Aims. To analyze outcomes reported in trials of childhood fractures. Methods. OVID MEDLINE, Embase, and Cochrane CENTRAL databases were searched on the eighth August 2019. A manual search of trial registries, bibliographic review and internet search was used to identify additional studies. 11,476 studies were screened following PRISMA guidelines. 100 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Study quality was not evaluated. Outcomes reported by trials were mapped onto domains in the World Health Organization (WHO) International Classification of Function framework. Results. In all, 525 outcomes were identified representing 52 WHO domains. Four domains were reported in more than 50% of trials: structure of upper/lower limb, sensation of pain, mobility of joint function, and health services, systems and policies. The Activities Scale for Kids performance (ASK-p) score was the most common outcome score reported in 6/72 upper limb and 4/28 lower limb trials. Conclusion. There is a diverse range of outcomes reported in trials of childhood fractures covering all areas in the International Classification of Functioning, Disability and Health (ICF) framework. There were three common upper limb and three common lower limb outcomes. In the absence of a core outcome set, we recommend that upper limb trials report pain, range of movement and radiograph appearance of the arm and lower limb trials report pain, radiograph appearance of the leg and healthcare costs to improve consistency of reporting in future trials. Cite this article: Bone Joint Open 2020;1-5:167–174

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures

Aims

There is limited information on outcomes of revision ACL reconstruction (rACLR) in soccer (association football) athletes, particularly on return to sport and the rate of additional knee surgery. The purpose of this study was to report return to soccer after rACLR, and to test the hypothesis that patient sex and graft choice are associated with return to play and the likelihood of future knee surgery in soccer players undergoing rACLR.

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery. Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test. A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point. In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases

Aims

This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton’s neuroma.

The purpose of this study was to examine the complications and outcomes of total hip replacement (THR) in super-obese patients (body mass index (BMI) > 50 kg/m²) compared with class I obese (BMI 30 to 34.9 kg/m²) and normal-weight patients (BMI 18.5 to 24.9 kg/m²), as defined by the World Health Organization.

A total of 39 THRs were performed in 30 super-obese patients with a mean age of 53 years (31 to 72), who were followed for a mean of 4.2 years (2.0 to 11.7). This group was matched with two cohorts of normal-weight and class I obese patients, each comprising 39 THRs in 39 patients. Statistical analysis was performed to determine differences among these groups with respect to complications and satisfaction based on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, the Harris hip score (HHS) and the Short-Form (SF)-12 questionnaire.

Super-obese patients experienced significantly longer hospital stays and higher rates of major complications and readmissions than normal-weight and class I obese patients. Although super-obese patients demonstrated reduced pre-operative and post-operative satisfaction scores, there was no significant difference in improvement, or change in the score, with respect to HHS or the WOMAC osteoarthritis index.

Super-obese patients obtain similar satisfaction outcomes as class I obese and normal-weight patients with respect to improvement in their scores. However, they experience a significant increase in length of hospital stay and major complication and readmission rates.

Cite this article: Bone Joint J 2013;95-B:758–63.

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance. Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores. A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37). Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year. The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures

Introduction. Transfemoral osseointegration (TFOI) for amputees has substantial literature proving superior quality of life and mobility versus a socketed prosthesis. Some amputees have hip arthritis that would be relieved by a total hip replacement (THR). No other group has reported performing a THR in association with TFOI (THR+TFOI). We report the outcomes of eight patients who had THR+TFOI, followed for an average 5.2 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TFOI and also had THR, performed at least two years prior. Six patients had TFOI then THR, one simultaneous, one THR then TFOI. All constructs were in continuity from hip to prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in subjective hip pain, K-level, daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but one patient did not have complete mobility and quality of life survey data at both time periods. Results. Four (50%) were male, average age 52.7±14.8 years. Three patients (38%) had amputation for trauma, three for osteosarcoma, one each (13%) infected total knee and persistent infection after deformity surgery. One patient died one year after THR+TOFA from subsequently diagnosed pancreatic cancer. One patient had superficial debridement for infection with implant retention after five years. No implants were removed, no fractures occurred. All patients reported severe hip pain preoperatively versus full relief of hip pain afterwards. K-level improved from 0/8=0% K>2 (six were wheelchair-bound) to 5/8=63% (p=.026). At least 8 hours of prosthesis wear was reported by 2/7=29% before TOFA vs 5/7=71% after (p=.286). The QTFA improved in all categories, but not significantly: Global (40.0±21.6 vs 60.0±10.9, p=.136), Problem (50.2±33.2 vs 15.4±8.4, p=.079), and Mobility (35.9±26.8 vs 58.3±30.7, p=.150). The SF36 also improved minimally and not significantly: Mental (53.6±12.0 vs 54.7±4.6, p=.849) and Physical (32.5±10.9 vs 36.3±11.2, p=.634). Conclusions. THR+TFOI is a successful reconstruction option for amputees who desire relief from severe pain related to hip joint degeneration, and also the opportunity for improved mobility and quality of life that TFOI typically confers. In our cohort, the procedure proved safe: no associated deaths, no removals, one soft tissue debridement. Mobility improved markedly. Quality of life improved, but not to significant thresholds as measured by the surveys. THR+TFOI appears safe and reasonable to offer to transfemoral amputees with painful hip joint degeneration

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures

Immigrated Canadians make up approximately 20% of the total population in Canada, and 30% of the population in Ontario. Despite universal health coverage and an equal prevalence of severe arthritis in immigrants relative to non-immigrants, the former may be underrepresented amongst arthroplasty recipients secondary to challenges navigating the healthcare system. The primary aim of this study was to determine if utilization of arthroplasty differs between immigrant populations and persons born in Canada. The secondary aim was to determine differences in outcomes following total hip and knee arthroplasty (THA and TKA, respectively). This is a retrospective population-based cohort study using health administrative databases. All patients aged ≥18 in Ontario who underwent their first primary elective THA or TKA between 2002 and 2016 were identified. Immigration status for each patient was identified via linkage to the ‘Immigration, Refugee and Citizenship Canada’ database. Outcomes included all-cause and septic revision surgery within 12-months, dislocation (for THA) and total post-operative case cost and were compared between groups. Cochrane-Armitage Test for Trend was utilized to determine if the uptake of arthroplasty by immigrants changed over time. There was a total of 186,528 TKA recipients and 116,472 THA recipients identified over the study period. Of these, 10,193 (5.5%) and 3,165 (2.7%) were immigrants, respectively. The largest proportion of immigrants were from the Asia and Pacific region for those undergoing TKA (54.0%) and Europe for THA recipients (53.4%). There was no difference in the rate of all-cause revision or septic revision at 12 months between groups undergoing TKA (p=0.864, p=0.585) or THA (p=0.527, p=0.397), respectively. There was also no difference in the rate of dislocations between immigrants and people born in Canada (p=0.765, respectively). Despite having similar complication rates and costs, immigrants represent a significantly smaller proportion of joint replacement recipients than they represent in the general population in Ontario. These results suggest significant underutilization of surgical management for arthritis among Canada's immigrant populations. Initiatives to improve access to total joint arthroplasty are warranted

Introduction. Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods. Results. Six (67%) were male, average age 51.2±14.7 years. All primary amputations were performed to manage traumatic injury or its sequelae. No patients died. Five patients (56%) developed infection leading to eventual transfemoral amputation 36.0±15.3 months later, and 1 patient had a single debridement six years after TTOI with no additional surgery in the subsequent two years. All patients who had transfemoral amputation elected for and received transfemoral osseointegration, and no infections occurred, although one patient sustained a periprosthetic fracture which was managed with internal fixation and implant retention and walks independently. The proportion of patients who wore their prosthesis at least 8 hours daily was 5/9=56%, versus 7/9=78% (p=.620). Even after proximal level amputation, the QTFA scores improved versus prior to TKR+TTOI, although not significantly: Global (45.2±20.3 vs 66.7±27.6, p=.179), Problem (39.8±19.8 vs 21.5±16.8, p=.205), Mobility (54.8±28.1 vs 67.7±25.0, p=.356). SF36 changes were also non-significant: Mental (58.6±7.0 vs 46.1±11.0, p=.068), Physical (34.3±6.1 vs 35.2±13.7, p=.904). Conclusions. TKR+TTOI presents a high risk for eventual infection prompting subsequent transfemoral amputation. Although none of these patients died, in general, TKR infection can lead to patient mortality. Given the exceptional benefit to preserving the knee joint to preserve amputee mobility and quality of life, it would be devastating to flatly force transtibial amputees with severe degenerative knee joint pain and unable to use a socket prosthesis to choose between TTOI but a painful knee, or preemptive transfemoral amputation for transfemoral osseointegration. Therefore, TTOI for patients who also request TKR must be considered cautiously. Given that this frequency of infection does not occur in patients who have total hip replacement in association with transfemoral osseointegration, the underlying issue may not be that linked joint replacement with osseointegrated limb replacement is incompatible, but may require further consideration of biological barriers to ascending infection and/or significant changes to implant design, surgical technique, or other yet-uncertain factors

