Aims. This study assesses patient barriers to successful telemedicine care in orthopaedic practices in a large academic practice in the COVID-19 era. Methods. In all, 381 patients scheduled for telemedicine visits with three orthopaedic surgeons in a large academic practice from 1 April 2020 to 12 June 2020 were asked to participate in a telephone survey using a standardized Institutional Review Board-approved script. An unsuccessful telemedicine visit was defined as patient-reported difficulty of use or reported dissatisfaction with teleconferencing. Patient barriers were defined as explicitly reported barriers of unsatisfactory visit using a process-based satisfaction metric. Statistical analyses were conducted using analysis of variances (ANOVAs), ranked ANOVAs, post-hoc pairwise testing, and chi-squared independent analysis with 95% confidence interval. Results. The survey response rate was 39.9% (n = 152). The mean age of patients was 51.1 years (17 to 85), and 55 patients (38%) were male. Of 146 respondents with completion of survey, 27 (18.5%) reported a barrier to completing their telemedicine visit. The majority of patients were satisfied with using telemedicine for their orthopaedic appointment (88.8%), and found the experience to be easy (86.6%). Patient-reported barriers included lack of proper equipment/internet connection (n = 13; 8.6%), scheduling difficulty (n = 2; 1.3%), difficulty following directions (n = 10; 6.6%), and patient-reported discomfort (n = 2; 1.3%). Barriers based on patient characteristics were age > 61 years, non-English primary language, inexperience with video conferencing, and unwillingness to try telemedicine prior to COVID-19. Conclusion. The barriers identified in this study could be used to screen patients who would potentially have an unsuccessful telemedicine visit, allowing practices to provide assistance to patients to reduce the risk of an unsuccessful visit. Cite this article: Bone Jt Open 2021;2(9):745–751

The routine use of intraoperative vancomycin powder to prevent postoperative wound infections has not been borne out in the literature in the pediatric spine population. The goal of this study is to determine the impact of vancomycin powder on postoperative wound infection rates and determine its potential impact on microbiology. A retrospective analysis of the Harms Study Group database of 1269 adolescent idiopathic scoliosis patients was performed. Patients that underwent a posterior fusion from 2004-2018 were analyzed. A comparative analysis of postoperative infection rates was done between patients that received vancomycin powder to those who did not. Statistical significance was determined using Chi-squared test. Additionally, the microbiology of infected patients was examined. In total, 765 patients in the vancomycin group (VG) were compared to 504 patients in the non-vancomycin group (NVG). NVG had a significantly higher rate of deep wound infection (p<0.0001) and associated reoperation rate compared to VG (p<0.0001). Both groups were compared for age, gender, race, weight, surgical time, blood loss, number of levels instrumented, and preop curve magnitude. There were significant differences between the groups for race (p<0.0001); surgical time (p=0.0033), and blood loss (p=0.0021). In terms of microbiology, VG grew p.acnes (n=2), and serratia (n=1), whereas NVG grew p.acnes (n=1) and gram positive bacilli (n=1). The remaining cultures were negative. The use of intraoperative vancomycin powder in adolescent idiopathic scoliosis appears to contribute significantly to deep wound infection prevention and reduction of associated reoperations. Based on this study's limited culture data, Vancomycin does not seem to alter the microbiology of deep wound infections

Tibial pilon fractures are typically the result of high-energy axial loads, with complex intra- articular fractures that are often difficult to reconstruct anatomically. Only nine simultaneous pilon and talus fractures have been published previously, but we hypothesised the chondral surface of the dome is affected more frequently. Data was acquired prospectively from 154 acute distal tibial pilon fractures (AO/OTA 43B/C) in adults. Radiographs, photographs, and intra-operative drawings of each case were utilised to document the presence of any macroscopic injuries of the talus. Detailed 1x1mm maps were created of the injuries in each case and transposed onto a statistical shape model of a talus; this enables the cumulative data to be analysed in Excel. Data was analysed using a Chi-squared test. From 154 cases, 104 were considered at risk and their talar domes were inspected; of these, macroscopic injuries were identified in 55 (52.4%). The prevalence of talar dome injury was greater with B-type fractures (53.5%) than C-type fractures (31.5%) (ρ = .01). Injuries were more common in men than women and presented with different distribution of injuries (ρ = .032). A significant difference in the distribution of injuries was also identified when comparing falls and motor vehicle accidents (ρ = .007). Concomitant injuries to the articular surface of the dome of the talus are relatively common, and this perhaps explains the discordance between the post-operative appearance following internal fixation and the clinical outcomes observed. These injuries were focused on the lateral third of the dome in men and MVAs, whereas women and fall mechanism were more evenly distributed. Surgeons who operatively manage high-energy pilon fractures should consider routine inspection of the talar dome to assess the possibility of associated macroscopic osteochondral injuries

