There have been no studies assessing the acceptability of opioid tapering in the pre-arthroplasty setting. This qualitative study aimed to (1) explore barriers and facilitators to opioid tapering amongst patients with chronic non-cancer pain (CNCP), and (2) explore the similarities and differences in acceptability of opioid tapering between pre-arthroplasty patients and those participating in a biopsychosocial pain management program.

From January 2021, adult participants diagnosed with CNCP and taking opioids daily (any dose at time of screening for a period of 3 months) were recruited from either Fairfield Orthopaedic Hip and Knee Service (FOHKS) or Liverpool Hospital Pain Clinic (LHPC). Semi-structured interviews underwent thematic analysis using the framework method.

17 participants were recruited (FOHKS, n=9, mean age 67, female 77%, LHPC, n=8, mean age 54, female 63%). Both groups had participants who; (i) were reluctant to use opioid medications and used them out of “necessity”, (ii) were reluctant to taper due to concerns of worsening pain, quality of life, (iii) believed opioids were “toxins” causing bodily harm. Some FOHKS participants believed tapering should be a post-operative focus, whilst others believed tapering opioids pre-operatively will assist in post-op pain management. Few LHPC participants felt dependent/addicted to opioids, thus driving their intention to taper opioids.

The belief of tapering opioids causing worse pain was based on either previous experiences or concerns alone. Some FOHKS participants were more inclined to taper opioids if they were educated on the chronic and peri-operative risks associated with using opioids at time of arthroplasty.

Opioid users recognise the harms associated with chronic opioid use and believe they are used out of desperation for adequate analgesia, function, and quality of life. Tapering opioids in the pre-arthroplasty context may need coupling with patient education highlighting the importance of opioid tapering pre-operatively.

Aims

Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge.

Abstract. Objective. Meta-analysis of clinical trials highlights that non-operative management of degenerative knee meniscal tears is as effective as surgical management. Surgical guidelines though support arthroscopic partial meniscectomy which remains common in NHS practice. Physiotherapists are playing an increasing role in triage of such patients though it is unclear how this influences clinical management and patient outcomes. Methods. A 1-year cohort (July 2019–June 2020) of patients presenting with MRI confirmed degenerative meniscal tears to a regional orthopaedic referral centre (3× ESP physiotherapists) was identified. Initial clinical management was obtained from medical records alongside subsequent secondary care management and routinely collected outcome scores in the following 2-years. Management options included referral for surgery, conservative (steroid injection and rehabilitation), and no active treatment. Outcome scores collected at 1- and 2-years included the Forgotten Joint Score-12 (FJS-12) questionnaire and 0–10 numerical rating scales for worst and average pain. Treatment allocation is presented as absolute and proportional figures. Change in outcomes across the cohort was evaluated with repeated measures ANOVA, with Bonferroni correction for multiple testing, and post-hoc Tukey pair-wise comparisons. As treatment decision is discrete, no direct contrast is made between outcomes of differing interventions but additional explorative outcome change over time evaluated by group. Significance was accepted at p=0.05 and effect size as per Cohen's values. Results. 81 patients, 50 (61.7%) male, mean age 46.5 years (SD13.13) presented in the study timeframe. 32 (40.3%) received conservative management and 49 (59.7%) were listed for surgery. Six (18.8%) of the 32 underwent subsequent surgery and nine of the 49 (18.4%) patients switched from planned surgery to receiving non-operative care. Two post-operative complications were noted, one cerebrovascular accident and one deep vein thrombosis. The cohort improved over the course of 2-years in all outcome measures with improved mean FJS-12 (34.36 points), mean worst pain (3.74 points) average pain (2.42 points) scores. Overall change (all patients) was statistically significant for all outcomes (p<0.001), with sequential year-on-year change also significant (p<0.001). Effect size of these changes were large with all Cohen-d values over 1. Controlling for age and BMI, males reported superior change in FJS-12 (p=0.04) but worse pain outcomes (p<0.03). Further explorative analysis highlighted positive outcomes across all surgical, conservative and no active treatment groups (p<0.05). The 15 (18%) patients that switched between surgical and non-surgical management also reported positive outcome scores (p<0.05). Conclusion(s). In a regional specialist physiotherapy-led soft tissue knee clinic around 60% of degenerative meniscal tears assessed were referred for surgery. Over 2-years, surgical, non-operative and no treatment management approaches in this cohort all resulted in clinical improvement suggesting that no single strategy is effective in directly treating the meniscal pathology, and that perhaps none do. Clinical intervention rather is directed at individual symptom management based on clinical preferences. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. Large-diameter metal-on-metal (MoM) total hip arthroplasty (THA) has demonstrated unexpected high failure rates and pseudotumour formation. The purpose of this prospective cohort study is to report ten-year results in order to establish revision rate, prevalence of pseudotumour formation, and relation with whole blood cobalt levels. Methods. All patients were recalled according to the guidelines of the Dutch Orthopaedic Association. They underwent clinical and radiographical assessments (radiograph and CT scan) of the hip prosthesis and whole blood cobalt ion measurements. Overall, 94 patients (95 hips) fulfilled our requirements for a minimum ten-year follow-up. Results. Mean follow-up was 10.9 years (10 to 12), with a cumulative survival rate of 82.4%. Reason for revision was predominantly pseudotumour formation (68%), apart from loosening, pain, infection, and osteolysis. The prevalence of pseudotumour formation around the prostheses was 41%, while our previous report of this cohort (with a mean follow-up of 3.6 years) revealed a 39% prevalence. The ten-year revision-free survival with pseudotumour was 66.7% and without pseudotumour 92.4% (p < 0.05). There was poor discriminatory ability for cobalt for pseudotumour formation. Conclusion. This prospective study reports a minimum ten-year follow-up of large-head MoM THA. Revision rates are high, with the main reason being the sequelae of pseudotumour formation, which were rarely observed after five years of implantation. Blood ion measurements show limited discriminatory capacity in diagnosing pseudotumour formation. Our results evidence that an early comprehensive follow-up strategy is essential for MoM THA to promptly identify and manage early complications and revise on time. After ten years follow-up, we do not recommend continuing routine CT scanning or whole cobalt blood measurements, but instead enrolling these patients in routine follow-up protocols for THA. Cite this article: Bone Jt Open 2022;3(1):61–67

Abstract. Introduction. Total knee replacement (TKR) is a successful operation for many patients, however 15–20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics. We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR. Methodology. Between 2016–2019, 363 patients with troublesome pain, ≤14 on Oxford Knee score pain subscale, at three months after TKR from eight NHS hospitals were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4). Results. At three months post-operative, 53% reported neuropathic pain on painDETECT and 74% on DN4. Half (56%) remained in neuropathic pain over the twelve-month follow-up period, 26% reported improvement, and 9% reported new neuropathic symtpoms or fluctuated in and out of neuropathic pain (9%). Overall mean neuropathic pain scores improved between three and 15 months after TKR. When the painDETECT cut-off score of ≥13(ambiguous/possible) was used, DN4 and painDETECT measures showed similar prevalence rates at each timepoint. Conclusion. Neuropathic pain is common among patients with CPSP at three months after TKR. Although symptoms improved over time, one quarter to one half of our cohort continued to report symptoms at fifteen months. We propose a painDETECT cutoff score of ≥13 be used to identify neuropathic features in the TKR population. Postoperative care should include identification, assessment, and treatment of neuropathic pain in patients with CPSP after TKR

Periprosthetic joint infections (PJIs) centers are garnering the attention of different arthroplasty surgeons and practices alike. Nonetheless, their value has yet to be proven. Therefore, we evaluated weather PJI centers produce comparable outcomes to the national average of THA PJIs on a national cohort. We performed a retrospective review of patient data available on PearlDiver from 2015 – 2021. PJI THA cases were identified through ICD-10 and CPT codes. Patients treated by 6 fellowship trained arthroplasty surgeons from a PJI center were matched based on age, gender, Charlson Comorbidity Index and Elixhauser comorbidity index at a 1:1 ratio to patients from the national cohort. Compared outcomes included LOS, ED visits, number of patients readmitted, total readmissions. Sample sized did not allow the evaluation of amputation, fusion or explantation. Normality was tested through the Kolmogorov-Smirnov test. And comparisons were made with Students t-tests and Chi Square testing. A total of 33,001 THA PJIs and were identified. A total of 77 patients were identified as treated by the PJI center cohort and successfully matched. No differences were noted in regard to age, gender distribution, CCI or ECI (p=1, 1, 1 and 0.9958 respectively). Significant differences were noted in mean LOS (p<0.43), number of patients requiring readmissions (p=0.001) and total number of readmission events (p<0.001). No difference was noted on ED visits. Our study demonstrates that a PJI for THA cases may be beneficial for the national growing trend of arthroplasty volume. Future data, that allows comparison of patient's specific data will allow for further validation of PJI centers and how these can play a role in helping the national PJI growing problem

