high-rated radiolucencies, which at first sight reflect a poorer osteointegration. The first possible limitation with this study is an overinterpretation of the radiographs. Nevertheless, both observers were blinded regarding the patients groups and clinical outcomes and there was a strong inter-observer reliability. Although both cohorts were matched on their demographics and were similar on the cup anteversion, we noticed a slightly lower abduction angle in the Biofoam population. It could reduce the bone-implant coverage area and hence hinders the bony integration, but this difference was small and both groups remained in the Lewinneck security zone. Furthermore, even if patients were matched on age, gender, BMI and follow-up, other variables can influence early osteointegration (smoke status, osteoporosis) and have not been controlled even though we have no reasons to think their distribution could differ in the 2 groups. The real clinical meaning of these findings remains unknown but serious concerns are raised about the radiographic osteointegration of the Dynasty Biofoam acetabular components. Concerns are all the more lawful that this implants aim to enhance osteointegration

The effectiveness of total hip replacement as a surgical intervention has revolutionized the care of degenerative conditions of the hip joint. However, the surgeon is still left with important decisions in regards to how best deliver that care with choice of surgical approach being one of them especially in regards to the short-term clinical outcome. It is however unclear if a particular surgical approach offers a long-term advantage. This study aims to determine the influence of the three main surgical approaches to the hip on patient reported outcomes and quality of life after 5 years post-surgery. We extracted from our prospective database all the patients who underwent a Total Hip Replacement surgery for osteoarthritis or osteonecrosis between 2008 and 2012 by an anterior, posterior or lateral approach. All the pre-operative and post-operative HOOS (Hip disability and Osteoarthritis Outcome Score) and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scores were noted. Analysis of covariance (ANCOVAs) were used to study the relationship between amount of change in HOOS and WOMAC subscales (dependant variables) and approach used, by also including confounding factors of age, gender, ASA (American Society of Anaesthesiologists) score, Charnley score and Body Mass Index. A total of 1895 patients underwent a primary total hip arthroplasty during the considered period. Among them, 367 had pre-operative and ≥5 years post operative PROM scores (19.47%). The mean follow-up for the study cohort was 5.3 years (range 5 to 7 years) with, 277 at 5 years, 63 at 6 years, and 27 at 7 years. In the posterior approach group we had 138 patients (37.60%), 104 in the lateral approach (28.34%) and 125 in the anterior approach (34.06%). There were no significant differences between the 3 groups concerning the Charnley classification, BMI, Gender, ASA score, side and pre-operative functional scores. We did not observe any significant difference in the amount of change in HOOS and WOMAC subscales between the 3 groups. There were no differences either in the post-operative scores in ultimate value. Our monocentric observational study shows that these three approaches provide predictable and comparable outcomes on HRQL and PROMs at long-term follow-up both in terms of final outcome but also in percent improvement. This study has several limitations. We excluded patients who underwent revision surgery leaving the unanswered question of how choice of surgical approach could lead to different revision rates, which have an impact on the functional outcomes. Moreover, even if we controlled for the most important confounders by a multivariate analysis model, there is still some involved cofounders, which could potentially lead to a bias such as smoking, socio-economical status or femoral head diameter. But we do not have any reason to think that these parameters could be unequally distributed between the three groups. Finally, our study cohort represents of 19.47% of the complete cohort. The fact that not all patients have PROM's was pre-determined as eight years ago we instituted that only 1 in 5 patients that returned their pre-operative questionnaire would get their PROM's at follow-up. Despite this, our statistical power was sufficient