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori. A retrospective cohort study from January 1. st. , 2015, to December 31. st. 2020 inclusive. Eligible patients were 16–65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriate. No statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004). Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori. The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes. This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test. The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis. The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable

Australian Football (AF) is a popular sport in Australia, with females now representing one-third of participants. Despite this, the injury profiles of females versus males in largely unknown. The current study investigated fractures, dislocations and tendon ruptures in females versus males presenting to emergency departments (ED) with an AF injury. All patients, regardless of age, presenting to one of 10 EDs in Victoria, Australia, with an AF injury were included. Data were prospectively collected over a 10-month period, coinciding with a complete AF season. Data were extracted from patient medical records regarding injury-type, body-part injured and treatments required. Female and male data were compared with chi-squared tests. Of the 1635 patients presenting with an AF injury, 595 (36.0%) had a fracture, dislocation or tendon rupture, of whom 85 (14.3%) were female and the average age was 20.5 years (SD 8.0). Fractures accounted for most injuries (n=478, 80.3% of patients had a fracture), followed by dislocations (n=118, 19.8%) and tendon ruptures (n=14, 2.4%). Upper limb fractures were more common than lower limb fractures (71.1% v 11.5% of fractures). Females were more likely to fracture their hands or fingers than males (45.7% v 34.3%). Males were more likely to fracture ribs (5.4% v 0%). Most fractures (91.2%) were managed in the ED, with the remainder being admitted for surgery (GAMP/ORIF). Males were more likely to be admitted for surgery than females (11.2% v 5.9%). Regarding dislocations (n=118), females were more likely to dislocate the patella (36.8% v 8.1% of dislocations). Only males sustained a tendon rupture (n=14): finger extensor or flexor (57.1%), achilles tendon (28.6%) and patella tendon (14.3%). Orthopaedic AF injuries are common presentations to EDs in Victoria, though few require specialist orthopaedic intervention. Injury profiles differed between genders suggesting that gender specific injury prevention and management might be required

Hip resurfacing may be a useful surgical procedure when patient selection is correct and only implants with superior performance are used. In order to establish a body of evidence in relation to hip resurfacing, pseudotumour formation and its genetic predisposition, we performed a case-control study investigating the role of HLA genotype in the development of pseudotumour around MoM hip resurfacings. All metal-on-metal (MoM) hip resurfacings performed in the history of the institution were assessed. A total of 392 hip resurfacings were performed by 12 surgeons between February 1st 2005 and October 31st 2007. In all cases, pseudotumour was confirmed in the preoperative setting on Metal Artefact Reduction Sequencing (MARS) MRI. Controls were matched by implant (ASR or BHR) and absence of pseudotumour was confirmed on MRI. Blood samples from all cases and controls underwent genetic analysis using Next Generation Sequencing (NGS) assessing for the following alleles of 11 HLA loci (A, B, C, DRB1, DRB3/4/5, DQA1, DQB1, DPB1, DPA1). Statistical significance was determined using a Fisher's exact test or Chi-Squared test given the small sample size to quantify the clinical association between HLA genotype and the need for revision surgery due to pseudotumour. Both groups were matched for implant type (55% ASR, 45% BHR in both the case and control groups). According to the ALVAL histological classification described by Kurmis et al., the majority of cases (63%, n=10) were found to have group 2 histological findings. Four cases (25%) had group 3 histological findings and 2 (12%) patients had group 4 findings. Of the 11 HLA loci analysed, 2 were significantly associated with a higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) and 4 were noted to be protective against pseudotumour formation (DQA1*03:01:01, DRB1*04:04:01, C*01:02:01, B*27:05:02). These findings further develop the knowledge base around specific HLA genotypes and their role in the development of pseudotumour formation in MoM hip resurfacing. Specifically, the two alleles at higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) in MoM hip resurfacing should be noted, particularly as patient-specific genotype-dependent surgical treatments continue to develop in the future