Aim. Culture negative (CN) prosthetic joint infections (PJI) account for approximately 10% of all PJIs and present significant challenges for clinicians. We aimed to explore the significance of CN PJI within a large prospective cohort study, and to compare their characteristics and outcomes with culture positive cases. Methods. The Prosthetic joint Infection in Australia and New Zealand Observational (PIANO) study is a prospective, binational, multicentre observational cohort study conducted at 27 hospitals between July 2014 and December 2017. We compared baseline characteristics and outcomes of all patients with culture negative (CN) prosthetic joint infection (PJI) from the PIANO cohort with culture positive (CP) cases. “Treatment success” was defined as absence of clinical or microbiological signs of infection, no need for ongoing antibiotics, and no need for revision or resection arthroplasty since the end of the initial treatment. We also describe PJI diagnostic criteria in the CN cohort and apply internationally recognised PJI diagnostic guidelines. Results. Of the 650 patients eligible for inclusion, 55 (8.5%) were CN and 595 were CP. Compared with the CP cohort, CN patients were more likely to be female [32 (58.2%) vs 245 (41.2%); p=0.02], involve the shoulder joint [5 (9.1%) vs. 16 (2.7%); p=0.03] and have a lower mean C-reactive protein (142 mg/L vs. 187 mg/L; p=0.02). Overall, outcomes were superior in CN patients, with culture negativity an independent predictor of treatment success at 24 months (aOR 3.78; 95%CI 1.65 – 8.67). Of the 55 CN cases meeting Infectious Diseases Society of America (IDSA) diagnostic criteria, 45 (82%) met European Bone and Joint Infection Society (EBJIS) criteria (probable or definite) and 39 (71%) met the 2013 Musculoskeletal Infection Society (MSIS) criteria. Conclusions. Culture negativity is an independent predictor of treatment success in PJI. It is unclear whether this is because some of them are not actually infections, or for other reasons such as lower bacterial load or earlier effective antibiotic treatment. Diagnostic criteria for PJI vary substantially in their sensitivity, with MSIS criteria being the least sensitive. Acknowledgements. This work is being presented on behalf of the broader PIANO investigators and the Australasian Society for Infectious Diseases Clinical Research Network. The PIANO study received seed funding from Heraeus Medical and the John Hunter Hospital Charitable Trust Fund

Aims. Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method. Methods. We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed. Results. A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m. 2. (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively. Conclusion. In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38–45

We present a consecutive case cohort of the first 100 Birmingham Hip Resurfacing (BHR)'s in 90 patients with a minimum follow up of 20 years. All procedures were performed by a single surgeon having commenced the study in 1998. The original cohort included 68 males with 75 hips (7 bilateral) and 22 females with 25 hips (3 bilateral). The mean age at index procedure was 52. Patients were recalled to review in clinic as per Medicines and Healthcare products Regulatory Agency guidelines with x-rays, metal ions and Harris Hip Scores recorded. After a minimum of 20 year follow-up review the known overall revision rate is 11%. 11 have died and 7 have been lost to review. In males the known revision rate is 4/75 (5%), 3 of which were due to early fractures and 1 revision for infection at 5 years. The known revision rate in females is 7/25 (28%) of which 6 were due to adverse reactions to metal debris; 3 at 7–8 yrs, 1 at 15 yrs, 2 at 18 years, and 1 at 2 months for avascular necrosis. The mean 20 year metal ions results were cobalt 36.6 nmol/l (range 7.4–232.1) and chromium 32.1 nmol/l (range 6–120.8). The mean Harris hip score was 88.5 (range 38.6–99.8). This case series with 20 years follow-up demonstrates excellent long term survival of the BHRs further to registry BHR data and similar to THR for same age recipients. Applying today's strict criteria for patient selection would likely improve survival rate further. BHR has not demonstrated the catastrophic revision rates associated with some metal-on-metal resurfacing and remains a safe option for those who meet the criteria

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021. We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences. The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant. We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs

Introduction. Temporary spanning fixation aims to provide bony stability whilst allowing access and resuscitation of traumatised soft-tissues. Conventional monolateral fixators are prone to half-pin morbidity in feet, variation in construct stability and limited weight-bearing potential. This study compares traditional delta-frame fixators to a circular trauma frame; a virtual tibial ring block spanned onto a fine-wire foot ring fixation. Materials and Methods. The two cohorts were compared for demographics and fracture patterns. The quality of initial reduction and the maintenance of reduction until definitive surgery was assessed by two authors and categorised into four domains. Secondary measures included fixator costs, time to definitive surgery and complications. Results. Fifty-six delta-frames and 48 circular fixators were statistically matched for demographics and fracture pattern. Good or excellent initial reduction was achieved in 51 (91%) delta-frames and 48 (100%) circular fixators (p=0.022). Loss of reduction was observed in 15 (27%) delta-frames and 3 (6%) circular fixators (p<0.001). Post-fixator dislocation occurred in five (9%) delta-frames and one (2%) circular fixator (p=0.147). Duration in spanned fixation was equivalent (11.5 and 11.6 days respectively, p=0.211). Three (5%) delta-frames and 12 (25%) circular fixators were used as definitive fixation. The mean hardware cost was £3,116 for delta-frames and £2,712 for circular fixators. Conclusions. Temporary circular fixation offers statistically superior intra-operative reduction and maintenance of reduction, facilitates weight-bearing and provides more opportunity as the definitive fixation. Circular fixation hardware proved to be less expensive and protected against further scheduled and unscheduled operations

While Oxidized Zirconium (OxZr) femoral heads matched with highly cross-linked polyethylene (XLPE) have demonstrated the lowest rate of revision compared to other bearing couples in the Australian National Joint Registry, it has been postulated that these results may, in part, be due to the fact that a single company offers this bearing option with a limited combination of femoral and acetabular prostheses. The purpose of this study was to assess clinical and radiographic outcomes in a matched cohort of total hip replacements (THR) utilizing an identical cementless femoral stem and acetabular component with either an Oxidized Zirconium (OxZr) or Cobalt-Chrome (CoCr) femoral heads at a minimum of 10 years follow-up. We reviewed our institutional database to identify all patients whom underwent a THR with a single cementless femoral stem, acetabular component, XLPE liner and OxZr femoral head with a minimum of 10 years of follow-up. These were then matched to patients who underwent a THR with identical prosthesis combinations with CoCr femoral head by gender, age and BMI. All patients were prospectively evaluated with WOMAC, SF-12 and Harris Hip Score (HHS) preoperatively and postoperatively at 6 weeks, 3 months, 1 and 2 years and every 2 years thereafter. Charts and radiographs were reviewed to determine the revision rates and survivorship (both all cause and aseptic) at 10 years for both cohorts. Paired analysis was performed to determine if differences exist in patient reported outcomes. There were 208 OxZr THRs identified which were matched with 208 CoCr THRs. There was no difference in average age (OxZr, 54.58 years, CoCr, 54.75 years), gender (OxZr 47.6% female, CoCr 47.6% female), and average body max index (OxZr, 31.36 kg/m2, CoCr, 31.12 kg/m2) between the two cohorts. There were no significant differences preoperatively in any of the outcome scores between the two groups (WOMAC (p=0.449), SF-12 (p=0.379), HHS(p=0.3718)). Both the SF12 (p=0.446) and the WOMAC (p=0.278) were similar between the two groups, however the OxZr THR cohort had slightly better HHS compared to the CoCr THR cohort (92.6 vs. 89.7, p=0.039). With revision for any reason as the end point, there was no significant difference in 10 years survivorship between groups (OxZr 98.5%, CoCr 96.6%, p=0.08). Similarly, aseptic revisions demonstrated comparable survivorship rates at 10 year between the OxZr (99.5%) and CoCr groups (97.6%)(p=0.15). Both THR cohorts demonstrated outstanding survivorship and improvement in patient reported outcomes. The only difference was a slightly better HHS score for the OxZr cohort which may represent selection bias, where OxZr implants were perhaps implanted in more active patients. Implant survivorship was excellent and not dissimilar for both the OxZr and CoCr groups at 10 years. Therefore, with respect to implant longevity at the end of the first decade, there appears to be no clear advantage of OxZr heads compared to CoCr heads when paired with XLPE for patients with similar demographics. Further follow-up into the second and third decade may be required to demonstrate if a difference does exist

Aims. The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM). Patients and Methods. A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient’s contralateral knee (with vs without a history of APM). A total of 834 393 patients were included (mean age 50 years; 37% female). Results. Of those with at least 15 years of follow-up, 13.49% (16 256/120 493; 95% confidence interval (CI) 13.30 to 13.69) underwent subsequent arthroplasty within this time. In women, 22.07% (95% CI 21.64 to 22.51) underwent arthroplasty within 15 years compared with 9.91% of men (95% CI 9.71 to 10.12), corresponding to a risk ratio (RR) of 2.23 (95% CI 2.16 to 2.29). Relative to the general population, patients with a history of APM were over ten times more likely (RR 10.27; 95% CI 10.07 to 10.47) to undergo arthroplasty rising to almost 40 times more likely (RR 39.62; 95% CI 27.68 to 56.70) at a younger age (30 to 39 years). In patients with a history of APM in only one knee, the risk of arthroplasty in that knee was greatly elevated in comparison with the contralateral knee (no APM; HR 2.99; 95% CI 2.95 to 3.02). Conclusion. Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient’s affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with men. These important new reference data will inform shared decision making and enhance approaches to treatment, prevention, and clinical surveillance. Cite this article: Bone Joint J 2019;101-B:1071–1080