Abstract. Introduction. Previous research has demonstrated no clinically significant benefit of arthroscopic meniscectomy in patients with a meniscal tear, however, patients included in these studies would not meet current treatment recommendations. Prior to further randomised controlled trials (RCTs) research is needed to understand a younger population in more detail. Aim. To describe the baseline characteristics of patients with a meniscal tear and explore any association between baseline characteristics and outcome. Methodology. A prospective, national multicentre cohort study was performed recruiting patients aged 18 to 55 presenting to secondary care. MRI analysis of arthritis was performed using Whole Organ Magnetic Resonance Imaging Score (WORMS) and bone shape analysis. Outcomes included the Western Ontario Meniscal Evaluation Tool (WOMET) and Knee Injury and Osteoarthritis Outcome Score (KOOS4) at 12 months. Results. 150 participants were recruited across eight sites with a mean age of 43.47 (SD 9.63). MRI analysis using WORMS score and bone shape analysis revealed no or early osteoarthritis. At 12 months, 67 (44.67%) of participants were managed non-operatively and 68 (45.33%) were operatively. Participants in the operative group were significantly younger with a lower BMI (p<0.05). A stepwise logistic regression model including 17 characteristics revealed that only baseline score and surgery significantly affected 12-month WOMET and KOOS4. Conclusion. This study in contrast to previous trials demonstrated a benefit of surgery for patients with a meniscal tear. The METRO study demonstrates that it is feasible to recruit younger patients and a future RCT is required using the study population included in this cohort

Ganz's studies made it possible to address joint deformities on both femoral and acetabular side brought by the Legg-Calvè-Perthes disease (LCPD). Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency along with periacetabular osteotomy (PAO). The purpose of this study is to show the clinical and morphologic outcomes of the technique, and an implemented planning approach. From 2015 to 2023, 13 FHROs were performed on 11 patients for LCPD, in two centers. 11 of 13 hips had an associated PAO. A specific CT and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiographic parameters (sphericity index, extrusion index, integrity of the Shenton's line, LCE angle, Tonnis angle, CCD angle) and clinical parameters (ROM, VAS, Merle d'Aubigné-Postel score, modified-HHS, EQ5D-5L). Early and late complications were reported. The mean follow-up was 40 months. The mean age at surgery was 11,4 years. No major complications were recorded. One patient required a total hip arthroplasty. Femoral Head Sphericity increased from 45% to 70% (p < 0,001); LCE angle from 18° to 42,8° (p < 0,001); extrusion Index from 36,6 to 8 (p < 0,001); Tonnis Angle from 14,4° to 6,2° (p = 0.1); CCD Angle from 131,7 to 136,5° (p < 0,023). The VAS score improved from 3,25 to 0,75,(p = 0.06); Merle d'Aubigné-Postel score from 14.75 to 16 (p = 0,1); Modified-HHS from 65,6 to 89,05 (p = 0,02). The EQ 5D 5L showed significant improvements. ROM increased especially in abduction and extra-rotation. FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical and morphologic outcomes in LCPD. The newly introduced simulation and planning algorithm may help to further refine the technique

Lisfranc injuries account for 0.2% of all fractures and have been linked to poorer functional outcomes, in particular resulting in post-traumatic arthritis, midfoot collapse and chronic pain. This study assesses the longitudinal functional outcomes in patients with low and high energy Lisfranc injuries treated both operatively and non-operatively. Patients above 16 years with Lisfranc injuries from January 2008 and December 2017 were identified through the Victorian Orthopaedic Trauma Outcomes (VOTOR) registry. Follow-up performed at 6, 12 and 24 months through telephone interviews with response rate of 86.1%, 84.2% and 76.2% respectively. Longitudinal functional outcome data using Global Outcome Assessment, EQ-5D-5L, numerical pain scale, Short-Form 12, the WHO Disability Assessment Schedule and return to work status were collected. Univariate analysis was performed and variables showing a significant difference between groups (p < 0.25) were analysed with multivariable mixed effects regression model. 745 patients included in this retrospective cohort study. At 24 months, both the operative and non-operative groups demonstrated similar functional outcomes trending towards an improvement. Mixed effect regression models for the EQ items for mobility (OR 1.80, CI 0.91 – 3.57), self-care (OR 1.95, 95% CI 1.09-3.49), usual activities (OR 1.10, 95% CI 0.99-1.03), pain (OR 1.07, 95% CI 0.61-1.89), anxiety (OR 1.29, 95% CI 0.72-2.34) and pain scale (OR 1.07, 95% CI 0.51 – 2.22) and return to work (OR 1.28, 95% CI 0.56-2.91) between groups were very similar and not statistically significantly different. We concluded that there was no statistically significant difference between operative and non-operative patients with low and high energy Lisfranc injuries. Current clinical practices in Lisfranc injury management are appropriate and not inadvertently causing any further harm to patients. Future research comparing fracture patterns, fixation types and corresponding functional outcomes can help determine gold standard Lisfranc injury management

The Australia and New Zealand Sarcoma Association established the Sarcoma Guidelines Working Party to develop national guidelines for the management of Sarcoma. We asked whether surgery at a specialised centre improves outcomes. A systematic review was performed of all available evidence pertaining to paediatric or adult patients treated for bone or soft tissue sarcoma at a specialised centre compared with non-specialised centres. Outcomes assessed included local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival. Definitive surgical management at a specialised sarcoma centre improves local control as defined by margin negative surgery, local or locoregional recurrence, and local recurrence free survival. Limb conservation rates are higher at specialised centres, due in part to the depth of surgical experience and immediate availability of multidisciplinary and multimodal therapy. A statistically significant correlation did not exist for 30-day and 90-day mortality between specialised centres and non-specialised centres. The literature is consistent with improved survival when definitive surgical treatment is performed at a specialised sarcoma centre. Evidence-based recommendation: Patients with suspected sarcoma to be referred to a specialised sarcoma centre for surgical management to reduce the risk of local recurrence, surgical complication, and to improve limb conservation and survival. Practice point: Patients with suspected sarcoma should be referred to a specialised sarcoma centre early for management including planned biopsy

Abstract. Background. Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes. Methodology. A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints. Results. 35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant. Conclusions. Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications

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

Aims. We assessed the long-term outcomes of a large cohort of patients who have undergone a periacetabular osteotomy (PAO), and sought to validate a patient satisfaction questionnaire for use in a PAO cohort. Methods. All patients who had undergone a PAO from July 1998 to February 2013 were surveyed, with several patient-reported outcome measures (PROMs) and radiological measurements of preoperative acetabular dysplasia and postoperative correction also recorded. Patients were asked to rate their level of satisfaction with their operation in achieving pain relief, restoration of activities of daily living, ability to perform recreational activity, and their overall level of satisfaction with the procedure. Results. A total of 143 PAOs were performed between 1998 and 2013. Of those, 90 postoperative surveys were returned. Only 65 patients (73 hips) had both pre- and postoperative radiographs available for measurement. The mean time to follow-up was 15 years (6.5 to 20). Most patients were female (91%), with a mean age of 26.4 years (14.9 to 48.3) at the time of their surgery. A statistically significant improvement in radiological correction was detected in all hips (p < 0.001). A total of 67 patients (92.3%) remained either very satisfied or satisfied with their PAO. The internal consistency of the patient satisfaction questionnaire, measured using Cronbach’s α, ranged from 0.89 to 0.94 indicating ‘good’ to ‘excellent’ reliability. Conclusion. Outcomes of importance to patients undergoing a PAO include several key domains: pain relief, improve activities of daily living, and improve recreational ability. Our study demonstrates high rates of long-term patient satisfaction in all domains, and found the patient satisfaction questionnaire to be a valid and reliable instrument for use in this cohort. Cite this article: Bone Jt Open 2023;4(12):964–969