Aims. Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford. Methods. An observational study was conducted, using data from the Bradford Teaching Hospitals TB database of patients with a formal diagnosis of MSK TB between January 2005 and July 2017. Patient data included demographic data (including nationality/date of entry to the UK), disease focus, microbiology, and management strategies. Disease incidence was calculated using population data from the Office for National Statistics. Poisson confidence intervals were calculated to demonstrate the extent of statistical error. Disease incidence and nationality were also analyzed, and correlation sought, using the chi-squared test. Results. Between January 2005 and July 2017, 109 cases of MSK TB were diagnosed in Bradford. Mean incidence was 1.65 per 100,000 population, per calendar year (SD 0.75). A total of 38 cases required surgical intervention. Low rates of antimicrobial resistance were encountered. A low rate of loss to follow-up was observed (four patients; 3.7%). Overall, 94.5% of patients (n = 103) were successfully treated. 67% of patients (n = 73) reported their country of origin as either India, Pakistan, or Bangladesh. These ethnicities account for around 25% of the local population. Conclusion. Bradford maintains a high prevalence of MSK TB infection relative to national data; the prevalence within the local immigrant population remains grossly disproportionate. Typical associated factors (HIV/hepatitis coinfection, drug resistance), have only modest prevalence in our dataset. However, local socioeconomic factors such as deprivation and poverty appear germane as suggested by global literature. We advocate a high degree of suspicion in treatment of atypical infection in any area with similar population factors to ensure timely diagnosis. Cite this article: Bone Jt Open 2022;3(5):432–440

Aim. Debridement, antibiotic, and implant retention (DAIR) is an accepted treatment of early and late acute Total Knee Arthroplasty (TKA) infections. DAIR failure may adversely affect the outcome of a subsequent two-stage exchange arthroplasty. Controversy exists on risk factors that can affect DAIR's results. The aim of the study is to review presurgical, intrasurgical and postsurgical variables that could affect DAIR's result. Method. A retrospective study of 27 DAIRs performed between 2015–2019 to treat late acute TKA infections was carried out. Patients were divided into two groups depending on DAIR's outcome [Healing (H) vs non-healing group (NH)] according on the Delphi-based multidisciplinary consensus criteria on success after treatment of periprosthetic joint infection. We reviewed presurgical variables, including epidemiological variables (Age, Sex, comorbidities, ASA, Charlson, BMI, alcohol dependency), prosthesis variables (prosthesis type, primary cause of operation, primary TKA surgery center), infection variables (concomitant infection, previous antibiotic treatment, c-reactive protein, synovial WBC count, synovial % PMN, pathogen), KLIC score and CRIME 80 score. Surgical variables such as surgery duration and type of surgery (elective vs urgent). Post-surgical variables like antibiotic treatment duration and destination at discharge. Normal distribution was assessed by Shapiro-Wilk test. Mann Whitney U test was used to compare the two independent sample variables. Chi-squared test was used for qualitative variables. P-value was established at 0.05 and statistical power at 80%. Results. Infection Healing was achieved in 63% of patients. In presurgical variables, alcohol dependency, hypertension, liver disease, previous surgery performed in another institution were more frequent in NH group (p< 0.05). KLIC score value equal or greater than 4 had a higher risk of surgical failure (p < 0.05). Regarding surgical variables, the healing group had more negative cultures than de non-healing one (p<0.05). Regarding post-surgical variables, long term antibiotic treatment (six months) achieved more healing after DAIR (p<0.05). Conclusions. Alcohol dependency, hypertension, liver disease and KLIC score values equal or greater than 4, may increases the risk of DAIR failure. Finally, we observed that the long-term antibiotic treatment (6 months) favors healing after DAIR