Aims. Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort. Methods. A population-based cohort of people aged between 40 and 69 years in the UK (the UK Biobank) was studied. People who underwent surgery for RCD were identified through a link with NHS inpatient records covering a mean of eight years after enrolment. Multivariate Cox proportional hazards regression was used to calculate hazard ratios (HRs) as estimates of associations with surgery for RCD accounting for confounders. The risk factors which were considered included age, sex, race, education, Townsend deprivation index, body mass index (BMI), occupational demands, and exposure to smoking. Results. Of the 421,894 people who were included, 47% were male. The mean age at the time of enrolment was 56 years (40 to 69). A total of 2,156 people were identified who underwent surgery for RCD. Each decade increase in age was associated with a 55% increase in the incidence of RCD surgery (95% confidence interval (CI) 46% to 64%). Male sex, non-white race, lower deprivation score, and higher BMI were significantly associated with a higher risk of surgery for RCD (all p < 0.050). Greater occupational physical demands were significantly associated with higher rates of RCD surgery (HR = 2.1, 1.8, and 1.4 for ‘always’, ‘usually’, and ‘sometimes’ doing heavy manual labour vs ‘never’, all p < 0.001). Former smokers had significantly higher rates of RCD surgery than those who had never smoked (HR 1.23 (95% CI 1.12 to 1.35), p < 0.001), while current smokers had similar rates to those who had never smoked (HR 0.94 (95% CI 0.80 to 1.11)). Among those who had never smoked, the risk of surgery was higher among those with more than one household member who smoked (HR 1.78 (95% CI 1.08 to 2.92)). The risk of RCD surgery was not significantly related to other measurements of secondhand smoking. Conclusion. Many factors were independently associated with surgery for RCD, including older age, male sex, higher BMI, lower deprivation score, and higher occupational physical demands. Several of the risk factors which were identified are modifiable, suggesting that the healthcare burden of RCD might be reduced through the pursuit of public health goals, such as reducing obesity and modifying occupational demands. Cite this article: Bone Joint J 2020;102-B(3):352–359

The stem design in total hip arthroplasty (THA) is constantly evolving. The impact of the collar on the risk of periprosthetic fracture remains controversial. This study aimed to determine whether adding a collar to the femoral stem impacts the early periprosthetic fracture risk within 90 days of surgery. This retrospective study included 1,623 patients who underwent primary total hip arthroplasty in a single orthopedic department between January 2010 and December 2020. The inclusion criteria were uncemented stem with or without a collar, in a primary intention, without previous hip surgery with a similar “corail like” design. The assessed data were demographic characteristics (age, gender, number of obese (BMI > 30)), single or dual mobility, the surgical approach, the early complication, particularly the periprosthetic femoral fractures. Of the 1,623 patients, 1,380 received a collared stem (85%), and 243 received a collarless stem (15%). A multivariate analysis was performed to determine the collar's effect on the risk of early periprosthetic fracture (<90 days). Nine (0.55%) early periprosthetic fractures were identified in the whole cohort. There were four fractures (1.65%) in the collarless stem group and five fractures (0.36%) in the collared stem group (p=0,005). One patient required revision surgery in the collared stem group, while two patients required revision surgery in the collarless stem group. The multinomial logistic regression model indicated a statistically significant lower (p<0.05) risk of early periprosthetic fracture within 90 days of surgery in the collared stems group. No other risk factor for early periprosthetic fractures has been identified. Using collared stems in cementless THA protects early periprosthetic femoral fractures within 90 days of surgery

Introduction. Degenerative spondylosis (DS) represents a challenging condition to diagnose and treat. There are multiple modalities to investigate DS including X-ray, MRI and CT, but symptoms may not be equivocal to DS to support the clinical findings. The investigation of metastases commonly utilises SPECT/CT for identification of areas of increased osteoblastic activity to denote disease. The aim of the study was to analyse the prevalence of asymptomatic DS in a consecutive hospital cohort of oncology patients who had SPECT/CT for investigation of metastases. Methods. Oncology patients who underwent SPECT/CT at St. George's Hospital were analysed between 2015–2019. Exclusion criteria: back pain, inflammatory disorders, metastases, trauma, infection. Radiology reports were examined for DS and anatomical distribution of tracer uptake. Results. A total of 1182 patients had a Whole-Body SPECT CT used for the spinal analysis. After exclusions (age >80 [n=260], non-cancer [n=318], back pain [n=72]), 522 reports with cancer were utilised. Mean age was 65 (4–80). Age and distribution of DS are given in the table. Conclusion. The prevalence of radiological asymptomatic DS is prevalent in large proportions of patients without back pain, and its incidence increases with age. Approximately 60% of 60 year old and 70% of 70 years old patients have asymptomatic DS in the lumbosarcal region. We conclude that SPECT/CT will detect radiographic degenerative spondylosis in an asymptomatic hospital cohort and this prevalence increase with age. Therefore, this modality of imaging must be utilised with caution when investigating potential pain generators. For any figures or tables, please contact the authors directly

Patellofemoral instability (PFI) is a common cause of knee pain and disability in the paediatric population. Patella alta, lateralised tibial tubercle, medial patellofemoral ligament (MPFL) deficiency, genu valgum and trochlear dysplasia are well known risk factors.

A prospective database was created including patients referred through our physiotherapy pathway following first-time patella dislocation. Patella alta and lateralisation of the tibial tuberosity was treated with a Fulkerson-type tibial tubercle osteotomy(TTO). Medial patellofemoral ligament was reconstructed using quads tendon autograft pull-down technique. A modified Sheffield protocol was used postoperatively allowing weightbearing in a hinged knee brace.

Forty patients were identified with 8 patients having bilateral presentations. Male to female ratio was 12:28 with an age range of 4–17 years. Eight patients had congenital PFI, five patients acquired PFI through traumatic patella dislocation and twenty-seven patients developed PFI from recurrent dislocations. Structural abnormalities were found in 38(95%) of patients. Patella alta (Caton-Deschamps index >1.2) was identified in 19(47%) patients, genu valgum in 12(30%) patients, increased tibial tubercle-trochlear groove distance(TT-TG>20mm) was present in 9(22.5%) patients and persistent femoral anteversion(> 20 deg) in 7(17%) patients.

Eight patients were treated with TTO and MPFL reconstruction, three patients with MPFL reconstruction alone and five patients had guided growth for genu valgum correction. Ten patients are awaiting surgery. No postoperative patients had recurrence of PFI at their latest follow up.

PFI is a common problem in the adolescent paediatric population with identifiable structural abnormalities. Correcting structural pathology with surgery leads to predictable and safe outcomes.

Purposes and Background. Musculoskeletal disorders are leading causes of work disability. Our purpose was to develop a predictive model in a cohort from 2012 and validate the model in 2016 data. Methods and Results. Prospectively collected data was used to identify inception cohorts in 2012 (n=1652) and 2016 (n=199). Data from back pain claimants receiving treatment in physiotherapy clinics and the Ontario workers' compensation database were linked. Patients were followed for 1 year. Variables from a back pain questionnaire and clinical, demographic and administrative factors were assessed for predictive value. The outcome was cumulative number of calendar days receiving wage-replacement benefits. Cox regression revealed 8 significant predictors of shorter time on benefits in the 2012 cohort: early intervention (HR=1.51), symptom duration < 31 days (HR=0.88), not in construction industry (HR=1.89), high Low Back Outcome Score (HR=1.03), younger age (HR=0.99), higher benefit rate (HR=1.00), intermittent pain (HR=1.15), no sleep disturbance (HR=1.15). The 2012 model c-statistic was 0.73 with a calibration slope of 0.90 (SE=0.19, p=0.61) in the 2016 data, meaning not significantly different. The c-statistic in the 2016 data was 0.69. Median duration on benefits of those with a high risk score was 129 days in 2012 and 45 days in 2016. Conclusion. The 2012 model had a good fit and calibrated well in the 2016 data. Changes in case management by the WSIB might have resulted in significant differences between the 2012 and 2106 cohort. The difference in duration on benefits could affect treatment decision making in future. Conflicts of interest: IWH is funded by the Ministry of Labour in Ontario. Sources of funding: Funding was provided by the Canadian Institute for Health Research

Midfoot arthrodesis is the conventional surgical intervention for midfoot arthritis. Arthrodesis aims to stabilise, realign and fuse the affected joints, providing patients with improved pain and function. Current research neglects the measurement of patient reported outcomes.

This study aimed to investigate objective, and patient reported outcomes of midfoot arthrodesis. The secondary aim was to identify variables predicting the development of non-union.

An automated search of online patient records identified 108 eligible patients (117 feet). The rates of union, re-operations, and complications were calculated using radiographs and medical records. Logistic regression was used to model variables influencing the odds of non-union. All living patients were posted a Manchester Oxford Foot Questionnaire (MOx-FQ), a patient reported outcome assessment. Pre-operative MOx-FQ results were available in a minority of cases. Students t-test was used to compare pre- and post-operative MOx-FQ scores.

The rate of union achieved was 74%. The rate of re-operations was 35%. The rate of complications was 14%. Bone grafts and staple fixation independently impacted the odds of non-union. Bone grafts decreased the odds of non-union, whilst staple fixation increased the odds. This finding agrees with the opinion of other researchers.

We recommend the use of bone grafts, and the avoidance of fixation with staples. Previous attempts have been made to assess patient outcomes. However, this study is the first to use the MOx-FQ, a validated questionnaire. Therefore, this study establishes a baseline for improvements in patient reported outcomes.

Abstract. Objectives. Principal Component Analysis (PCA) is a useful method for analysing human motion data. The objective of this study was to use PCA to quantify the biggest variance in knee kinematics waveforms between a Non-Pathological (NP) group and individuals awaiting High Tibial Osteotomy (HTO) surgery. Methods. Thirty knees (29 participants) who were scheduled for HTO surgery were included in this study. Twenty-eight NP volunteers were recruited into the study. Human motion analysis was performed during level gait using a modified Cleveland marker set. Subjects walked at their self-selected speed for a minimum of 6 successful trials. Knee kinematics were calculated within Visual3D (C-Motion). The first three Principal Components (PCs) of each input variable were selected. Single-component reconstruction was performed alongside representative extremes of each PC to aid interpretation of the biomechanical feature reconstructed by each component. Results. Pre-operatively patient demographics included (age: 50.70 (8.71) years; height: 1.75 (.11) m; body mass: 90.57 (20.17) kg; mTFA: 7.75 (3.72) degrees varus; gait speed: 1.06 (0.23) m/s). The HTO cohort was significantly older and had a higher mass than the NP control participants. For knee kinematics the first three PCs explained 88%, 95% and 89% of the sagittal, frontal, and transverse planes, respectively. The main variances can be explained by sagittal plane magnitude differences, peak swing is associated with toe-off, a reduced knee flexion angle is associated with a longer time spent in stance, pre-HTO remain adducted during stance and pre-HTO patients remain more externally rotated during stance and latter part of swing. Conclusions. This study has introduced PCA in trying to better understand the biomechanical differences between a control group and a cohort with medial knee osteoarthritis varus deformity awaiting HTO. Further analysis will be undertaken using PCA comparing pre- and post-surgery which will be of importance in clinical decision making

Reduced cervical spine canal AP diameter is linked to the development of spinal cord injury and myelopathy. This is of particular interest to clinicians in New Zealand, given a unique socio-ethnic make-up and prevalent participation in collision sport. Our study builds upon previous unpublished evidence, by analysing normal cervical spine CT scans to explore morphological differences in the sub-axial cervical spine canal, between New Zealand European, Māori and Paciāca individuals.