The primary aim of this study was to compare the clinical outcomes of osteoid osteoma (OO) between the group of patients with the presence of nidus on biopsy samples from radiofrequency ablation (RFA) with those without nidus. Secondly, we aimed to examine other factors that may affect the outcomes of OO reflecting our experience as a tertiary orthopaedic oncology centre. We retrospectively reviewed 88 consecutive patients diagnosed with OO treated with RFA between November 2005 and March 2015, consisting of 63 males (72%) and 25 females (28%). Sixty-six patients (75%) had nidus present in their biopsy samples. Patients’ mean age was 17.6 years (4-53). Median duration of follow-up was 12.5 months (6-20.8). Lesions were located in the appendicular skeleton in seventy-nine patients (90%) while nine patients (10%) had an OO in the axial skeleton. Outcomes assessed were based on patients’ pain alleviation (partial, complete, or no pain improvement) and the need for further interventions. Pain improvement in the patient group with nidus in histology sample was significantly better than the group without nidus (OR 7.4, CI 1.35-41.4, p=0.021). The patient group with nidus on biopsy demonstrated less likelihood of having a repeat procedure compared to the group without nidus (OR 0.092, CI 0.016-0.542, p=0.008). Our study showed significantly better outcomes in pain improvement in appendicular lesions compared to the axially located lesions (p = 0.005). Patients with spinal lesions tend to have relatively poor pain relief than those with appendicular or pelvic lesions (p=0.007). Patients with nidus on histology had better pain alleviation compared to patients without nidus. The histological presence of nidus significantly reduces the chance of repeat interventions. The pain alleviation of OO following RFA is better in patients with appendicular lesions than spinal or axially located lesions

Background. Clinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants. Methods. Prospective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms. Results. Over 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4). Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing. Conclusion. Interim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment. Conflicts of interest. None. Sources of funding. This study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Aims. Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Methods. Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. Results. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. Conclusion. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769–774

The presence of metastatic bone disease (MBD) often necessitates major orthopaedic surgery. Patients will enter surgical care either through emergent or electively scheduled care pathways. Patients in a pain crisis or with an acute fracture are generally admitted via emergent care pathways whereas patients with identified high-risk bone lesions are often booked for urgent yet scheduled elective procedures. The purpose of this study is to compare the post-operative outcomes of patients who present through emergent or electively scheduled care pathways in patients in a Canadian health care system. We have conducted a retrospective, multicenter cohort study of all patients presenting for surgery for MBD of the femur, humerus, tibia or pelvis in southern Alberta between 2006 and 2021. Patients were identified by a search query of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or actual pathologic fracture in the Calgary, South and Central Alberta Zones. Subsequent chart reviews were performed. Emergent surgeries were defined by patients admitted to hospital via urgent care mechanisms and managed via unscheduled surgical bookings (“on call list”). Elective surgeries were defined by patients seen by an orthopaedic surgeon at least once prior to surgery, and booked for a scheduled urgent, yet elective procedure. Outcomes include overall survival from the time of surgery, hospital length of stay, and 30-day hospital readmission rate. We have identified 402 patients to date for inclusion. 273 patients (67.9%) underwent surgery through emergent pathways and 129 patients (32.1%) were treated through urgent, electively scheduled pathways. Lung, prostate, renal cell, and breast cancer were the most common primary malignancies and there was no significant difference in these primaries amongst the groups (p=0.06). Not surprisingly, emergent patients were more likely to be treated for a pathologic fracture (p<0.001) whereas elective patients were more likely to be treated for an impending fracture (p<0.001). Overall survival was significantly shorter in the emergent group (5.0 months, 95%CI: 4.0-6.1) compared to the elective group (14.9 months 95%CI: 10.4-24.6) [p<0.001]. Hospital length of stay was significantly longer in the emergent group (13 days, 95%CI: 12-16 versus 5 days, 95%CI: 5-7 days). There was a significantly greater rate of 30-day hospital readmission in the emergent group (13.3% versus 7.8%) [p=0.01]. Electively managed MBD has multiple benefits including longer post-operative survival, shorter length of hospital stay, and a lower rate of 30-day hospital readmission. These findings from a Canadian healthcare system demonstrate clinical value in providing elective orthopaedic care when possible for patients with MBD. Furthermore, care delivery interventions capable of decreasing the footprint of emergent surgery through enhanced screening or follow-up of patients with MBD has the potential to significantly improve clinical outcomes in this population. This is an ongoing study that will justify refinements to the current surgical care pathways for MBD in order to identify patients prior to emergent presentation. Future directions will evaluate the costs associated with each care delivery method to provide opportunity for health economic efficiencies

Introduction. Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique. Methods. This is a prospective observational case series of all patients who underwent surgical reconstruction of Charcot foot deformity in a single centre between June 2017 and June 2023. Patient demographics, smoking status, diabetic control and BMI were recorded. Outcomes were determined from case notes and included clinical outcomes (complications, return to theatre, amputation and mortality) radiological outcomes and patient reported outcomes. The follow up period was 1–7 years post operatively. Results. 42 reconstructions were included. At the time of surgery the mean age was 59.1 years (29 – 91 years), average HbA1c was 65.2 (33–103); this did not correlate with return to theatre rate. 4 procedures were internal fixation alone (9.5%), 3 external fixation alone (7.1%) and 35 were combined fixation (83.3%). At most recent follow up 7 patients were deceased (16.7%), 2 patients had ipsilateral amputations, 2 had contralateral amputations. 11 patients had issues with recurrent ulcerations. Excluding refreshing of frames and operations on the contralateral side, 17 patients (40%) returned to theatre. We aim to present a detailed analysis of the rate of post-operative complications, return to theatre, radiographic outcomes and patient reported outcomes. Conclusion. This is the largest UK based case series of hybrid type Charcot joint reconstructions and shows that hybrid fixation is a viable option for patients undergoing Charcot joint reconstruction. To best confirm findings and determine which patients have the best post-operative prognosis a larger multi-centre study is required

Introduction and Objective. Kinematic Alignment (KA) is a surgical technique that restores the native knee alignment following Total Knee Arthroplasty (TKA). The association of this technique with a medial pivot implant design (MP) attempts to reestablish the physiological kinematics of the knee. Aim of this study is to analyze the clinical and radiological outcomes of patients undergoing MP-TKA with kinematic alignment, and to assess the effect of the limb alignment and the orientation of the tibial component on the clinical outcomes. Materials and Methods. We retrospectively analyzed 63 patients who underwent kinematic aligned medial pivot TKA from September 2018 to January 2020. Patient-Related Outcomes (PROMs) and radiological measures were collected at baseline, 3 months and 12 months after surgery. Results. We demonstrated a significant improvement in the clinical and functional outcomes starting from 3 months after surgery. This finding was also confirmed at the longest follow-up. The clinical improvement was independent from the limb alignment and from the orientation of the tibial component. The radiological analysis showed that the patient's native limb alignment was restored, and that the joint line orientation maintained the parallelism to the floor when standing. This latter result has a particular relevance, as it may positively influence the outcomes, reducing the risk of wear and mobilization of the implant. Conclusions. The association of kinematic alignment and a medial pivot TKA implant allows for a fast recovery, good clinical and functional outcomes, independently from the final limb alignment and the tibial component orientation

Abstract. Objectives. Outcomes following different types of surgical intervention for FAI are well reported individually but comparative data is deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyse the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO) and surgical hip dislocation (SHD). Methods. This SR was registered with PROSPERO. An electronic database search of Pubmed, Medline and EMBASE for English and German language articles over the last 20 years was carried out according to the PRISMA guidelines. We specifically analysed and compared changes in patient reported outcome measures PROMs, α-angle, rate of complications, rate of revision and conversion to total hip arthroplasty (THA). Results. A total of 48 articles included for final analysis with a total of 4384 hips in 4094 patients. All subgroups showed a significant correction in mean alpha angle post-operatively with a mean change of 28.8° (95% CI, 21°-36.5°; p <0.01) after AMO, 21.1° (95% CI, 15.1°-27°; p <0.01) after SHD and 20.39° (95% CI, 15.66°-25.12°; p <0.01) after HA. AMO group showed a significantly higher increase in PROMs (3.7; 95% CI, 3.2–4.2; p <0.01) versus arthroscopy (2.47; 95% CI, 2.22–2.73; p <0.01) and SHD (2.4; 95% CI, 1.5–3.3; p <0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. Conclusion. All three surgical approaches offered significant improvements in outcomes and radiological correction of cam deformities. All three groups showed similar rates of revision procedures and SHD had the highest rate of conversion to a THA. Revision rates was similar for all three revision procedures