Aim. Septic arthritis is a painful infection of articular joints that is typically treated by irrigation & debridement along with antibiotic therapy. There is debate amongst the medical community whether antibiotic administration should be delayed until fluid cultures have been taken to improve culture yield. However, delaying antibiotics can also have negative consequences, including joint destruction and sepsis. Therefore, the purposes of this study were to determine: 1) whether delayed antibiotic treatment affects culture yield and prognosis and 2) if the culture yield of patients treated for septic arthritis differs for hip, knee, and shoulder based on timing of antibiotic administration. Method. A retrospective analysis was conducted on 111 patients with septic arthritis of the hip, knee, or shoulder admitted from 3/2016 to 11/2018. In patients with multiple septic joints, each joint was analyzed individually (n=122). Diagnosis was determined by the treatment of irrigation & debridement and/or a positive culture. Patients without all intervention times recorded or with periprosthetic joint infection were excluded. Demographics, laboratory tests, culture results, and intervention times were obtained through chart review. Patients were grouped based on antibiotic therapy timing: >24 hours prior to arthrocentesis (Group 1), between 24 hours and 1 hour prior (Group 2), and 1 hour prior to post-arthrocentesis (Group 3). Analysis was conducted using chi-squared tests. Results. The mean age of each group were similar: Group 1 (n=38) 55.7 years, Group 2 (n=20) 57.2 years, and Group 3 (n=64) 54.8 years. No difference was observed in culture sensitivity between groups (p=0.825) with 71.1% (27/38) positive cultures in Group 1, 75% (15/20) in Group 2, and 76.6% (49/64) in Group 3. Similarly, frequency of related readmissions within 90 days (p=0.863) did not significantly vary: 26.3% (10/38) in Group 1, 20% (4/20) in Group 2, and 25% (16/64) in Group 3. Additionally, there were no significant differences in culture sensitivity in the knee (p=0.618; Groups: 87.5%, 75%, 70.6%), shoulder (p=0.517; Groups: 77.8%, 66.7%, 90%), and hip (p=0.362; Groups: 61.9%, 80%, 80%). Conclusions. Culture sensitivities and rates of readmission were similar for all patients regardless of antibiotic administration timing. These results suggest that antibiotic administration should not be delayed in septic arthritis to improve culture yield. However, the data does not suggest that early antibiotic administration will result in better clinical outcomes by lowering readmission rates. Further research is needed to better determine the clinical benefits that early administration of antibiotics may have on patient outcomes

Although the impact of sexual difficulties on quality of life in patients with hip osteoarthritis has been documented in previous literature, recent research has shown that surgeons rarely discuss this sensitive topic with patients. The purpose of this study was to develop an educational tool to address common questions that patients may have regarding returning to sexual activity following their total hip arthroplasty (THA). The study was conducted in two phases. In Phase 1, patients who underwent a THA between 2013–2017 at a single centre were retrospectively identified and sent an anonymous online survey. This survey was aimed at assessing patient-specific concerns regarding whether they would have liked to receive information about returning to sexual activity, what information they would have liked to know and how they would have liked to receive this information. An educational tool was developed based on the findings of Phase 1. In Phase 2, prospective patients who were scheduled for a unilateral or bilateral THA were provided with the educational tool prior to their surgery. A questionnaire was administered to evaluate the effectiveness of this educational tool. Descriptive statistics and chi-squared tests were used for data analysis. In Phase 1, the overall response rate was 34.7% (n = 58/167). Out of the total respondents, 51.7% indicated an interest in receiving information on when to return to sexual activity following a THA. Patients selected an informational pamphlet as the most desired method of receiving information (p = .044). In Phase 2, the response rate was 54.5% (n = 30/55). Overall, 90% of patients felt that the pamphlet addressed all their concerns, and 93.3% felt they were provided with adequate information on how they could get more information. The pamphlet addressed questions regarding when it was safe to resume sexual activity following a THA, what positions were safe, and the associated risks. Individuals undergoing a THA are modestly interested in receiving information regarding when to return to sexual activity following their surgery, especially those who are sexually active preoperatively. This educational pamphlet may be useful in routine clinical practice in addressing concerns regarding returning to sexual activity. Understanding patients' goals and expectations for their postoperative course may help surgeons provide a more comprehensive approach to patient care

Introduction. Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome. Objective. To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible. Methods. 2953 consecutive complex spine operations (male 36% female 64%, median age 25yrs) prospectively performed using spinal cord monitoring at a single institution (2005–2009). All traces and neurophysiological events were prospectively recorded by the neurophysiology technician. All patients with a significant neurophysiology event were examined clinically by a neurologist, separate from the spinal surgery team. Significant trace abnormality was defined as a decrease in signal amplitude of 50% or a 10% increase in latency. Timing of trace abnormality, surgeon's response and prospective neurological outcome were recorded. Sensitivity, specificity, positive/negative predictive value were calculated. A Chi-squared test was performed to assess the impact of intervention on neurological outcome (p < 0.05). Results. 2953 operations involving SSEP monitoring were performed and 106 recorded a significant trace abnormality. This most often occurred during instrumentation and the most common reaction was adjustment of metalwork. SSEP monitoring had a sensitivity of 100%, specificity 97.3%, PPV 24%, NPV 100%. There were 79 false positives and no false negatives in this series. Chi-squared test was not significant (p=0.18) suggesting that intervention might not affect neurological outcome in this cohort. Conclusions. Triggering events are uncommon and the development of a persistent neurological deficit is rare with an incidence of 0.85% in this series of 2953 operations. In the majority of cases detection of a monitoring abnormality prompts a corrective reaction by the surgeon. Of those with an abnormal trace 76% were neurologically normal at follow up