670 sub-axial cervical vertebrae (C3-C7) were analysed radiographically using high resolution CT trauma scans, showing no acute pathology with respect to the cervical spine. All measurements were made uPlising mulP-planar reconstruction software to obtain slices parallel to the superior endplate at each vertebral level. Maximal canal diameter was measured in the AP and transverse planes. Statistical analysis was performed using analysis of variance (ANOVA).

We included 250 Maori, 250 NZ European and 170 Paciāca vertebrae (455 male, 215 female). Statistically and clinically signiācant differences were found in sagittal canal diameter between all ethnicities, at all spinal levels. NZ European vertebrae demonstrated the largest AP diameter and Paciāca the smallest, at all levels. Transverse canal diameter showed no signiācant difference between ethnicities, however the raatio of AP:transverse diameter was signiācantly different at all spinal levels except C3. Subjective morphological differences in the shape of the vertebral canal were noted, with Māori and Paciāca patients tending towards a flatter, curved canal shape.

A previous study of 166 patients (Coldham, G. et al. 2006) found cervical canal AP diameter to be narrower in Māori and Paciāca patients than in NZ Europeans. Our study, evaluating the normal population, conārms these differences are likely reflecPve of genuine variation between these ethniciPes. Future research is required to critically evaluate the morphologic differences noted during this study.

Purpose. The success of total knee replacement (TKR) surgery can be attributed to improvements in TKR design, instrumentation, and surgical technique. Over a decade ago oxidized zirconium (OxZr) femoral components were introduced as an alternative bearing surface to cobalt-chromium (CoCr), based on strong in-vitro evidence, to improve the longevity of TKR implants. Early reports have demonstrated the clinical success of this material however no long-term comparative studies have demonstrated the superiority of OxZr implants compared to a more traditional CoCr implant. This study aims to compare long-term survivorship and outcomes in OxZr and CoCr femoral components in a single total knee design. Methods. We reviewed our institutional database to identify all patients whom underwent a TKA with a posterior stabilized OxZr femoral component with a minimum of 10 years of follow-up. These were then matched to patients whom underwent a TKA with the identical design posterior stabilized CoCr femoral component during the same time period by gender, age and BMI. All patients had their patella resurfaced. All patients were prospectively evaluated preoperatively and postoperatively at 6 weeks, 3 months, 12 months, 2 years and every 1 to 2 years thereafter. Prospectively collected clinical outcome measures included, Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Short-Form 12 (SF-12) and Knee Society clinical rating scores (KSCRS). Charts and radiographs were reviewed to determine the revision rates and survivorship (both all cause and aseptic) at 10 years allowing comparison between the two cohorts. Paired analysis was performed to determine if differences existed in patient reported outcomes. Results. There were 194 OxZr TKAs identified and matched to 194 CoCr TKAs. There was no difference in average age (OxZr, 54.2 years; CoCr, 54.4 years), Gender (OxZr, 61.9% female; CoCr, 61.9% female) and average body mass index (OxZr, 35.9 kg/m2; CoCr, 36.4 kg/m2) between the two cohorts. There were no significant differences preoperatively in any of the outcome scores between the two groups (WOMAC (p=0.361), SF-12 (p=0.771) and KSCRS (p=0.161)). Both the SF12 (p=0.787) and WOMAC (p=0.454) were similar between the two groups, however the OxZr TKA cohort had superior KSCRS compared to the CoCr TKA cohort at a minimum of 10 years (173.5 vs. 159.1, p=0.002). With revision for any reason as the end point, there was no significant difference in 10-year survivorship between the two groups (OxZr and CoCr, 96.4%, p=0.898). Similarly, aseptic revisions demonstrated comparable survivorship rates at 10-year between the OxZr (98.9%) and CoCr groups (97.9%) (p=0.404). Conclusion. In this matched cohort study, both groups demonstrated similar improvements in patient reported outcomes, although the OxZr cohort had greater KSCRS scores compared to the CoCr cohort. The reason for this difference is not clear but may represent selection bias, where OxZr implants were perhaps used in more active patients. Implant survivorship, based on revision rates for all causes and/or aseptic reasons, was excellent and similar for both the OxZr and CoCr femoral components at 10 years. Therefore, with respect to implant longevity at the end of the first decade, there appears to be no clear advantage of OxZr compared to CoCr for patients with similar demographics with this specific posterior stabilized TKA design. Further follow-up into the second and third decade may be required to demonstrate if a difference does exist

The purpose of this study was to compare intra-operative, clinical, functional, and patient-reported outcomes following revision anterior cruciate ligament reconstruction (ACL-R) with a matched cohort of primary isolated ACL-R. A secondary purpose was to compare patient-reported outcomes within revision ACL-R based on intra-operative cartilage pathology. Between January 2010 and August 2017, 396 patients underwent revision ACL-R, and were matched to primary isolated ACL-R patients using sex, age, body mass index (BMI), and Beighton score. Intra-operative assessments including meniscal and chondral pathology, and graft diameter were recorded. Lachman and pivot shift tests were completed independently on each patient at two-years post-operative by a physiotherapist and orthopaedic surgeon. A battery of functional tests was assssed including single-leg Bosu balance, and four single-leg hop tests. The Anterior Cruciate Ligament-Quality of Life Questionnaire (ACL-QOL) was completed pre-operatively and two-years post-operatively. Descriptive statistics including means (M) and standard deviations (SD), and as appropriate paired t-tests were used to compare between-groups demographics, the degree and frequency of meniscal and chondral pathology, graft diameter, rate of post-operative ACL graft laxity, the surgical failure rate, and ACL-QOL scores. Comparative assessment of operative to non-operative limb performance on the functional tests was used to assess limb symmetry indices (LSI). Revision ACL-R patients were 52.3% male, mean age 30.7 years (SD=10.2), mean BMI 25.3 kg/m2 (SD=3.79), and mean Beighton score 3.52 (SD=2.51). In the revision group, meniscal (83%) and chondral pathology (57.5%) was significantly more frequent than in the primary group (68.2% and 32.1%) respectively, (p < 0 .05). Mean graft diameter (mm) in the revision ACL-R group for hamstring (M=7.89, SD=0.99), allograft (M=8.42, SD=0.82), and patellar or quadriceps tendon (M=9.56, SD=0.69) was larger than in the primary ACL-R group (M=7.54, SD=0.76, M=8.06, SD=0.55, M=9, SD=1) respectively. The presence of combined positive Lachman and pivot shift tests was significantly more frequent in the revision (21.5%) than primary group (4.89%), (p < 0 .05). Surgical failure rate was higher in the revision (10.3%) than primary group (5.9%). Seventy-three percent of revision patients completed functional testing. No significant LSI differences were demonstrated between the revision and primary ACL-R groups on any of the functional tests. No statistically significant differences were demonstrated in mean preoperative ACL-QOL scores between the revision (M=28.5/100, SD=13.5) and primary groups (M=28.5/100, SD=14.4). Mean two-year scores demonstrated statistically significant and minimally clinically important differences between the revision (M=61.1/100, SD=20.4) and primary groups (M=76.0/100, SD=18.9), (p < 0 .05). Mean two-year scores for revision patients with repair of the medial (M=59.4/100, SD=21.7) or lateral meniscus (M=59.4/100, SD=23.6), partial medial meniscectomy (M=59.7/100, SD=20), grade three or four osteoarthritis (M=55.9/100, SD=19.5), and medial femoral condyle osteoarthritis (M=59.1/100, SD=18) were lower compared with partial lateral meniscectomy (M=67.1/100, SD=19.1), grade one or two osteoarthritis (M=63.8/100, SD=18.9), and lateral femoral condyle osteoarthritis (M=62, SD=21). Revision ACL-R patients demonstrated a greater amount of meniscal and chondral pathology at the time of surgery. Two-years post-operative these patients demonstrated higher rates of graft laxity and lower ACL-QOL scores compared with the primary ACL-R group. Higher grade and medial sided osteoarthritis was associated with inferior ACL-QOL scores in revision ACL-R

Background

Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects.