Aims. The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018 by Westerman et al. Excellent results were reported at a minimum of ten years for the first 540 cases performed at the designer centre in the Exeter NHS Trust, with stem survivorship of 96.8%. The aim of this current study is to report long-term outcomes and survivorship for the Exeter V40 stem in a non-designer centre. Methods. All patients undergoing primary total hip arthroplasty using the Exeter V40 femoral stem between 1 January 2005 and 31 January 2010 were eligible for inclusion. Data were collected prospectively, with routine follow-up at six to 12 months, two years, five years, and ten years. Functional outcomes were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Outcome measures included data on all components in situ beyond ten years, death occurring within ten years with components in situ, and all-cause revision surgery. Results. A total of 829 stems in 745 patients were included in the dataset; 155 patients (20.8%) died within ten years, and of the remaining 664 stems, 648 stems (97.6%) remained in situ beyond ten years. For the 21 patients (2.5%) undergoing revision surgery, 16 femoral stems (1.9%) were revised and 18 acetabular components (2.2%) were revised. Indications for revision in order of decreasing frequency were infection (n = 6), pain (n = 6), aseptic component loosening (n = 3), periprosthetic fracture (n = 3), recurrent dislocation (n = 2), and noise production (ceramic-on-ceramic squeak) (n = 1). One patient was revised for aseptic stem loosening. The mean preoperative WOMAC score was 61 (SD 15.9) with a mean postoperative score of 20.4 (SD 19.3) (n = 732; 88.3%). Conclusion. The Exeter V40 cemented femoral stem demonstrates excellent functional outcomes and survival when used in a high volume non-designer centre. Outcomes are comparable to those of its serially validated predecessor, the Exeter Universal stem. Cite this article: Bone Jt Open 2020;1-12:743–748

Outcomes following carpal tunnel release are generally favorable. Understanding factors that contribute to inferior outcomes may allow for strategies targeted at improving results in these patients. Our purpose was to determine if patients' underlying personality traits, specifically resiliency and catastrophization, impact their post-operative outcomes following carpal tunnel release. A prospective case series was performed. Based on our power analysis, 102 patients were recruited. Patients completed written consent, the Boston Carpal Tunnel Questionnaire (BCTQ), the Pain Catastrophizing Scale (PCS) and the Brief Resiliency Scale (BRS). A single surgeon, or his resident under supervision, then performed an open carpal release under local anaesthetic. Our primary outcome measure was a repeat BCTQ at three- and six-months. Univariate and multivariate analysis was performed to assess the correlation between PCS and BRS scores and final BCTQ scores. Forty-three and sixty-three participants completed the BCTQ at three and six months respectively. All patients showed improvement in their symptoms (p = 0.001). There was no correlation between patients PCS or BRS and the amount of improvement. There was also no correlation between PCS or BRS and the patients' raw scores at baseline or follow-up. Patients self-assessed resiliency and degree of pain catastrophization has no correlation with the amount of improvement they have three or six months post-operatively. Most patients improved following carpal tunnel release, and patients with low resiliency and high levels of pain catastrophization should expect comparable outcomes to patients without these features

Aims. Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). Methods. We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Results. Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Conclusion. Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735–1742

A significant portion of ankle arthroplasty and ankle arthrodesis procedures performed in British Columbia are funded by the public medical services plan (MSP). However, some patients are treated privately through self-pay or by the workers compensation board (WCB), with the latter two groups being more likely to receive treatment sooner. The potential effect of payer on patient-reported outcomes and reoperation rates has not been previously explored. A retrospective chart review was performed using data from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. N=443 patients (393 MSP, 26 self-pay, 24 WCB), treated with total ankle replacement or ankle arthrodesis by three subspecialty-trained surgeons in Vancouver from 1999–2003, were analyzed. Outcomes were compared, by payer, preoperatively and at long-term follow-up (6.3 years, range 2–14 years). Function was assessed using the Ankle Osteoarthritis Scale (AOS) Total score (primary outcome) and the AOS Pain and Difficulty subscores. Expectation and satisfaction with symptoms was assessed using the Musculoskeletal Outcomes Data Evaluation and Management Scale, and physical and emotional quality of life was assessed using the Short Form-36 (SF-36) Health Survey in terms of the mental component summary (MCS) and physical component summary (PCS). Swelling and reoperation rates were also compared. AOS Total score was not significantly different between payers. WCB patients had significantly worse preoperative AOS Difficulty scores (73, 95%CI 65–80) compared to MSP (65, CI 63–67) and self-pay patients (56, CI 49–63)(p < 0 .008). Their SF-36 MCS scores were also significantly worse pre- and postoperatively (WCB: 43, CI 38–49, 45, CI 40–50, MSP: 51, CI 50–52, 51, CI 50–52, self-pay: 51, CI 46–56, 54, CI 49–58)(p < 0 .03). AOS Pain scores and SF-36 PCS scores were not different. Pre- and postoperatively, MSP patients reported more satisfaction with symptoms (1.31, CI 1.24–1.38, 3.21, CI 3.07–3.35), compared to WCB (1.13, CI 0.84–1.41, 2.83, CI 2.26–3.41) and self-pay patients (1.19, CI 0.91–1.47, 2.88, CI 2.33–3.44). Preoperatively, WCB patients had the lowest expectations (76, CI 69–84), the worst AOS Total (64, CI 57–71) and SF-36 scores (MCS 43, CI 38–49, PCS 28, CI, 25–32), and the most swelling (3.5, CI 3.1–4). Conversely, self-pay patients had the highest preoperative expectations (88, CI 81–95), the best AOS Total (53, CI 46–60) and SF-36 scores (MCS 51, CI 46–56, PCS: 34, CI 30–37) and the least swelling (3, CI 2.6–3.4). Postoperatively, WCB and self-pay patients had lower expectations met (35, CI 23–47 and 40, CI 28–51) and worse AOS Total scores (36, CI 27–45 and 35, 26–43), compared to MSP patients (Expectations: 29, CI 26–32, AOS Total: 31, CI 29–33). Reoperation rates were similar among groups. WCB patients had significantly more difficulty with symptoms prior to surgery and worse SF-36 MCS scores pre- and postoperatively. The preoperative expectations of WCB patients were lowest, while those of self-pay patients were highest. Both groups had lower expectations met postoperatively

Aims. The objective of this systematic review was to describe trapeziectomy outcomes and complications in the context of osteoarthritis of the base of the thumb after a five-year minimum follow-up. Methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide study design, and 267 full-text articles were assessed for eligibility. After exclusion criteria application, 22 studies were included, involving 728 patients and 823 trapeziectomies. Outcomes included pre- and postoperative clinical and radiological characteristics. Complications and revisions were recorded. Results. All the studies reported good results regarding pain and range of motion at the last follow-up of 8.3 years (5 to 22); the mean satisfaction rate was 91% (84% to 100%). It was difficult to assess the impact on metacarpophalangeal joint motion in extension with contrary results. The key pinch returned to its preoperative values, whereas tip pinch showed a modest improvement (+14%), with a mild improvement found in grip strength (+25%) at the last follow-up. The mean progressive trapezial collapse was 48% (0% to 85%) and was not correlated with pain, grip strength, or satisfaction. The most represented complications were linked to tendons or nerves affected during additional procedures to stabilize the joint (11.6%; n = 56). Mechanical complications included symptomatic scapho-M1 impingement (3.1%; n = 15/580), leading to nine surgical revisions out of 581 trapeziectomies. Meta-analysis was not possible due to study heterogeneity and limited data. Conclusion. After a minimum five-year follow-up, trapeziectomy achieved high patient satisfaction and pain relief. However, strength seemed to be deteriorating with detrimental consequences, but this did not correlate with trapezial collapse. The issues related to underestimating mechanical complications and varying degrees of success should be highlighted in the information given to patients. Evidence-based analyses should help the surgeon in their decision-making. Cite this article: Bone Jt Open 2021;2(3):141–149

Aims. The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up. Methods. Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening. Results. Mean OSS at mean follow-up of 6.67 years (5.0 to 10.74) was 40.12 (9 to 48), with no statistically significant difference between those implanted for a non-OA indication and those for OA (p = 0.056) or time-dependent deterioration between two years and five years (p = 0.206). Ranges of motion significantly improved compared with preoperative findings and were maintained between two and five years with a mean external rotation of 38° (SD 18.1, 0 to 100) and forward elevation of 152° (SD 29.9, 90 to 180). Of those components with radiographs suitable for analysis (n = 83), 23 (28%) were found to have a least one humeral radiolucent line, which were predominantly incomplete, less than 2 mm, and in a single anatomical zone. No humeral components were loose. A radiolucent line was present around 22 (15%) of glenoid components, and 15 (10%) of components had failed. Rotator cuff failure was found in 21 (15%) components. The mean time to either glenoid or rotator cuff failure was greater than three years following implantation. Survivorship was 96.4% (95% CI 91.6 to 98.5, number at risk 128) at five years, and 94.3% (95% CI 88.2 to 97.3, number at risk 76) at seven years, both of which compare favourably with best results taken from available registries. Conclusion. Functional and radiological outcomes of the Eclipse stemless TSA are excellent, with no loose humeral components at minimum five-year follow-up. The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. Of the eight revisions required, this was predominantly for glenoid and rotator cuff failure. Cite this article: Bone Joint J 2022;104-B(1):83–90