Aim. Two stage revision is the most commonly used surgical treatment strategy for periprosthetic hip infections (PHI). The aim of our study was to assess the intra- and postoperative complications during and after two stage revision using resection arthroplasty between ex- and reimplantation. Method. In this retrospective cohort study, all patients treated with a two stage revision using resection arthroplasty for PHI were included from 2008 to 2014. During the first stage, the prosthesis was removed resulting in a resection arthroplasty without the use a PMMA spacer. During second stage, (cemented or uncemented) reimplantation of the hip prosthesis was performed. The cohort was stratified into two groups according to the length of prosthesis-free interval (≤10 weeks and >10 weeks). Data on complications during explantation, prosthesis-free interval, reimplantation, and after reimplantation was collected. The overall complication rate between both groups was compared using the chi-squared test. The revision-free and infection-free survival was estimated using Kaplan-Meier survival analysis. Results. Overall, 93 patients with hip PJI treated with two-stage revision performing resection arthroplasty were included, 49 had a prosthesis-free interval of ≤10 weeks, and 44 an interval of >10 weeks. A total of 146 complications was documented in the cohort. Patients were followed-up for a mean duration of 42.7 months, range: 13.1 – 104.6 months. Blood loss during reimplantation [n=25], blood loss during explantation [n=23], persistent infection during prosthesis-free interval [n=16], leg length discrepancy [n=13], and reinfection [n=9] were the most common complications. No complication showed a statistically significant difference between both groups except for wound healing disorder after reimplantation, which was more often reported in the group with > 10 weeks interval (p=0.009). A statistically significant increase of periprosthetic bone fractures (p=0.05), blood loss (p=0.039), and total number of complications (p=0.008) was seen with increasing acetabular bone defects (after Paprosky). Infection-free survival rate at 24 months was 93.9% (95% CI: 87.2 – 100) in the group with ≤10 weeks interval and 85.9% (95% CI: 75.4 – 96.4) with an interval of > 10weeks. Conclusions. After two years of follow-up, the infection-free survival rate using resection arthroplasty during two stage revision for PHI was higher in the group with ≤10 weeks interval compared to the group with >10 weeks interval. The most common complications during and after a two stage revision using resection arthroplasty were blood loss during the two surgeries, persistent infection during the prosthesis-free interval, leg length discrepancy, and reinfection

Level of evidence (LOE) determination is a reliable tool to assess the strength of research based on study design. Improvements in LOE are necessary for the advancement of evidence-based clinical care. The objectives of this study were to determine if the LOE presented at the Musculoskeletal Tumour Society (MSTS) annual meeting has improved over time and to determine how the LOE presented at MSTS annual meetings compares to that of the Orthopaedic Trauma Association (OTA) annual meetings. We reviewed abstracts from the MSTS and OTA annual meeting podium presentations from 2005 to 2014. Three independent reviewers evaluated a total of 1222 abstracts for study type and LOE. Changes in the distributions of study type and LOE over time were evaluated by Pearson Chi-Squared test. There were a total of 577 podium abstracts from the MSTS and 645 from the OTA. Of the MSTS therapeutic studies, 0.5% (2/376) were level I, while 75% (281/376) were level IV. There was a seven-fold higher proportion of level I studies (3.4% [14/409]) and less than half as many level IV studies (32% [130/409]) presented at OTA. There was no improvement in the MSTS LOE for all study types (p=0.13) and therapeutic study types (p=0.36) over the study decade. In contrast, the OTA LOE increased significantly over this time period for all study types (p<0.01). The proportion of controlled therapeutic studies (LOE I through III) versus uncontrolled studies (LOE IV) increased significantly over time at the OTA (p<0.021), but not at the MSTS (p=0.10). Uncontrolled case series continue to dominate the MSTS scientific program, whereas over the past decade, higher-level studies and more modern study methodology has been employed by members of the OTA