Background. Cam morphology develops during adolescence and predisposes individuals to future hip pain and osteoarthritis. An improved understanding of cam development is required to determine whether the process is modifiable. Hypothesis/Purpose. The aim of this study was to characterise the risk factors, timing, and pathogenesis of cam formation. Study Design. Longitudinal prospective observational cohort study. Methods. Longitudinal observational cohort study over three years of individuals from football club academies and an age-matched control population, aged 9–18 years at baseline. Assessments include questionnaires, clinical examination, and MRI of both hips. Alpha angle and epiphyseal extension were measured on radial images. Results. Cohort comprised male academy footballers (121 at baseline and 78 at follow-up) and male and female controls (107 at baseline and 71 at follow-up). Mean change in cartilage alpha angle was 12.4° (SD 8.4) for footballers, 7.3° (SD 6.0) for male controls and 4.0° (SD 4.1) for female controls. A positive correlation was found between Physical Activity Questionnaire Score and change in cartilage alpha angle (coefficient 0.787, p=<0.001). The greatest change in cartilage alpha angle occurred in individuals aged 11–12 years at baseline, with no significant change after 14 years of age. A positive correlation between mean cartilage alpha angle and lateral epiphyseal extension was observed (r. 2. = 0.294, p=0.029). Conclusions. Males undertaking intense sporting activity during adolescence at greatest risk of developing cam morphology, but there is no significant change in hip morphology after 14 years of age. The findings are consistent with physiological adaptation and epiphyseal extension in response to hip loading during skeletal immaturity

Introduction:. The role of total ankle replacements remains unproven within orthopaedic literature. We present a prospective series of patients who underwent a SALTO TAR (Tornier) between October 2006 and January 2014. Methods:. A cohort of 53 TAR (50 patients) were prospectively followed up and assessed clinically, radiologically and asked to complete FAOS, VAS and Modified AOFAS scores. Four patients had bilateral procedures. The mean age was 71 years old (range 42–92). The mean follow up was 55 months (range 6–92). Nineteen TARs (19 patients) have a follow up of more than 60 months. Results:. Our survival rate is 98% as one patient proceeded to have an ankle fusion at 12 months due to loosening. Three patients had ankle arthroscopies at 1 year post TAR; one for removal of a fibula cyst, one for synovitis in the lateral gutter and another for fibula impingement. One patient had an early postoperative infection. Mean overall FAOS scores were 73.4 for the entire cohort and 74.2 for the cohort with over 5 years follow-up. Mean modified AOFAS scores for the entire cohort and the cohort with over 5 years follow up was 71.5 and 78.9 respectively. Mean VAS scores for the entire cohort and the cohort with over 5 years follow-up was 18.8 and 25.8 respectively. Discussion:. Ankle joint arthrodesis has been shown to be a reliable in relieving pain and result in good patient satisfaction. However, total ankle replacement provides an alternative surgical option for the management of ankle arthritis. The improving survivorship of ankle replacements is making this an increasingly popular option. Our follow-up of almost five years as an entire cohort, but also those with over five years, show that these latest generations of TAR have excellent mid term survivorship, accompanied by high levels of patient satisfaction and function

Introduction. Missile injuries are very serious injuries particularly in the cervical region. They are classified into high and low missile injuries when it involves the cervical spine. In modern guerrilla warfare, one must be aware of ballistic pathology with bullets as well as from explosives. In particular, improvised explosive devices commonly known as IED's play a new and important pathophysiology whether they are suicided vests or roadside bombs. They usually produce severe or lethal injuries and serious neurovascular deficit is frequent. We present the details of 40 patients with local experience on how to handle serious penetrating cervical missile injuries. Methods. All cases were collected from the record of Basrah University Hospital, Iraq. Healthy military gentlemen with ages ranging between 20–35 years were included. Results. 11 patients had bullet injuries and 29patients had fragments of shell injuries. The sites of injuries were 9: C2–C3, 12: C5–C6, 12: C4–C5 and 7: C7-T1. Bullet entrance was anterior in 23 patients, posterior in 7 patients and lateral in 10 patients. The cervical vertebrae were injured in 37 patients at body or lamina level while in 3 patients it was only neural tissue injuries. Missiles were retained in 13 patients. All injuries showed some degree of neurological deficit with quadriplegia in 26 patients. 9 patients presented with very serious injuries. No relation was found between the size of the missile and the extent of damage. Outcome of treatment in all patients was poor. Conclusion. Gunshot wounds only account for approximately one third of penetrating missile injuries in patients who survive and are well enough to receive medical treatment. 62% of patients' cohort were from explosive devices, consistent with data from 2010, where 58% of fatalities were from IED's occurring in foreign soldiers in Afghanistan. We discuss the importance of general supportive measures, generous wound excision, removal of the retained missiles and heavy cover of antibiotics

Post-operative periprosthetic fracture of the femur (POPFF) is a growing problem associated with increased mortality. Most registry derived estimates of mortality only record patients who undergo revision and cohort studies are generally limited to a single center, which makes comparison for the purposes of service improvement difficult. The aim of this study is to perform a systematic review and meta-analysis of cohort studies reporting mortality following POPFF in the last decade. Study methodology was peer-reviewed (PROSPERO: CRD42020170819). Literature search was conducted using Medline and EMBASE. Primary exposure was the diagnosis of POPFF, and the primary outcome measure was all-cause mortality: whilst an inpatient, within 30-days, within 90-days and within one year of POPFF. Proportion of patients dying (95% CI [confidence interval]) was estimated using metaregression. Results were compared to mortality following neck of femur fracture (NOF) from international NOF registry data. 4841 patients from 35 cohort studies were included. Study quality was generally low with a majority limited to a single centre. Weighted mean follow-up was 2.3 years and the most common POPFF was UCS B. Pooled proportion dying as an inpatient was 2.4% (95% CI 1.6% to 3.4%). Pooled proportion dying within 30 days was 3.3% (95% CI 2.0% to 5.0%). Pooled proportion dying within 90 days was 4.8% (95% CI 3.6% to 6.1%). Pooled proportion dying within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality following POPFF was similar to that of NOF up to 30 days, but better at one year. 3.3% of patients die following POPFF within 30 days of injury. Mortality is similar to that experienced by patients following NOF up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future

Given the high prevalence of psychiatric illness in the total joint arthroplasty (TJA) population, relatively little is known about how these two conditions affect each other. Therefore, the purpose of this study is to evaluate the role of major psychiatric illness on patient specific outcomes after TJA. We hypothesize that patients with major psychiatric illnesses will report inferior outcomes and have more complications after TJA compared to those without any psychiatric illness. We matched and compared two cohorts of patients undergoing TJA from a prospectively collected database registry, which included those with and without a major psychiatric disorder. Major psychiatric disorder was identified in the registry database by determining if patients had been formally diagnosed with any of the following conditions: bipolar disorder, major personality disorder, chronic mental health diagnoses, depression, or schizophrenia. Primary outcomes of interest included patient specific outcomes measured using the WOMAC or EQ5D. Secondary outcomes included complications, infections, hospital length of stay, 30-day readmission rates and final discharge destination. In total we included 1828 TJAs (1000 THAs, 828 TKAs). In terms of the primary outcome, both the THA experimental group (37.80 ± 17.91 vs. 40.74 ± 19.3, p=0.023) and TKA experimental group (43.38 ± 18.41 vs 45.45 ± 20.07, p=0.050) had significantly lower preoperative WOMAC scores compared to their respective control groups. At the 3-month period both the THA experimental group (76.74 ± 16.94 vs. 79.16 ± 16.19, p=0.036) and TKA experimental group (71.09 ± 18.64 vs. 75.92 ± 16.22, p=0) again had significantly lower 3-month postoperative WOMAC score. Clinical outcomes at the 1-year mark were similar for both groups in terms of WOMAC and EQ5D. Patients with psychiatric illness were more likely to have increased LOS and non-routine discharge from hospital. In the THA subset, the experimental group had an increased LOS by 1.43 days (p=0.0028), in the TKA subset, the experimental group had an increased LOS by 0.77 days (p= 0.050). In terms of non-routine discharge, the THA experimental group was discharged home 86.9% of the time compared to the control group at 91.8% (p=0.024). In the TKA subset, the experimental group was discharged home 87.6% of the time compared to the control group at 92% (p=0.022). There were no other differences between the two subsets in regards to transfusions, 30-day readmissions, infections, mechanical adverse events, and medical complications. In conclusion, our results demonstrate that psychiatric illness can result in worse outcomes in the early perioperative period after TJA, although outcomes are equivalent 1 year postoperatively. Patients with psychiatric illness can be expected to gain significant improvements in outcome after surgery that are comparable to a baseline population without psychiatric illness. Nonetheless, patients with psychiatric illness are at increased risk of delayed discharge and non-routine discharge. As such, they may require personalized care post-operatively, and should be counseled accordingly. Based on our results, psychiatric illness should not be an impediment to proceeding with TJA

Introduction. There is considerable interest in the orthopaedic community in understanding the multifactorial process of taper fretting corrosion in total hip arthroplasty (THA). Previous studies have identified some patient and device factors associated with taper damage, including length of implantation, stem flexural rigidity, and head offset. Due to the complexity of this phenomenon, we approached the topic by developing a series of matched cohort studies, each attempting to isolate a single implant design variable, while controlling for confounding factors to the extent possible. We also developed a validated method for measuring material loss in retrieved orthopaedic tapers, which contributed to the creation of a new international standard (ASTM F3129-16). Methods. Based on our implant retrieval collection of over 3,000 THAs, we developed independent matched cohort studies to examine (1) the effect of femoral head material (metal vs. ceramic, n=50 per cohort) and (2) stem taper surface finish (smooth vs. microgrooved, n=60 per cohort). Within each individual study, we adjusted for confounding factors by balancing implantation time, stem taper flexural rigidity, offset, and, when possible, head size. We evaluated fretting and corrosion using a four-point semiquantitative score. We also used an out-of-roundness machine (Talyrond 585) to quantify the material loss from the tapers. This method was validated in a series of experiments of controlled material removal on never-implanted components. Results. In the first study, the ceramic cohort exhibited a 92% reduction in cumulative volumetric loss from both the head and neck taper surfaces compared to the CoCr cohort (p < 0.001). In the CoCr cohort, there was greater material loss from femoral head tapers as compared with stem tapers (p < 0.0001). There was also a correlation between visual scoring and volumetric material loss (ρ = 0.67, p < 0.01). In the second study, taper damage was not different between the smooth and microgrooved taper cohorts when evaluated at the head bore (p=0.14) or the stem tapers (p=0.35). There was also no difference in material loss between the most damaged CoCr heads in the two cohorts (p>0.05). Conclusions. Our findings suggest that fretting and corrosion damage and material loss from the stem taper are mitigated, and on the head taper, eliminated with the use of a ceramic vs. metal femoral head. We also found that fretting and corrosion damage was insensitive to differences in stem taper surface finish and the presence of microgrooves. Although visual scoring was effective for preliminary screening to separate tapers with no or mild damage from tapers with moderate to severe damage, it was not capable of discriminating within the large range of material loss observed at the taper surfaces with high fretting-corrosion scores. Thus, for moderate to severely damaged conical tapers, direct measurement is necessary. A drawback of a matched cohort approach is that a large retrieval collection is necessary to effectively match an investigational group of implants with an appropriate control cohort. Notwithstanding this limitation, the matched cohort approach has been an effective approach to study the complex multifactorial problem of taper fretting and corrosion

Aim

Currently, gram-negative bacteria (GNB), including multidrug-resistant (MDR-GNB) pathogens, are gaining importance in the aetiology of prosthetic joint infection (PJI). To characterize the antimicrobial resistance patterns of Gram-negative bacteria (GNB) causing hip prosthetic joint infections in elderly patients treated at a Brazilian tertiary academic hospital.

Aim

Surgical treatment of ankle fractures comes with a substantial risk of complications, including infection. An unambiguously definition of fracture-related infections (FRI) has been missing. Recently, FRI has been defined by a consensus group with a diagnostic algorithm containing suggestive and confirmatory criteria. The aim of the current study was to report the prevalence of FRI in patients operated for ankle fractures and to assess the applicability of the diagnostic algorithm from the consensus group.

We present a prospective two-year follow-up study of 1038 hip arthroscopies performed at a high volume tertiary referral centre for hip preservation. We feel that this manuscript is both pertinent and timely due to the advances in the field of hip preservation. We used four validated patient-reported outcome (PRO) scores along with the visual analog scale (VAS) and patient satisfaction scores to assess preoperative and postoperative outcomes in all patients undergoing hip arthroscopy. We divided the entire cohort into patients undergoing primary and revision hip arthroscopies. We found a statistically significant improvement from preoperative to two-year postoperative PRO scores in the two subgroups. We also found a significant difference in the PRO scores at three months, one year, and two years postoperatively between the primary and revision subgroups. The revision subgroup had inferior VAS and patient satisfaction compared to the primary subgroup, however these results were not significant. The conversion to total hip arthroplasty/hip resurfacing (THA/HR) was 5.6% and 11.2% in the primary and revision subgroups, respectively. This resulted in a relative risk of 2.0 for conversion to THA/HR in the revision subgroup. We had a complication rate of 5.3 (only 0.5% of which were considered major) which was similar to that reported in the literature for hip arthroscopy. The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopy at a high volume tertiary referral centre for hip preservation with minimum two-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopy. From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopy. Patients were assessed pre- and post-operatively with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport Specific Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. There were a total of 1155 arthroscopies performed, including 1040 primary arthroscopies (926 patients) and 115 revision arthroscopies (106 patients). Of these, 931 primary arthroscopies (89.5%) in 824 patients (89.0%) and 107 revision arthroscopies (93.0%) in 97 patients (91.5%), were available for follow-up and included in our study. The mean change in patient reported outcome (PRO) scores at two-year follow-up in the primary subgroup was 17.4 for mHHS, 19.7 for HOS-ADL, 23.8 for HOS-SSS, 21.3 for NAHS, and −3.0 for VAS. The mean change in PRO scores at two-year follow-up in the revision subgroup was 13.4, 10.9, 16.1, 15.4, and −2.7, respectively. All scores improved significantly compared to pre-operatively (p<0.001). PRO scores were higher at all time points for the primary subgroup compared to the revision subgroup (p<0.05). Satisfaction was 7.7 and 7.2 for primary and revision subgroups, respectively. Of 931 primary arthroscopies, 52 (5.6%) underwent THA/HR. Of 107 revision arthroscopies, 12 (11.2%) underwent THA/HR. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures. The overall complication rate was 5.3%. Hip arthroscopy showed significant improvement in all PRO, VAS, and satisfaction scores at two years postoperatively. Primary arthroscopy patients showed greater PRO scores and a trend towards greater VAS compared to the revision subgroup. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures

Objectives. The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient’s recollection of their own preoperative OHS and OKS one year following surgery. Methods. A total of 335 patients (mean age 72.5; 22 to 92; 53.7% female) undergoing total hip arthroplasty (n = 178) and total knee arthroplasty (n = 157) were prospectively assessed. Patients undergoing hip and knee arthroplasty completed an OHS or OKS, respectively, preoperatively and were asked to recall their preoperative condition while completing the same score one year after surgery. Results. A mean difference of 0.04 points (95% confidence intervals (CI) -15.64 to 15.72, p = 0.97) between the actual and the recalled OHS was observed. The mean difference in the OKS was 1.59 points (95% CI -11.57 to 14.75, p = 0.10). There was excellent reliability for the ‘average measures’ intra-class correlation for both the OHS (r = 0.802) and the OKS (r = 0.772). However, this reliability was diminished for the individuals OHS (r = 0.670) and OKS (r = 0.629) using single measures intra-class correlation. Bland–Altman plots demonstrated wide variation in the individual patient’s ability to recall their preoperative score (95% CI ± 16 for OHS, 95% CI ± 13 for OKS). Conclusion. Prospective preoperative collection of OHS and OKS remains the benchmark. Using recalled scores one year following hip and knee arthroplasty is an alternative when used to assess a cohort of patients. However, the recall of an individual patient’s preoperative score should not be relied upon due to the diminished reliability and wide CI. Cite this article: T. F. M. Yeoman, N. D. Clement, D. Macdonald, M. Moran. Recall of preoperative Oxford Hip and Knee Scores one year after arthroplasty is an alternative and reliable technique when used for a cohort of patients. Bone Joint Res 2018;7:351–356. DOI: 10.1302/2046-3758.75.BJR-2017-0259.R1

The purpose of this study was to define the risk and incidence of eventual ankle arthroplasty or fusion after documented ankle fracture in a large cohort, and compare that rate to matched healthy patients from the general population. The Ontario health insurance plan (OHIP) physician billing database, Institute for Clinical Evaluative Sciences (ICES) Physician Database, the Canadian Institute for Health Information (CIHI) databases, Discharge Abstract Database (DAD) and Same Day Surgery (SDS) were used to identify patients treated surgically and non-surgically for ankle fractures. Each patient was matched to four individuals from the general population (13.5 million) with no documented prior treatment for ankle fracture, according to age, sex, income, and urban/rural residence. Fusion and replacement incidence was compared using time-to-event analysis (Kaplan-Meier). A Cox Proportional Hazards model was used to explore the influence of patient, provider and surgical factors on time to surgery. We identified 45,444 (58.8% female, mean age 48.7 years) and 140, 629 (53.9% female, mean age 47.1 years) patients who had undergone open reduction internal fixation (ORIF) or non-operative management of an ankle fracture (NOA), respectively. Among ORIF patients, n=237 (0.5%) and n=69 (0.15%) patients underwent fusion or arthroplasty after a median 2.8 and 6.9 years, respectively. Among non-operatively treated ankle fractures, n=198 (0.14%) and n=36 (0.03%) patients underwent fusion or arthroplasty after a median of 3.2 and 5.6 years, respectively. Surgical treatment (vs. non-operatively treated fracture), older age, greater co-morbidity and a history of infection post fracture significantly increased the risk of eventual fusion or arthroplasty (HR 3.6 (3.1–4.3), p < 0 .001, HR 1.01 (1.01–1.02), p=0.009, HR 1.2 (1.1–1.3), p < 0 .001, HR 11.3 (6.8–18.7), p < 0 .001, respectively). Compared to matched controls, the risk of fusion/arthroplasty was not independent of time, following an exponential decay pattern. ORIF patient risk was 20 times greater than the general population in the first three years post-ORIF, and approached the risk of non-operatively treated patients (HR 4.5 (95CI: 3.5–5.8), p < 0 .0001) by approximately 14 years out from injury on time and comorbidity adjusted KM curves. Rates of fusion/arthroplasty are very low after ORIF and non-operative treatment of an ankle fracture in the general population of a public healthcare system. Utilization patterns suggest fusion is more common earlier, and arthroplasty remote, which may be a factor of patient age, injury severity, and complications from initial injury/surgery. Patients who underwent ORIF have >20 times the risk of fusion/arthroplasty in the short-term, however, the risk decreases over time eventually approaching that of non-operatively treated patients (∼4.5x the general population) when compared to non-fractured controls

Anterior cruciate ligament (ACL) rupture with associated meniscal pathology commonly occurs in a young, active population. Preserving a greater proportion of the meniscus may improve long-term outcomes by maintaining shock absorption and knee stability. However, meniscal repair procedures involve longer healing and rehabilitation than meniscal debridement, which could affect return to work and activity. The purpose of this study was to examine the functional outcomes and quality of life scores through two years in patients undergoing ACL reconstruction (ACL-R) who had meniscal repair, meniscal debridement, or no meniscal damage at the time of reconstruction. Data for 1814 skeletally mature patients with isolated primary ACL-R was prospectively collected at a single centre from January 2010 to December 2015. Functional testing of operative to non-operative limb performance was completed at one- and two-years following surgery and included single-leg balance, single-leg hop for distance, timed six-meter hop, triple-hop for distance, and triple cross-over hop for distance. ACL-Quality-of-life questionnaires (ACL-QoL) were completed pre-operatively and at 1- and 2-years post-operatively. Descriptive statistics were completed for patient demographics and intra-operative pathology. Unpaired t-tests using 95% confidence intervals were conducted to compare groups. The patient cohort was 45% female, with a mean age of 31 years (SD 11, range 14–66). Meniscal injury was detected in 1229/1814 knees (67.8%). There were 729 debridements and 538 repairs performed. Graft choice was hamstring autograft in 85.8% of cases, bone-patellar-tendon-bone autograft in 2.5%, allograft in 10.1% and other graft types in 1.5%. Pre-operative ACL-QoL scores were 29 and 28.5 for knees without and with meniscal damage, respectively (p>0.05). Of 1814 patients, 1269 (69.9%) completed the ACL-QoL at the two-year appointment, and 1225 (67.5%) completed the functional testing. At two years post-operative, patients with no meniscal damage at surgery demonstrated superior limb symmetry performance on triple-hop for distance compared to patients with meniscal damage (98.4% vs 97.1%, p < 0 .05, CI 0.1–2.5%). No other functional testing parameters showed statistical significance. There was no difference in functional outcome between patients undergoing an isolated meniscal repair versus debridement at one- or two-years. ACL-QoL scores were statistically significantly higher at one- and two-years post-operative for patients without meniscal damage (1-year: 73 vs 70.2, p < 0 .05, CI 0.51–5.1, 2-years: 79.2 vs 76.1, p < 0 .05, CI 0.79–5.4). ACL-QoL scores were minimally higher for isolated meniscal debridement compared to isolated meniscal repair at both time points (1-year: 71.4 vs 68, p < 0 .05, CI 0.4–6.4, 2-years: 78.3 vs 74, p < 0 .05, CI 1.3–7.3). Functional outcomes do not differ at one or two years post-operatively for patients undergoing meniscal repair versus debridement concomitant with ACL-R. Quality of life scores were statistically significantly higher for the patients with no meniscal pathology at both one- and two-years post-operative. ACL-QoL scores were also statistically significantly different for the meniscal repair and debridement groups however these differences are unlikely to be clinically significant. Extended follow-up is needed to determine if the differences detected in ACL-QoL scores are sustained over time, as well as the long-term role of meniscal injury on functional outcomes

In Norway total joint replacement after hip dysplasia is reported more commonly than in neighbouring countries, implying a higher prevalence of the condition. We report on the prevalence of radiological features associated with hip dysplasia in a population of 2081 19-year-old Norwegians. The radiological measurements used to define hip dysplasia were Wiberg’s centre-edge (CE) angle at thresholds of < 20° and < 25°, femoral head extrusion index <  75%, Sharp’s angle > 45°, an acetabular depth to width ratio < 250 and the sourcil shape assessed subjectively. The whole cohort underwent clinical examination of their range of hip movement, body mass index (BMI), and Beighton hypermobility score, and were asked to complete the EuroQol (EQ-5D) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The prevalence of hip dysplasia in the cohort varied from 1.7% to 20% depending on the radiological marker used. A Wiberg’s CE angle <  20° was seen in 3.3% of the cohort: 4.3% in women and 2.4% in men. We found no association between subjects with multiple radiological signs indicative of dysplasia and BMI, Beighton score, EQ-5D or WOMAC. Although there appears to be a high prevalence of hip dysplasia among 19-year-old Norwegians, this is dependent on the radiological parameters applied. Cite this article: Bone Joint J 2013;95-B:279–85

Aims

Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications.

This is quite an innovative study that should lead to a multicentre validation trial. We have developed an FDG-PET/MRI texture-based model for the prediction of lung metastases (LM) in newly diagnosed patients with soft-tissue sarcomas (STSs) using retrospective analysis. In this work, we assess the model performance using a new prospective STS cohort. We also investigate whether incorporating hypoxia and perfusion biomarkers derived from FMISO-PET and DCE-MRI scans can further enhance the predictive power of the model. A total of 66 patients with histologically confirmed STSs were used in this study and divided into two groups: a retrospective cohort of 51 patients (19 LM) used for training the model, and a prospective cohort of 15 patients (two patients with LM, one patient with bone metastases and suspicious lung nodules) for testing the model. In the training phase, a model of four texture features characterising tumour sub-region size and intensity heterogeneities was developed for LM prediction from pre-treatment FDG-PET and MRI scans (T1-weighted, T2-weighted with fat saturation) of the retrospective cohort, using imbalance-adjusted bootstrap statistical resampling and logistic regression multivariable modeling. In the testing phase, this multivariable model was applied to predict the distant metastasis status of the prospective cohort. The predictive power of the obtained model response was assessed using the area under the receiver-operating characteristic curve (AUC). In the exploratory phase of the study, we extracted two heterogeneity metrics from the prospective cohort: the area under the intensity-volume histogram of pre-treatment DCE-MRI volume transfer constant parametric maps and FMISO-PET hypoxia maps (AU-IVH-Ktrans, AU-IVH-FMISO). The impact of the addition of these two individual metrics to the texture-based model response obtained in the testing phase was first investigated using Spearman's correlation (rs), and lastly using logistic regression and leave-one-out cross-validation (LOO-CV) to account for overfitting bias. First, the texture-based model reached an AUC of 0.94, a sensitivity of 1, a specificity of 0.83 and an accuracy of 0.87 when tested in the prospective cohort. In the exploratory phase, the addition of AU-IVH-FMISO did not improve predictive power, yielding a correlation of rs = −0.42 (p = 0.12) with lung metastases, and a relative change in validation AUC of 0% in comparison with the texture-based model response alone in LOO-CV experiments. In contrast, the addition of AU-IVH-Ktrans improved predictive power, yielding a correlation of rs = −0.54 (p = 0.04) with lung metastases, and a change in validation AUC of +10%. Our results demonstrate that texture-based models extracted from pre-treatment FDG-PET and MRI anatomical scans could be successfully used to predict distant metastases in STS cancer. Our results also suggest that the addition of perfusion heterogeneity metrics may contribute to improving model prediction performance

A retrospective review of 57 military patients undergoing ankle arthroscopy between 1999 and 2011 was performed. A case-note review of medical records was undertaken pertaining to military role, ankle injury sustained, mechanism, presenting symptoms and their duration. Arthroscopic findings were compared to findings on radiographs and MRI scans. At first presentation 23 patients had features of arthritis on radiographs. We found MRI was both highly sensitive (97.7%) and specific (93.4%) in detecting osteochondral defects (OCD). 16 of the patients had evidence of osteochondral injury. All OCDs picked up on MRI were confirmed at arthroscopy. Ankle injury may not be a benign injury in military personnel, with over half of these young patients having radiological features of osteoarthritis at presentation. We found MRI an effective tool for identifying occult injuries not seen on radiographs. Lateral ligament injury with associated gutter scarring can be successfully treated with arthroscopic debridement. This suggests pseudoinstability rather than a true mechanical instability as the main cause for patient's symptoms in this cohort

Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England.

Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs.

In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1.

Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology.

For any figures or tables, please contact the authors directly.

Critical shoulder angle (CSA), lateral acromial angle (LAA), and acromion index (AI) are common radiologic parameters used to distinguish between patients with rotator cuff tears (RCT) and those with an intact rotator cuff. This study aims to assess the predictive power of these parameters in degenerative RCT.

This retrospective study included data from 92 patients who were divided into two groups: the RCT group, which included 47 patients with degenerative full-thickness supraspinatus tendon tears, and a control group of 45 subjects without tears. CSA, AI, and LAA measurements from standardized true anteroposterior radiographs were independently derived and analyzed by two orthopedic surgeons. Receiver operating characteristic (ROC) analyses were performed to determine the cutoff values.

No significant differences were found between patients in the RCT and control groups in age (p = 0.079), gender (p = 0.804), or injury side (p = 0.552). Excellent inter-observer reliability was seen for CSA, LAA, and AI values. Mean CSA (38.1°) and AI (0.72) values were significantly larger in the RCT group than in the control group (34.56° and 0.67°, respectively, p < 0.001) with no significant difference between groups for LAA (RCT, 77.99° vs. control, 79.82°; p = 0.056). ROC analysis yielded an area under the curve (AUC) of 0.815 for CSA with a cutoff value of 37.95°, and CSA was found to be the strongest predictor of the presence of a RCT, followed by AI with an AUC of 0.783 and a cutoff value of 0.705.

We conclude that CSA and AI may be useful predictive factors for degenerative RCT in the Turkish population.