The primary aim was to assess patient-reported outcomes following a humeral diaphyseal fracture. The secondary aim was to compare the outcomes of patients who achieved union after initial management (operative or non-operative) with those that achieved union after nonunion surgery. From 2008–2017, 291 patients (mean age 55yrs [17–86], 58% [n=168/291] female) were retrospectively identified and available to complete a survey. Sixty-four (22%) were managed with primary surgery and 227 (78%) non-operatively. Outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12) were obtained at a mean of 5.5yrs (1.2–11.0). After initial management, 229 patients (79%) united (n=62 operative, n=167 non-operative) and 62 (21%) developed a nonunion (n=2 operative, n=60 non-operative; p<0.001). Fifty-two of 56 patients (93%) achieved union after nonunion surgery. The overall mean QuickDASH was 20.8, EQ-5D 0.730, EQ-VAS 74, SF-12 PCS 44.8 and MCS 50.2. Patients who united after nonunion surgery reported a worse functional outcome (mean QuickDASH 27.9 vs. 17.6, p=0.003) and health-related quality of life (HRQoL; mean EQ-5D 0.639 vs. 0.766, p=0.008; EQ-VAS 66 vs. 76, p=0.036; SF-12 PCS 41.8 vs. 46.1, p=0.036) than those who united primarily. When adjusting for confounders, union after nonunion surgery was independently associated with poorer function (difference in QuickDASH 8.1, p=0.019) and HRQoL (difference in EQ-5D -0.102, p=0.028). Humeral diaphyseal union after nonunion surgery was associated with poorer function and HRQoL compared to patients who united primarily. Targeting early operative intervention to patients at risk of nonunion may have an important role, given the potential impact of nonunion on longer-term outcome

Aims. Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens. Patients and Methods. MEDLINE, Web of Science, Embase, and Scopus databases were searched for studies reporting outcomes following ankle arthrodesis, in which standardized postoperative rehabilitation regimens were employed. Eligible studies were grouped according to duration of postoperative nonweightbearing: zero to one weeks (group A), two to three weeks (group B), four to five weeks (group C), or six weeks or more (group D). Outcome data were pooled and compared between groups. Outcomes analyzed included union rates, time to union, clinical scores, and complication rates. Results. A total of 60 studies (2426 ankles) were included. Mean union rates for groups A to D were 93.2%, 95.5%, 93.0%, and 93.0%, respectively. Mean time to union was 10.4 weeks, 14.5 weeks, 12.4 weeks, and 14.4 weeks for groups A to D, respectively. Mean complication rates were 22.3%, 23.0%, 27.1%, and 28.7% for groups A to D, respectively. Reporting of outcome scores was insufficient to conduct meaningful analysis. Conclusion. Outcomes following ankle arthrodesis appear to be similar regardless of the duration of postoperative nonweightbearing, although the existing literature is insufficient to make definitive conclusions. Cite this article: Bone Joint J 2019;101-B:1256–1262

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

Introduction. The effect of using thicker liners in primary total knee arthroplasty (TKA) on functional outcomes and aseptic failure rates remains largely unknown. As such, we devised a multicenter study to assess both the clinical outcomes and survivorship of thick vs thin liners after primary TKA. Methods. A search of our institutional databases was performed for patients having undergone bilateral (simultaneous or staged) primary TKA with similar preoperative and surgical characteristics between both sides. Two cohorts were created: thick liners and thin liners. Outcomes collected were as follows: change in Knee Society Score (DKSS), change in range of motion, and aseptic revision. Ad hoc power analysis was performed for DKSS (α ¼ 0.05; power ¼ 80%). Differences between cohorts were assessed. Results. 195 TKAs were identified for each cohort. DKSS and change in range of motion in the thin vs thick cohorts were similar: 51.4 vs 51.6 (P ¼ .86) and 11.1 vs 10.0 (P ¼ .66), respectively. No difference in aseptic revision rates were observed between thin and thick cohorts: all cause (4.1%, 3.1%; P ¼ .59), aseptic loosening (0.5%, 0.5%; P ¼ 1.0), instability (0.5%, 0.5%; P ¼ 1.0), all-cause revision for stiffness (3.1%, 2.1%; P ¼ .52), manipulation under anesthesia (2.1%, 2.1%; P ¼ 1.0), and liner exchange (0.5%, 0%; P ¼ .32). Conclusion. The results of this study suggest that both rates of revision surgery and clinical outcomes are similar for TKAs performed with thick and thin liners. Preoperative factors are likely to play an important role in liner thickness selection, and emphasis should be placed on ensuring sound surgical technique

Introduction. Cementless total knees were historically associated with early failure. These failures, likely associated with implant design, made cemented total knee arthroplasty (TKA) the “gold standard”. Manufacturers have introduced newer uncemented technologies that provide good initial stability and utilize a highly-porous substrates for bony in-growth. Outcome data on these implants has been limited. In addition, these implants typically have a price premium which makes them difficult to use in the setting of cost containment and in at risk 90-day bundles. Our purpose was to compare 90-day outcomes of a new uncemented implant with those of a comparable cemented implant from the same manufacturer. We hypothesized that the implants would have equivalent 90-day clinical and economic outcomes. Methods. Ninety-day clinical and economic outcomes for 252 patients with prospectively collected data from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database were reviewed. Ninety-day outcomes were compared between uncemented knees and an age-matched group of cemented knees (Triathlon cemented vs uncemented Triathalon-tritanium, Stryker Orthopedics, Mahwah, NJ, USA). Both cruciate retaining and posterior stabilized designs were included. MARCQI data: demographics, co-morbidities, length of stay, complications, emergency department visits, discharge disposition, and readmissions were reviewed. Financial data provided by the hospital's finance department was used for economic comparisons. Fischer's test was done to assess categorical data and a student's t-test was used to compare numerical data. Results. Uncemented knees had shorter length of stay (1.58 vs. 1.87, p<0.0001), were more frequently discharged home (90.48% vs. 68.75%; p<0.0001) and used less home care or extended care facilities (6.35% vs. 19.14%, p<0.0001; 2.78% vs. 11.72%, p=0.0001). More uncemented knees had “no complications”. Moreover, there were no reoperations in uncemented knees, compared to 19 reoperations in cemented knees most being manipulations (14 vs. 0, p=0.0028). Uncemented knees scored better than age matched counterparts Knee Injury and Osteoarthritis Outcomes Score (63.69 vs. 47.10, n=85 and 43, p<0.0001), and Patient Reported Outcomes Measurement Information System T-physical and T-mental (44.12 vs. 39.45, n=95 and 59, p<0.0001; 51.84 vs 47.82, n=97 and 59, p=0.0018). Cemented cases were more expensive overall, the surgical costs were higher ($6806.43 vs. $5710.78 p<0.01) and the total hospital costs were higher ($8347.65 vs. $7016.11 p<0.01). The 90-day readmission and hospital outpatient costs were not significantly different between the designs. Conclusion. The use of a modern uncemented TKA implants has increased, but data on outcomes and the economic impact has been limited particularly in regard to 90-day at risk global periods. Our study suggests that patients receiving an new uncemented TKA have a shorter length of stay, higher rate of discharge to home, better patient reported outcome measures, fewer complications and fewer reoperations than an age-matched group of patients receiving a similar, cemented design during the 90-day global period. Importantly, the uncemented knees had $1,095 less surgical episode costs (p< 0.001) and a 90-day cost savings of over $1,300 (p< 0.001). Uncemented TKA, when utilizing modern technologies, is successful and economically viable for an at-risk bundle. The results of this study should alleviate fears increased cost, early failure, complications or poor outcomes with the use of a modern uncemented TKA

Aims

The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Background. Total hip arthroplasty (THA) is a highly successful procedure, yet access to arthroplasty is limited in many developing nations. In response, organizations around the world have conducted service trips to provide international arthroplasty care to underserved populations. Little outcomes data are currently available related to these trips. We present a 1-year follow up. Methods. We completed an arthroplasty service trip to Brazil in 2017 where we performed 46 THAs on 38 patients. Patient demographic data, comorbidity profile, complication data, and pre- and postoperative Modified Harris Hip Score (mHHS), PROMIS Short Form Pain (SF-Pain), PROMIS Short Form Physical Function (SF-Function), and HOOS Jr scores were collected. Outcomes were collected postoperatively at 2, 6, and 12 weeks and 1 year. A multivariate regression analysis was performed to identify associations between patient factors and 12-week outcomes. Results. The mean patient age was 48.8 years. 47% were female. 30 patients had a unilateral THA and 8 had bilateral simultaneous THA (table 1). 61% of patients had a preoperative diagnosis of osteoarthritis (OA), 13% avascular necrosis, 13% post-traumatic OA, 8% developmental hip dysplasia, and 5% rheumatoid arthritis. Mean pain duration was 1–5 years for 45% of patients and >5 years for 55% of patients. The mean mHHS, HOOS, PROMIS SF-Pain and PROMIS SF-Function all improved significantly compared to baseline at 2, 6, 12 weeks and 1 year post-operatively (table 2, figure 1 & 2). At 1 year, only 11 of 38 patients (29%) were reachable by phone for follow up. The mobile phones were out of service for 27 of 38 patients (71%). Multivariate regression analysis did not reveal any associations at 12 weeks between patient reported outcomes and age, gender, pain duration, preoperative diagnosis or unilateral versus bilateral surgery (table 3). Conclusion. We found that patients in a developing country benefitted significantly from THA when performed by a visiting surgical team. Outcomes were similar to those seen in the United States. Of those that could be contacted, outcomes were stable at 1 year. This study highlights the difficulty of following patients in developing countries once they leave the hospital. Methods need to be developed to assure that the outcomes of these potentially valuable procedures can be determined. We are currently establishing the capability of using email and smart phone applications linked through email addresses to improve follow up on future missions

Essex-Lopresti injuries are often unrecognized acutely with resulting debilitating adverse effects. Persistent axial forearm instability may affect load transmission at both the elbow and wrist, resulting in significant pain. In the setting of both acute and chronic injuries metallic radial head arthroplasty has been advocated, however there is little information regarding their outcome. The purpose of this study was to assess the efficacy of a radial head arthroplasty to address both acute and chronic Essex-Lopresti type injuries. A retrospective review from 2006 to 2016 identified 11 Essex-Lopresti type injuries at a mean follow-up of 18 months. Five were diagnosed and treated acutely at a mean of 11 days (range, 8 to 19 days) from injury, while 6 were treated in a delayed fashion at a mean of 1.9 years (range, 2.7 months to 6.2 years) from injury with a mean 1.5 (range, 0 to 4) prior procedures. The cohort included 10 males with a mean age was 44.5 years (range, 28 to 71 years). A smooth stem, modular radial head arthroplasty was used in all cases. Outcomes included range of motion and radiographic findings such as ulnar variance, capitellar erosion, implant positioning and implant lucency using a modification of the method described by Gruen. Reoperations, including the need for ulnar shortening osteotomy, were also recorded. Three patients in each group (55%) reported persistent wrist pain. The mean ulnar variance improved from +5 mm (range, 1.8 to 7 mm) to +3.7 mm (range, 1 to 6.3 mm) at the time of final follow-up or prior to reoperation. Three (50%) patients in the chronic group underwent a staged ulnar shortening osteotomy (USO) to correct residual ulnar positive variance and to manage residual wrist pain. There were no reoperations in the acute group. Following USO, the ulnar variance in those three cases improved further to +3.5, +2.1, and −1.1 mm. No radial head prostheses required removal. Capitellar erosion was noted in five (45%) elbows, and was rated severe in one, moderate in two, and mild in two. Lucency about the radial head prosthesis stem was noted in eight (73%) cases, and rated as severe in 2 (18%), based on Gruen zones. Treatment of acute and chronic Essex-Lopresti lesions with radial head arthroplasty often results in persistent wrist pain. In the chronic setting, a planned USO was often necessary to restore axial forearm stability after radial head arthroplasty. Essex-Lopresti lesions represent a rare clinical entity that are difficult treat, particularly in the chronic setting. Early recognition and management with a smooth stem modular radial head arthroplasty may provide improved outcomes compared to chronic reconstruction

Introduction. The association between preoperative opioid use and adverse outcomes after total hip arthroplasty (THA) has been reported. However, a quantitative assessment used to evaluate the combined effect of controlled substance use and define a threshold for adverse outcomes after THA has not been established. The current study aimed to identify the association between the NarxCare Score (NCS) (indicative of controlled substance use) and length of stay (LOS), discharge disposition, 90-day emergency department (ED) visits, readmission, and reoperation after primary THA, necessary to identify a preoperative NCS threshold for adverse outcomes. Methods. A total of 2,787 THAs (57.3% female; mean age: 64.3±11.14 years; NCS range: 0–800) were performed between November 2018-January 2020 at an integrated healthcare system with preoperative NCSs. Outcomes assessed included LOS, discharge disposition, 90-day ED visits, readmission (all-cause, procedure and non-procedure-related) and reoperation. The association between NCS category (in 100-point increments) and was analyzed through multivariate logistic regression accounting for risk factors. Results. NCS of zero, 1–99 and 100–199 were similar regarding all investigated outcomes (p>0.05 for all). Compared to a NCS of zero, NCS of 300–399 was independently associated with higher odds of a LOS >2 days (odds ratio [OR]:2.27; 95% confidence interval [CI][1.59–3.24]; p<0.001), non-home discharge (OR: 2.0; 95% CI [1.34–2.99]; p=0.001), 90-day all-cause readmission (OR: 2.0; 95% CI [1.16–3.36]; p=0.012). Furthermore, NCS of 300–399 exhibited higher odds of a procedure-related readmission (OR: 3.74; 95% CI [1.48–8.13]; p=0.004). There were no differences between the NCS strata in 90-day reoperation and non-procedure related readmission rates (p>0.05 for each). Conclusion. Higher NCS was associated with greater LOS and 90-day readmission, as well as lower odds of discharge to home. A NCS threshold of 300 can potentially designate high-risk patients for adverse outcomes after THA. This score may help stratify patients in the current alternative payment environment

Introduction. Although we know that smoking damages health, we do not know impact of smoking on a patient's outcome following primary knee arthroplasty (KA). In the UK, clinical commissioning groups (CCGs) have the authority (& funds) to commission healthcare services for their communities. Over the past decade, an increasing number of CCGs are using smoking as a contraindication for patients with end-stage symptomatic knee arthritis being referred to a specialist for due consideration of KA without any clear evidence of the associated risks & benefits. The overall objective of this study is to compare clinical outcomes after knee arthroplasty surgery in smokers, ex-smokers & non-smokers. Methods. We obtained data from the UK Clinical Research Practice Datalink (CPRD) that contains information on over 11 million patients (7% of the UK population) registered at over 600 general practices. CPRD data was linked to Hospital Episode Statistics, hospital admissions & Patient Reported Outcome Measures (PROMs) data. We collected data on all KAs (n=64,071) performed over a 21-year period (1995 to 2016). Outcomes assessed included: local & systemic complications (at 6-months post-surgery): infections (wound, respiratory, urinary), heart attack, stroke & transient ischaemic attack, venous thromboembolism, hospital readmissions & GP visits (1-year), analgesic use (1-year), surgical revision (up to 20-years), mortality (90-days and 1-year), & 6-month change from pre-operative scores in Oxford Knee Score (OKS). Regression modelling is used to describe the association of smoking on outcomes, adjusting for confounding factors. Results. Smoking was associated with an increased risk of lower respiratory tract infections (LRTI) (4.2% smokers vs. 2.7% non-smokers) (Odds Ratio (OR) 0.76, p-value 0.017). LRTI were similar in ex-smokers & smokers at 3.9%. There was no association with any of the other 6-month complications. Pain medication use over 1-year post surgery was higher in smokers compared to non-smokers: gabapentinoids 7.4% vs. 5.2% (OR 0.74, p< 0.001), opioids 45.9% vs. 35.3% (OR 0.79, p< 0.001), NSAIDs 51.6% vs. 46.1% (OR 0.91, p = 0.044). Mortality was higher in smokers at 1-year compared to non-smokers (hazard ratio (HR) 0.53, p<0.001) & ex-smokers (HR 0.65, p = 0.037), but there was no difference observed at 90-days. There was no association of smoking on revision surgery over 20-years follow up. Smoking was associated with worse postoperative OKS being 3.1 points higher in non-smokers (p<0.001) & 3.0 points higher in ex-smokers (p<0.001). The overall change in OKS before & after surgery was 13.9 points in smokers versus 16.3 points in non-smokers (p<0.001) & 15.7 points in ex-smokers (p<0.001). Over the year following surgery, smokers were more likely to visit their GP, but there was no association with hospital readmission rates. Conclusion. This is the largest study with linked primary care & secondary care data highlighting impact of a preventable patient factor on outcome of a routinely performed planned intervention. Smokers achieved clinical meaningful improvements in patient reported pain & function (OKS) following KA, although their attained post-operative OKS was lower than in non-smokers & ex-smokers. Levels of pain medication use were notably higher in both smokers & ex-smokers. As smokers achieved good clinical outcomes following KA surgery, smoking should not be a barrier to referral for or consideration of KA. However, the study does highlight particular risks a patient is taking if he/she continues to smoke when being considered for elective knee arthroplasty. This study will help the family physicians as well as patients to make an informed decision on whether to go ahead with a planned intervention whilst patient continues to be an active smoker or not. Key Words: Knee Arthroplasty, Smoking, Patient Reported Outcomes, Epidemiology, Complications