INTRODUCTION. Osteoarthritis (OA) is a growing societal burden, due to the ageing population. Less invasive, less damaging, and cheaper methods for diagnosis are needed, and sound technology is an emerging tool in this field. Some studies investigate ultrasound signals, while others look at acoustic signals in the audible range. AIMS. The aim of the current research was to: 1) investigate the potential of visual scalogram analysis of Acoustic Emission (AE) frequencies within the human audible range (20–20000 Hz) to diagnose knee OA, 2) correlate the qualitative visual scalogram analysis of the AE with OA symptoms, and 3) to do this based on information gathered during gait. METHODS. The analysis was carried out on a database collected during a prospective sound study on healthy and osteoarthritic knees. Sound recordings obtained with a contact microphone mounted on the patella and attached to a digital pre-amplifier, whilst patients were walking on a treadmill, were visualised, manually sampled, and transformed into scalograms. Features of the scalograms were described and qualitatively analysed through chi-squared tests for association with healthy or OA knees (knee status), and with severity of OA pain and functional symptoms and impact on quality of life (QoL), activities of daily living (ADL) and sports using the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales. RESULTS. 28 patients (56 knees) were included in the analysis. Our method provides a wide variety of different scalogram features: if no events were recorded, the scalogram was classified as ‘quiet’ (Fig 1). In case of abnormal recordings, data analysis evaluated association with the total count of the three most common events that appeared: 1. Peak (Fig 2), 2. Scattered (Fig 3) or 3. Island (localized noise but not presenting as a peak) (Fig 4) – “scalogram features”. No association was found between global scalogram characteristics (quiet versus ‘any noise’) and knee status (healthy or OA) (χ. 2. =3.163, p=0.075), but was found between knee status and three specific scalogram features (χ. 2. =9.743, p=0.008). The strongest association was a higher frequency of the “scattered” feature in the OA group (χ. 2. =9.06, p=0.01). Scalogram characteristics had no significant association with the sports and recreation (χ. 2. =1.74, p=0.419) nor the activities of daily living (χ. 2. =1.80, p=0.406) KOOS subscales. Significant association was found between scalogram characteristic and the pain (χ. 2. =10.34, p=0.006), quality of life (χ. 2. =6.58, p=0.037), and symptoms (χ. 2. =7.54, p=0.023) subscales. CONCLUSION. Promising results from analysis of individual features and of KOOS subscales establish the potential of acoustic analysis in evaluation of OA knees. More analysis of the data is needed to better define the variety of scalogram features. The future consequences of this research would be the development of a fast and affordable, non-invasive, radiation-free and potentially portable approach to evaluation, diagnosis and longitudinal monitoring of knee disorders. For any figures or tables, please contact the authors directly

Introduction. Hip arthroplasty is one of the most common procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following hip arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing hip arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,011,184 (64.8% Medicare, 29.3% private insurance, 3.7% Medicaid or uninsured, 2.0% Other) patients fulfilled criteria for inclusion into the study. Most were primary total hip arthroplasties (64.2%) and primary hip hemiarthroplasty (29.8%), with 6% revision hip arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.8, p=<0.001) and those with Medicaid or no insurance had more medical complications (OR 1.06, p=0.005) compared to Medicare patients. Similar trends were found for surgical complications and mortality. The matched cohort showed Medicare and private insurance patients had similar complication rates. The most common complication was postoperative anemia, occurring in 22.6% of Medicare patients and 21.1% of patients with private insurance (RR=1.06, p<0.001). Discussion and. Conclusion. This data reveals that patients with Medicare, Medicaid or no insurance have higher risk of medical complications, surgical complications and mortality following hip arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications are similar and generally low with the notable exception of the most common complication, postoperative anemia, which occurs more frequently in patients with Medicare

Introduction. Knee arthroplasty is one of the most common inpatient surgeries procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following knee arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing knee arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,352,505 (57.8% Medicare, 35.6% private insurance, 2.6% Medicaid or uninsured, 3.3% Other) patients fulfilled criteria for inclusion into the study. Most were primary total knee arthroplasties (96.1%) with 3.9% revision knee arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.82, p=<0.001) compared to Medicare patients. Similar trends were found for surgical complications and mortality. Patients with Medicare or no insurance had more surgical complications but equivalent rates of medical complications and mortality. The matched cohort showed Medicare and private insurance patients had overall low mortality rates and complication. The most common complication was postoperative anemia, occurring in 16.2% of Medicare patients and 15.3% of patients with private insurance (RR=1.06, p<0.001). Mortality (RR 1.34), wound dehiscence (RR 1.32), CNS, GI complications, although rare, were all statistically more common in Medicare patients (p<0.05) while cardiac complications (RR 0.93, p=0.003) was more common in patients with private insurance. Discussion and Conclusion. This data reveals that patients with Medicare insurance have higher risk of medical complications, surgical complications and mortality following knee arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications were low overall (with the exception of postoperative anemia), but in general were more common in Medicare patients