Background. Total ankle replacement (TAR) design has evolved greatly in recent years and offers a reasonable alternative to ankle arthrodesis in a select patient population with end-stage arthritis. Originator series’ report good longevity and excellent patient reported outcomes (PROMs). We report our outcomes in an independent, non-inventor cohort. Method. We collected prospective data on consecutive patients undergoing total ankle replacement between April 2008 and March 2012, under the care of one Consultant Orthopaedic surgeon. The primary outcome measure was time to revision. Secondary outcomes measures included American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Score (VAS) for pain, and complications. Results. 70 patients underwent TAR with a mean follow-up of 64 months (39–86). Three patients underwent revision of TAR to ankle arthrodesis, two for aseptic loosening and one for infection, equating to survivorship of 96%. Three patients sustained intra-operative fractures, one of the lateral malleolus and two of the medial malleolus. The patient who sustained the lateral malleolus fracture later went on to develop aseptic loosening requiring revision. One patient developed a late stress fracture of the medial malleolus. Two patients underwent open exploration, grafting of bone cysts and fixation for ongoing pain at a mean time of 4.5 years following the primary TAR. At the most recent review all patients reported improved AOFAS scores from 39.55 (21–52) to 82.10 (57–100) and VAS from 9.11 (6–10) to 1.79 (0–6) respectively. Conclusions. Longevity of the Zenith TAR in our non-inventor series is comparable to that of originator outcomes. Fractures are a recognized complication of TAR and when affecting the medial malleolus, do not appear to have an adverse effect on outcome. We feel that TAR offers an effective alternative solution to ankle arthrodesis with satisfactory relief of pain whilst preserving movement at the ankle joint

Aim. To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap. Method. This is a prospective cohort of 43 patients (24 male, 19 female) with average age of 62 years. The primary indication of surgery was pain. Patients with massive rotator cuff tear involving supraspinatus and infraspinatus, showing retraction and fatty infiltration in MRI were selected. Few (8/43) were with failed surgical treatment and rest had conservative treatment failed. They underwent rotator cuff repair during Feb 1999 to Jan 2004. The long head of the triceps was detached from the olecranon, rotated 180 degrees from its pivot point with its major vascular pedicle under the deltoid and acromion through the posterior capsule and attached to the greater tuberosity and any remnant of remaining cuff. All patients were assessed pre-operatively, at 3, 6 and 12 months post-operatively clinically and also using UCLA pain and functional score for shoulder. Shoulder range of motion was assessed before and after the surgery. 24 patients had minimum of 1 year and 19 had 2 year minimum follow-up. Results. The mean total UCLA score of 9.7 pre-operatively improved to 27.8 (p<0.0001) following the operation. The mean pre-operative UCLA pain score 2.2 improved to 7.8 post-operatively (p<0.001). The UCLA functional score improved from a pre-operative average of 3.4 to 8.2 (p<0.0001) following the operation. There was significant improvement in forward elevation, external and internal rotation but not abduction. There was no weakness in elbow extension. Complications: 3 superficial infections, 1 ulnar neuritis (resolved in 6 weeks), 1 olecranon bursitis (resolved in 3 months). Conclusion. Long head triceps tendon transfer is an effective technique to alleviate pain and improve functions in patients with massive rotator cuff tear, specially in difficult group of patients with limited options

Purpose: Total knee arthroplasty is one of the most successful modern surgical interventions with excellent clinical outcomes and implant survivorship. Nevertheless, with the increasing numbers of primary knee replacements being performed and increasing life expectancy, the need for revision arthroplasty continues to grow and is expected to grow considerably in to the future. Stemmed implants are commonly used in revision knee arthroplasty to provide adequate support for the joint interfaces. Controversy exists amongst surgeons as to the relative merits of cemented versus uncemented stems in revision knee arthroplasty. Cementing stemmed components in revision knee arthroplasty surgery is well established, and has well documented success rates. Though in widespread use, there is little data published regarding the technique of cementing short stubby tibial stems in revision TKA. We describe modes of failure in knee arthroplasty, our technique for revision, and early outcomes for this patient cohort. Method: This was a retrospective analysis of a cohort of patients who have undergone revision knee arthroplasty. We evaluated the early clinical results looking for early failure in patients who have undergone revision knee arthroplasty using a short cemented tibial stem. All patients were operated on by a single surgeon in a single hospital. Baseline data was collected on all patients (age, gender, BMI, reason for revision, preoperative knee scores, details of surgery). Latest follow up clinical data, knee scores, and x-rays were evaluated to determine early patient outcomes and identify any implant or technical failure. Results: Between 2003 and 2009, 77 of 241(32%) revision knee arthroplasty surgeries were performed using a short cemented tibial stem. This cohort of 77 patients included 49 females and 27 males. Eight knees (10%) were operated in two stages in the setting of deep infection. Average follow up for this group was 17 months (range 4 to 60 months). One patient developed a deep prosthetic infection requiring further revision surgery. No other patients to our knowledge have undergone further surgery and none have further surgery planned for mechanical failure or significant malalignment of the tibial prosthesis. No failure or early mechanical complication of using a short cemented tibial stem was identified clinically or radiographically. Conclusion: We surmise the use of short cemented tibial stems in revision knee arthroplasty surgery is a safe and effective technique with potential advantages over longer cemented or uncemented stems. We have recorded satisfactory early outcomes, and continue to use this technique

Hip fracture is a global public health problem. The National Hip Fracture Database provides a framework for service evaluation in this group of patients in the United Kingdom, but does not collect patient-reported outcome data and is unable to provide meaningful data about the recovery of quality of life.

We report one-year patient-reported outcomes of a prospective cohort of patients treated at a single major trauma centre in the United Kingdom who sustained a hip fracture between January 2012 and March 2014.

There was an initial marked decline in quality of life from baseline measured using the EuroQol 5 Dimensions score (EQ-5D). It was followed by a significant improvement to 120 days for all patients. Although their quality of life improved during the year after the fracture, it was still significantly lower than before injury irrespective of age group or cognitive impairment (mean reduction EQ-5D 0.22; 95% confidence interval (CI) 0.17 to 0.26). There was strong evidence that quality of life was lower for patients with cognitive impairment. There was a mean reduction in EQ-5D of 0.28 (95% CI 0.22 to 0.35) in patients <  80 years of age. This difference was consistent (and fixed) throughout follow-up. Quality of life does not improve significantly during recovery from hip fracture in patients over 80 years of age (p = 0.928). Secondary measures of function showed similar trends.

Hip fracture marks a step down in the quality of life of a patient: it accounts for approximately 0.22 disability adjusted life years in the first year after fracture. This is equivalent to serious neurological conditions for which extensive funding for research and treatment is made available.

Cite this article: Bone Joint J 2015;97-B:372–82.

Aims: To assess the failure rate at 5 years of the Elite Plus (DePuy) femoral stem and identify reasons for early failure. Particular attention was paid to the quality of the cement mantle. Methods: A cohort of the first 241 primary THR performed in 234 patients were identified. Each patient completed the Oxford Hip Score (OHS), and had AP and lateral radiographs. The cement mantle was graded by Mulroy’s modification of Barrack’s system using all AP and lateral radiographs. Results: At follow up 39 patients (42 hips) had died, 14 were lost to follow up and 35 (36 hips) too unwell/ unwilling to take part leaving149 hips in 146 patients available for independent assessment. The mean follow up was 60.2 months (range 48.3–75.8 months). Five hips (3.4%), have been revised, 1 after traumatic dislocation, 1 for deep infection and 3 for aseptic loosening. In a further 11 (7.4%) patients there was radiological evidence of progressive femoral loosening, although only 2 of the 7 available for review were symptomatic. The median OHS was 20 (range 12–51). All those revised or radiologically loose had defective cement mantles (C2). A cement mantle less than 1 mm thick was associated with early failure (p< 0.03). Conclusions: The revision rate at 5 years is 3.4%. Loosening is related to suboptimal cement mantles in particular mantle thickness of less than 1 mm. We have documented the invisible cohort of those who have loosened radiologically but are asymptomatic. Regular surveillance of this cohort is mandatory to allow comparison with longer-term results of other prostheses

Background. Combined physical and psychological (CPP) programmes are widely recommended for Chronic Low Back Pain (CLBP) patients, but not often implemented. Patients with longstanding CLBP participating in a two-week CPP programme improve in functional status and quality of life and this is maintained at two-year follow up. One-year follow-up data is available of 955 participants. Purpose:. Evaluation of one-year follow-up outcomes of a large cohort (n=848) compared to previously published results of the first 107 patients. Methods and Results. Pre-treatment age (43.4 years [SD8.4]), CLBP duration (12.3 years [SD10.9]), being employed (70%), and previous surgery (32%) were compared. Except for age (48.0 [SD 11.6], t=−4.0, p<0.001), no significant differences in pre-treatment characteristics were found. Primary outcome was functional status (Oswestry Disability Index [ODI;0-100]). Secondary outcomes: self-efficacy and quality of life. A Repeated Measures analysis of variance was used to identify changes over time (R. 2. ) and to compare differences between cohorts. The mean ODI score showed a similar pattern: improvement at post-treatment and maintenance of results over time (ODI df[1,848], F = 917.0, p<0.001; R. 2. = 0.52). Secondary outcomes showed the same pattern. Compared to previously reported results, significantly more improvement over time is shown. Half of the CLBP patients (50.1%) reached a functional status equivalent to an acceptable value (ODI ≤ 20). Conclusion. These results demonstrate the efficacy of this CPP programme. Patients improve during the programme, have further improved at one-year follow up, and half of the patients improve such that their functional status is comparable to that of the healthy population

Aims

We have previously demonstrated raised cobalt and chromium levels in patients with larger diameter femoral heads, following metal-on-polyethylene uncemented total hip arthroplasty. Further data have been collected, to see whether these associations have altered with time and to determine the long-term implications for these patients and our practice.

In the young and highly active population of military patients, femoroacetabular impingement can be a source of serious disability as well as a threat to their career. This morbidity can be treated with hip arthroscopy with debridement of cam lesion, and excision or repair of a corresponding labral tear. We report on the long term outcomes (>1 year) of 26 military cases who underwent hip arthroscopy for femoroacetabular impingement, in a single surgeon's series. Twenty two patients (four bilateral cases) underwent hip arthroscopy as a day case procedure during the period February 2013 to October 2014. Non-Arthritic Hip Scores (NAHS) were obtained from patients pre-operatively, at two months, four months and at least one year post-operatively. There was a significant improvement in NAHS at two months (75.6)(p<0.05), four months (85.1)(p<0.001) and one year (84.8)(p<0.001), compared to pre-operative NAHS (65.8). There was no significant change in NAHS beyond four months. Only three out of the 22 patients were medically discharged secondary to persistent hip symptoms. Hip arthroscopy for femoroacetabular impingement is an effective, viable procedure for military patients. Mobility, pain and function is significantly improved after surgery. This improvement is sustained in the long term up to and beyond one year.