Aims. Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA. Methods. This was a single institution registry review of prospectively gathered data from 341 cementless Triathlon Tritanium TKAs at four to 6.8 years follow-up. Outcomes were determined by comparing pre- and postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores, and pre- and postoperative 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores. Aseptic loosening and revision for any reason were the endpoints which were used to determine survivorship at five years. Results. At mid-term follow-up, the mean KOOS JR score improved significantly from 33.14 (0 t0 85, standard deviation (SD) 21.88) preoperatively to 84.12 (15.94 to 100, SD 20.51) postoperatively (p < 0.001), the mean VR/SF-12 scores improved significantly from physical health (PH), 31.21 (SD 5.32; 23.99 to 56.77) preoperatively to 42.62 (SD 10.72; 19.38 to 56.82) postoperatively (p < 0.001) and the mental health (MH), 38.15 (SD 8.17; 19.06 to 60.75) preoperatively to 55.09 (SD 9.64; 19.06 to 66.98) postoperatively (p < 0.001). A total of 11 revisions were undertaken, with an overall revision rate of 2.94%, including five for periprosthetic joint infection (1.34%), three for loosening (0.80%), two for instability (0.53%), and one for pain (0.27%). The overall survivorship was 97.06% and survivorship for aseptic loosening as the endpoint was 98.40%, with a 99.5% survivorship of the 3D-printed tibial component. Conclusion. This 3D-printed cementless total knee system shows excellent survivorship at mid-term follow-up. This design and the ability to obtain cementless fixation offers promise for excellent long-term durability. Cite this article: Bone Joint J 2021;103-B(6 Supple A):32–37

Chronic massive irreparable rotator cuff tears represent a treatment challenge and the optimal surgical technique remains controversial. Superior capsular reconstruction (SCR) has been proposed as a means to provide superior stability to the glenohumeral joint, thus facilitating restoration of shoulder function. However, despite the growing use of SCR there is a paucity of data evaluating the outcomes when performed using a dermal allograft. The purpose of this study was to (1) report the overall survival rate (reoperation and clinical failure) of SCR (2) evaluate for pre-operative factors predicting reoperation and clinical failure. From January 1, 2015 to November 31, 2017, 65 patients were diagnosed with irreparable rotator cuff tears and consented for a superior capsular reconstruction. These surgeries were performed by 6 surgeons, all fellowship trained in either sports or shoulder and elbow fellowships. Outcomes were graded as excellent, satisfactory, or unsatisfactory using the modified Neer scale. An unsatisfactory result was defined as a clinical “failure”. The Kaplan-Meier survival models were created to analyze reoperation-free and failure-free survival for the entire group. The reconstruction was performed using a dermal allograft. There were 31 patients excluded due to insufficient follow-up (< 6 months), leaving 34 included in this study. The mean follow-up was 12 months (range, 6–23). The average number of prior surgeries was 0.91 (range, 0–5), with 52.9% of patients receiving a prior rotator cuff repair and 38.2% of patients with a prior non-rotator cuff arthroscopy procedure. The one and two-year survival-free of surgery was 64% and 44% and the one and two-year survival free of failure was 34% and 16% following SCR, respectively. For the patients that underwent a reoperation, 62.5% (n= 5/8) underwent reverse shoulder replacements, 25% (n= 2/8) latissimus dorsi tendon transfers, and 12.5% (n= 1/8) a diagnostic arthroscopy. The average period between the primary and revision surgery was 10.2 months (range, 2.1–18.5). All but two patients (75%, n= 6/8) had at least one surgery prior to the SCR. There were 14/34 (41.2%) patients who experienced pain, weakness, and restricted range of motion. These patients were defined as clinical failures with an unsatisfactory grading on Neer's criteria. Previous surgery predicted reoperation (80% vs 43%, p = 0.03). Female gender predicted clinical failure (100% vs 43%, p < 0 .01). Superior Capsule Reconstruction performed for large to massive rotator cuff tears has a high rate of persistent pain and limited function leading to clinical failure in 65% (n= 22/34) of patients. The rate of failure is increased in revision cases, female gender and increased Goutallier fatty infiltration of the infraspinatus. Narrowed indications are recommended given the surgical complexity and high rate of early failure

To compare 24-month patient-reported outcomes after surgical treatment or casting in patients age 60 years of age or older with unstable distal radius fractures (DRF's). The Wrist and Radius Injury Surgical Trial (WRIST), is the largest randomized, multicenter trial in Hand Surgery, which enrolled 304 adults with isolated, unstable DRF's at 24 institutions. WRIST participants were followed for 24 months- longest follow-up among prospective studies comparing four treatment methods. Patients who agreed to surgical treatment (n=187) were randomized to internal fixation with volar plate (VLPS), external fixation, or percutaneous pinning; patients who preferred conservative management (n=117) received casting. The primary outcome was 24-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes were MHQ Domain scores. At 24-month assessment, participants' mean MHQ Summary score was 86 (95% CI: 83,88), representing good hand function. Participants reported good return of their Activities of Daily Living (ADLs) with a mean MHQ ADL score of 88 (95% CI: 85,91). Finally, participants were satisfied, with a mean MHQ Satisfaction score of 84 (95% CI: 80,88). There were no significant differences in score by treatment group in any MHQ domain at 24 months. Six weeks after surgery, VLPS participants scored significantly higher than the other three groups on (ADLs) and Satisfaction (both p<0.0001), whereas participants who received external fixation scored significantly lower than the casting and VLPS groups on the same domains. By the 3-month assessment, the gap between VLPS and casting had disappeared but external fixation participants continued to report significantly worse scores. External fixation participants did not report comparable ADL scores to the other three groups until 12 months after surgery. Participants reported good outcomes 24 months after DRF regardless of treatment. Casting and VLPS are both acceptable treatments for older adults. The decision between the two treatments should be made considering patient goals regarding recovery speed and desire to avoid surgical risks. External fixation should be avoided because of worse outcomes in the year after surgery and the risk of pin site infections

There is evidence that preoperative physical fitness impacts surgical outcomes, specifically preceding abdominal, cardiovascular and spine surgery. To our knowledge, there are no papers on self-reported exercise frequency as a predictor of cervical spine surgery outcomes. Our objectives were to quantify self-report of exercise frequency in cervical spine surgery patients, and to elucidate if self-reported exercise prior to surgery confers less pain, improved health state and/or less disability post-surgery. We performed a retrospective review of prospectively collected data from the Canadian Spine Outcomes and Research Network (CSORN) Database from the time of its inception. Inclusion criteria specified all elective cervical surgery patients over 18 years old with degenerative pathology who proceeded to surgery and completed the pre- and post-operative outcomes measures up to 24 months post surgery (n=460). Outcome measures were visual analog scales (VAS) for neck and arm pain, Neck Disability Index (NDI), and EuroQOL score at baseline and 3, 12 and 24 months post-op. Exercise frequency was self-reported as “none” (n=212) versus “some” (n=248). These groups were further categorized into “none due to physical limitations”, “none” (not due to physical limitations), those to exercised “once or less per week” and those that exercised “twice or more per week”. Student's t-tests were used to compare the mean scores of the outcome measures, and analysis of variance for subgroup comparisons, with results considered significant at p < 0 .05. At baseline, 56% of total patients reported exercise prior to surgery, of which 73% reported doing so twice or more per week. Of the 44% reporting no exercise, 74% could not exercise due to physical limitations. Those who reported “some” exercise had more favorable VAS neck and arm pain scores pre-operatively (neck: 5.55 vs 6.11, p < 0 .001) (arm: 5.69 vs 6.04, p=0.011), but no difference at 3 and 24 months post-operatively. Significantly lower NDI scores and higher EuroQOL Index scores were seen in the exercise group compared to the no exercise group pre-operatively (NDI: 39 vs 48, p < 0 .001) (EuroQOL: 0.60 vs 0.50 p < 0 .001) as well as at 3, 12, and 24 months post-op (NDI: 24 vs 31, p=0.007) (EuroQOL: 0.75 vs 0.68, p=0.001). Further subgroup analysis demonstrated that compared to the “no exercise due to physical limitation” group, the “twice or more” exercise group showed favorable NDI and EuroQOL scores up to 24 months post-op (NDI: 24.32 vs 32.33, p=0.001) (EuroQOL: 0.76 vs 0.66, p=0.001), whereas the “once or less times per week” group no longer demonstrated any significant difference at 24 months (NDI: 28.79 vs 32.33, p=1) (EuroQOL: 0.73 vs 0.66, p=0.269). Self-reported exercise prior to cervical spine surgery does not predict improved long-term neck and arm pain at 2 years post-op. However, self-reported exercise does demonstrate less disability and improved health state at baseline and up to 2 years post-op and this relationship is dose dependent

Proximal humerus fracture dislocations are amongst the most severe proximal humerus injuries, presenting a challenging management problem. The aim of this study was to report on the long-term outcomes of the management of proximal humerus fracture dislocations.