Background: In Denmark there is every year performed 5000 total knee Arthroplasty, and the number increase fast every year. The most common indication for total knee Arthroplasty is arthrosis which constitute 80 %. Convincing studies shows that overweight and obesity are the most important reason for develop arthrosis. On the contrary the relationship between overweight and outcome are ambiguous. This study examinant whether there is association between body mass index and the clinical outcome at 1 year following primary total knee Arthroplasty. Method and material: A total of 158 patients, 116 woman and 42 men undergoing a total knee Arthroplasty replacement from the hospital of southern Jutland Sonderborg in the period January 1. 2005 – December 31. 2006. Each patient where followed from the day of the surgery to 1 year postoperative. There were four clinical outcome measures; functional score, knee score, functional score improvement and knee score improvement. Data was collected from medical records and the database Dansk Knæalloplastik Register. Results: In woman there were found significant negative linear relationship between body mass index and knee score improvement – 0.97 (p=0.003). The correlations coefficient for body mass index and knee score was significant (p=0.04). There were significant associations between body mass index and all four outcome measures for patients > 65 years; functional score (p= 0.006), knee score (p=0.01), functional score improvement – 1.09 (p=0.017) and knee score improvement – 1.14 (p=0.006). For the patients < 65 years there was a positively significant linear relationship between body mass index and functional score improvement 1.47 (p=0.01). In the functional score there was not found significant relationship whit body mass index in this age group (p=0.12). Conclusion: This study shows evidence for overweight and obesity in patients undergone a total knee Arthroplasty has implications for how much the patient achieves clinical improvement after 1 year postoperative. The higher body mass index the patient has, the worse score obtained

The October 2023 Trauma Roundup³⁶⁰ looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution.

Introduction. The management of early OA in young patients with joint preservation techniques utilizing cartilage repair remains challenging and a suitable treatment remains unclear. The management of bipolar chondral lesions in the patello-femoral (PF) and in the tibio-femoral (TF) compartment with cartilage repair is especially troublesome. The purpose of this study was to evaluate the clinical outcomes and survivorship after ACI for the treatment of bipolar chondral lesions in the PF and TF compartment. Methods. This was an IRB approved, prospectively collected case series, level 4 study. We evaluated 115 patients. 58 patients who had ACI for the treatment of symptomatic bipolar chondral lesions in the PF compartment and 57 in the TF compartment with a minimum 2-year follow up. A single surgeon performed all the surgeries between October 1995 and June 2014. In the PF group, all 58 patients (60 knees; mean age, 36.6 years) were included, and for the TF group one patient did not return for follow-up, 56 patients (58 knees) were included. For the PF group, an average size of the patella and trochlea lesions were 5.6 ± 2.7 cm2 and 4.2 ± 2.8 cm2, respectively. For the TF group, an average of 3.1 lesions per knee were treated, representing a total surface area of 16.1 cm2 (range, 3.2 – 44.5 cm2) per knee. Patients were evaluated with the modified Cincinnati Knee Rating Scale, Visual Analogue Scale, Western Ontario and McMaster Universities Osteoarthritis Index, and the Short Form 36. Patients also answered questions regarding self-rated knee function and satisfaction with the procedure. Standard radiographs were evaluated for progression of OA. Results. Patients did well for bipolar ACI in both compartments. In the PF compartment overall, the survival rate was 83% and 79% at 5 and 10 years, respectively. Of the 49 (82%) knees with retained grafts, all functional scores significantly improved postoperatively with a very high satisfaction rate (88%) at a mean of 8.8 years after ACI (range, 2 – 16 years). Outcomes for 11 patients were considered as failures at a mean of 2.9 years. In the TF group, the overall survival rate was 80% at 5 years and 76% at 10 years. Significantly better survival rate in patients with the use of collagen membrane than periosteum (97% vs. 61% at 5 years, P = 0.0014) was found. Of 46 knees with retained grafts, all functional scores significantly improved postoperatively with a very high satisfaction rate (85%) at a mean of 8.3 years after ACI (range, 2–20 years). Outcomes for 12 patients were considered as failures at a mean of 4.1 years. Of them, 9 patients were converted to a partial or total knee arthroplasty at a mean of 4.4 years. Two patients had revision ACI at 5 and 17 months. The other one patient did not require a revision surgery. At the most recent follow-up for both groups there was no radiographic progression to OA. Conclusions. Our study showed that ACI for the treatment of bipolar chondral lesions in the PF and TF compartments provided successful clinical outcomes in patients with retained grafts and could possibly prevent or delay OA progression. The best results in the PF joint are as primary repairs and not after failed osteotomy or cartilage repair with a 91% 10-year survival. Collagen membrane is more encouraging than periosteum for bipolar lesions in both the PF and TF compartments. ACI could be an adequate salvage procedure for bipolar chondral lesions in the TF compartment for the relatively young arthritic patient who wishes to avoid an arthroplasty

Aims

The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults.

Aims

Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations.

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents.