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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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