Patients with a proximal humerus fracture dislocation managed at a Level 1 trauma centre from January 2010 to December 2018 were included. Patients with an isolated tuberosity fracture dislocation or a pathological fracture were excluded. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, non-union/malunion, and avascular necrosis.

A total of 69 patients were included with a proximal humerus fracture dislocation in the study period; 48 underwent surgical management and 21 were managed with closed reduction alone. The mean (SD) age of the cohort was 59.7 (±20.4), and 54% were male. Overall patients reported a mean OSS of 39.8 (±10.3), a mean EQ-5D utility score of 0.73 (±0.20), and 78% were able to return to work at a median of 1.2 months. There was a high prevalence of complications in both patients managed operatively or with closed reduction (25% and 38% respectively). In patients undergoing surgical management, 21% required subsequent surgery.

Patient reported outcome measures post proximal humerus fracture dislocations do not return to normal population levels. These injuries are associated with a high prevalence of complications regardless of management. Appropriate patient counselling should be undertaken before embarking on definitive management.

Background. The purpose of this study was to report functional outcome scores following arthroscopic acetabular chondral procedures using the U.K. Non-Arthroplasty Hip Registry (NAHR). Methods. Data on adult patients who underwent hip arthroscopy between January 2012 and December 2018 was extracted from the NAHR. Patients who underwent femoral sided chondral procedures were excluded. Patients who underwent osteophyte excision or a concurrent extra-articular procedure were also excluded. Cases were then classified according to the acetabular chondral procedure performed – ‘chondroplasty’, ‘microfracture’ or ‘none’ (no chondral procedure recorded). 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 4,978 arthroscopies were identified (chondroplasty 26.4%, microfracture 5.4%, none 68.2%). Patients who underwent microfracture were significantly older (37.9y vs 37.3y) and of higher BMI (26.4 vs 25.8 kg/m2) than patients who underwent chondroplasty. Pre-operative, 6 and 12-month follow-up were available for 77%, 42% and 38% of cases respectively. This registry study found significant clinical improvement in all groups based on arthroscopic chondral procedure following hip arthroscopy. Patients who have microfracture seem to take longer to improve and have lower peak scores as compared with chondroplasty. All groups saw significant (p <0.0001) EQ-5D and iHOT-12 gain compared to pre-operative baseline scores at 6 months which was maintained at 12 months (12 month iHOT-12 gain: chondroplasty = +27.6 (95%CI 25.0 to 30.2), microfracture = +22.6 (95%CI 17.6 to 27.6), none = +25.4 (23.8 to 27.0)). There were no statistically significant between group differences in iHOT-12 gain. Comparing <40y vs >40y age groups, all saw significant improvements in baseline scores maintained up to 12 months however patients over 40y were slower to improve, particularly in microfracture with significantly poorer iHOT-12 gain at 6 months in comparison to patients under 40y but significance was lost by 12 months. Conclusion. Whilst patient selection is crucial (and we acknowledge selection bias as a key limitation), all three chondral procedures were effective at improving patient outcomes for both younger and older patients

Objectives. The aim of this study was to use registry data to report and compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum. Methods. Data on adult patients who underwent arthroscopic labral debridement or repair between January 2012 and March 2019 was extracted from the UK Non-Arthroplasty Hip Registry dataset. Patients who underwent microfracture, osteophyte excision or a concurrent extra-articular procedure were excluded. 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 3,553 arthroscopies comprising 1,986 labral debridement (56%) and 1,567 labral repairs (44%) were identified. Both groups saw significant (p <0.0001) EQ-5D and iHOT-12 gain compared to pre-operative baseline scores at 6 months (iHOT-12: repair = +27.4 (95%CI 25.2 to 29.5), debridement = +24.8 (95%CI 22.7 to 26.9)) which was maintained at 12 months (repair = +28.3 (95%CI 26.0 to 30.6), debridement = +24.3 (95%CI 22.0 to 26.5)) with improvement being significantly greater in the repair group by 12 months (p = 0.016) including after modelling for patient and surgical factors. Overall, 64% of cases achieved the minimum clinically important difference (MCID) and 47% achieved substantial clinical benefit (SCB: repair = 51%, debridement = 43%, p = 0.005) at 12 months. Significant functional improvement was seen for both genders and in younger and older (>40 years) cohorts. Conclusion. Both labral repair and debridement techniques were successful in significantly improving 12-month outcomes following hip arthroscopy regardless of age or gender. Labral repair was associated with superior outcomes in comparison to debridement. Whilst patient selection is crucial, our findings support the repair of an injured labrum where possible. A multi-centre randomised controlled trial would be the most appropriate next step to overcome bias inherent in the existing literature

Aims

Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m²) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m²) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach.

There is a lack of evidence as to the best way to deliver rehabilitation following TKA. Previous work has suggested that postoperative physiotherapy applied to all patients is not effective at improving one-year post-surgical outcomes. The aim of this study was to target physiotherapy to those at risk of poor outcome following TKA, and to determine if a therapist-led intervention offered superior results compared to a home-exercise based protocol in this ‘at risk’ group. The Targeted Rehabilitation to Improve Outcomes (TRIO) study was a prospective randomised controlled trial run at 15-centres in the UK. Patients were identified as ‘potential poor outcome’ based on an Oxford Knee Score (OKS) classification at 6-weeks post-surgery and randomised to either therapist-led or home-exercise based protocols. Patients were reviewed by a physiotherapist and commenced 18-exercise sessions over 6-weeks. The therapist-led group undertook a progressive functional protocol (modified weekly in 1-1 contact sessions) in contrast to the static home-exercise based regime. Evaluation took place following rehabilitation intervention, then at 6-months and 1-year post-surgery. Primary outcome was comparative group OKS at 1-year. Secondary outcomes included, ‘worst’ and ‘average’ pain scores, OXS and EQ-5D, and satisfaction questionnaire. Health economic (cost-utility) analysis was undertaken from NHS perspective up to 1-year post-surgery. Incremental cost per Quality Adjusted Life Years (QALYs) were calculated from intervention costs, patient reported primary and secondary care usage, and EQ-5D data. 4264 patients were screened, 1296 were eligible, 334 patients were randomised, 8 were lost to follow-up, therapy compliance was >85%. Clinically meaningful improvement in OKS (between baseline and 1-year) was seen in both arms (p < 0 .001). Between group difference in 1-year OKS was 1.91 (95%CI, −0.17–3.99) points favouring the therapist-led arm (p=0.07). Incorporating all time point data, between group difference in OKS was 2.25 points (95%CI, 0.61–3.90, p=0.008). Small, non-significant reductions (< 5 %) in both worst and average pain scores were observed favouring the therapist-led group. Enhanced satisfaction with pain relief (OR 1.65, p < 0 .02), ability to perform daily functional tasks (OR 1.66, p < 0 .02), and perform heavy functional tasks (OR 1.6, p=0.04) was reported in the therapist-led group. There was a small non-significant difference of 0.02 points (95%CI −0.02–0.06) between groups in EQ-5D, resulting in a £12,125 cost per QALY of delivering the therapist led intervention with a 57% chance of being cost-effective at the standard UK policy threshold of £20,000 per QALY. TRIO is the largest randomised trial of physiotherapy following TKA, and the first to target rehabilitation to patients at risk of poor outcomes. Both therapist-led and home-exercise based rehabilitation groups made clinically meaningful improvements in outcome by 1-year. We observed a modest difference in OKS in favour of therapist-led rehabilitation compared to the home-exercises which was not statistically significant. The relatively tight confidence intervals suggests that any difference which might exist is too small to be clinically relevant. Patient satisfaction with outcome was however higher in those that received greater physiotherapist contact. While cost per QALY estimates were below UK policy threshold, this result is uncertain and insufficient to make accept-decline recommendations