Background. Intravenous and topical tranexamic acid (TXA) has become increasingly popular in total joint arthroplasty to decrease perioperative blood loss. In direct comparison, the outcomes and risks of either modality have been found to be equivalent. In addition, current literature has also demonstrated that topical TXA is safe and effective in the healthy population. To our knowledge, there is a scarcity of studies demonstrating the safety of topical TXA in high risk patient populations undergoing total joint arthroplasty or revision joint arthroplasty. The purpose of this study is to determine the safety of topical TXA in patients undergoing total or revision arthroplasty that are also on chronic anticoagulant or anti-platelet therapy. Methods. We performeded a retrospective review of patients undergoing primary and revision total hip or knee arthroplasties that received topical TXA (3g/100mL NS) from November 2012 to March 2015. All patients, regardless of co-morbidities, were included in the study population. Patients were divided into 3 groups:. Group 1: Patients without any antiplatelet or anticoagulant therapy within 90 days of surgery. Group 2: Patients receiving antiplatelet therapy (Aspirin and/or Plavix) within 90 days of surgery. Group 3: Patients receiving anti-coagulant therapy within 90 days of surgery (low molecular weight heparin, unfractionated heparin, warfarin, dabigatran, rivaroxaban, apixaban). Chart review analyzing ICD-9 and ICD-10 coding was then utilized to establish any peri-operative complications within the 30 day post-operative period in all groups. Complications amongst the groups were evaluated via chi-squared testing as well as multivariate linear regression. Review of current literature and CMS protocols were used to establish reportable peri-operative complications. Wound infections, thromboembolic events and vascular complications such as myocardial infarction, pulmonary embolism, deep venous thrombosis, stroke, aortic dissection were included. Results. During the study period, a total 1471 total joint arthroplasties were performed on 1324 patients (88.7% knee arthroplasty, 11.3% hip arthroplasty). Group 1 included 1033 patients who were not on any prior anti-platelet or anticoagulant therapy. Group 2 included 254 patients receiving chronic antiplatelet therapy 90 days prior to surgery. Group 3 included 184 patients receiving chronic anticoagulant therapy 90 days prior to surgery. No statistically significant differences were found between the groups for any of the included peri-operative complications. The most common complication occurring amongst all the groups was superficial wound infection, which occurred in a total of 60 (4.1%) patients in contrast to 18 (1.2%) patients who sustained an acute deep peri-prosthetic infection. Twenty (1.4%) patients sustained an ultrasound proven deep vein thrombosis, with the highest prevalence occurring in those patients receiving no anticoagulation prior to surgery (15/20, 75%), however this was not statistically significant following linear regression analysis. Conclusions. To our knowledge, this is the first study that demonstrates that topical tranexamic acid is safe to use in so-called high risk patients who are being treated prior to surgery with anti-platelet or anti-coagulation therapy

Background. Hospital acquired MRSA is globally endemic and is a leading cause of surgical site infection (SSI). Of great concern is the emergence of community acquired MRSA (CA MRSA) with its unique virulence characteristics. Infected hip or knee prostheses due to MRSA are associated with multiple reoperations and prolonged hospital stay. Few studies have been done to assess for risk of SSI in MRSA carriers undergoing elective orthopaedic surgery following decolonisation. However in these studies, the eradication status was not confirmed prior to proceeding for surgical intervention. Aim. The purpose of the study was to evaluate the incidence of SSI in MRSA carriers undergoing elective hip and knee arthroplasty, who had confirmed eradication of MRSA carrier status and to compare it with incidence of SSI in non MRSA carriers. Material and Methods. This is a retrospective analysis of 6613 patients who underwent elective hip (3347) and knee arthroplasty (3266) at our institution between January 2008 and August 2012. A cohort of patients who were preoperatively colonised with MRSA was identified. These patients were offered decolonisation protocol and successful eradication was ensured prior to surgery. The MRSA negative patients served as the control group and we looked into the incidence of SSI in both groups up to one year after surgery. Categorical variables were investigated between groups using chi-squared tests and p value of < 0.05 was taken as significant. Results. Out of 6613 patients, MRSA colonisation was observed in 83 patients (a mean age of 76 years with a M:F ratio of 1:1.2) pre-operatively with a colonisation rate of 1.3%. A total of 79 patients had confirmed eradication of carrier status prior to surgical intervention. Of these 38 were THRs and 41 were TKRs. Total number of MRSA negative patients were 6530 with 3307 THRs and 3223 TKRs in control group. Teicoplanin was used for antibiotic prophylaxis in these patients. 5 of 79 patients had “deep SSI” within 1 year of surgery giving an infection rate of 6.32%. There were 2 MRSA infections in hip replacements with an infection rate of 5.26%. There were 2 MRSA and 1 MSSA infection in TKR resulting in an infection rate of 7.31%. These patients did not belong to the “high-risk” group for MRSA colonisation. A significant statistical difference in infection rates from MRSA negative control group was noted, which had a deep sepsis rate of 1.17% (p value − 0.03) in THRs and 0.87% in TKRs (p value − 0.0016). Conclusions and Clinical Implication. In spite of a selective treatment program for carriers and confirmed eradication in terms of achieving a reduction in the rate of SSI, there is still a significantly increased risk of SSI in MRSA colonised patients undergoing hip and knee replacements. Also, should infection develop, MRSA is the most likely causative organism. Patients should be made aware of this higher risk of infection and the serious consequences of developing MRSA SSI

Aim. Computer-navigated total knee arthroplasty has been shown to improve the outcome in outliers with consistent results. The aim of this study is to evaluate the clinical and radiographic outcomes of computer-navigated knee arthroplasty with respect to deformity and body mass index (BMI). Materials and Methods. Data was prospectively collected for 117 consecutive patients undergoing primary computer-navigated total knee arthroplasty using Ci Brainlab system with J&J PFC PS implants by a single surgeon utilising a tibia cut first, gap-balancing technique. Pre-operative and post-operative long-leg films, weight-bearing, films were taken and the long-axis was measured by a single observer. Intra-operative computer navigation long-axis values were stored as screenshots intra-operatively after registration and after implant was cemented. BMI, range of motion (ROM), SF 36 and Oxford knee scores were recorded both before surgery and on follow-up. Minimum 2-year follow-up. Eight patients were lost to follow-up and 8 had incomplete 2 year data. Data was analysed using the Chi-squared test for categorical variables and the t-test for continuous variables. Results. Eighty-four (83.2%) female, 17 (16.8%) male patients age 65.3±6.9 years with a pre-operative BMI of 27.2±4.1 (18.6 to 40.0). Eighty-eight (87.1%) met the Singapore definition of overweight with BMI>23 kg/m2. Forty-two (41.6%) had a BMI>27.5 kg/m2 indicative of obesity in Singapore. Pre-operative radiographic axis was 9.3±10.6° varus. Thirty (29.7%) patients had a pre-operative coronal plane deformity of more than 15°. Meanoperative duration 96.0±10.7 mins. Post-operative radiographic axis was 0.05±3.0° valgus. Significant improvement was seen in knee extension, knee flexion, SF 36 and Oxford knee scores at 2 years. No significant improvement in extensor lag and straight leg-raising at 2 years. Pre-operative axis >15° was not significantly related to operative duration. BMI>23 kg/m2 was significantly related to longer operative time (88.8±10.8 vs. 97.1±10.3 min, p<0.021). BMI >27.5 kg/m2 not significantly related to operative duration, pre-operative SF36 or Oxford knee scores. Post-operative axis deviation of more than 3° not significantly related to BMI > 23 or 27.5 kg/m2, similar to post-implant navigation axis. BMI >23 kg/m2 not significantly related to 2 year SF36, Oxford knee score and range of motion at 2 years. BMI >27.5 kg/m2 not significantly related to 2 year SF36 or Oxford knee scores. Conclusion. Although restoration of coronal alignment even in deformity >15° is possible with computer navigation, post-operative extensor lag and weakness is still a problem determined by pre-operative extensor lag and weakness in straight leg raising. Computer navigation is useful when exposure and landmarks to assess alignment are difficult such as in obesity where the standard external tibia jig doesn't sit well with the thick subcutaneous layer and for determining the epicondylar axis of the femur in a deep wound. Despite the technical challenges of performing a total knee arthroplasty with obesity, BMI is not a determinant of functional scores when computer navigation is used