Introduction. Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device. Materials and Methods. Prospectively collected clinical data was reviewed of all consecutive patients who underwent repair of the ruptured Achilles tendon using the Achillon device. Patients were contacted using a postal questionnaire for assessment of their functional status using the validated Achilles Tendon Total Rupture Score (ATRS) and compared with their uninjured side. The outcomes were compared to the published results. Results. We present patient demographics; and clinical and functional outcomes of 140 consecutive patients who underwent repair of ruptured Achilles tendon using the minimally invasive technique between June 2007 to August 2010. Our complication rate was of two-three percent each of proximal DVT, scar sensitivity, superficial wound infection and no re-rupture after a minimum of 6 months. There was no case of nerve injury leading to permanent neurological deficit. Discussion. This study demonstrates good clinical and functional outcomes from using the Achillon device in repair of ruptured Achilles tendon with a low complication rate comparable to other published series. We recommend Achillon device as a safe minimally invasive technique for repair of the ruptured Achilles tendon

Aims. The Bankart and Latarjet procedures are two of the most common surgical techniques to treat anterior shoulder instability with satisfactory clinical and functional outcomes. However, the outcomes in the adolescent population remain unclear, and there is no information regarding the arthroscopic Latarjet in this population. The purpose of this study was to evaluate the outcomes of the arthroscopic Bankart and arthroscopic Latarjet procedures in the management of anterior shoulder instability in adolescents. Methods. We present a retrospective, matched-pair study of teenagers with anterior glenohumeral instability treated with an arthroscopic Bankart repair (ABR) or an arthroscopic Latarjet (AL) procedure with a minimum two-year follow-up. Preoperative demographic and clinical features, factors associated with dislocation, and complications were collected. Recurrence, defined as dislocation or subluxation, was established as the primary outcome. Clinical and functional outcomes were analyzed using objective (Rowe), and subjective (Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE)) scores. Additionally, the rate of return to sport was assessed. Results. A total of 51 adolescents were included, of whom 46 (92%) were male, with 17 (33%) in the Latarjet group and 34 (66%) in the Bankart group. The mean age at time of surgery was 18 years (15 to 19). There were no intraoperative complications. At a median follow-up of nine years (IQR 2 to 18), recurrence was observed in 12 patients in the Bankart group (35.3%) and one patient in the Latarjet group (5.9%) (p = 0.023). Satisfactory postoperative outcomes were obtained, with mean Rowe, WOSI, and SANE scores noted at 95 (10 to 100), 325 (25 to 1,975), and 87.5 (10 to 100), respectively. Most patients (29 in the Bankart group (85.3%) and 16 in the Latarjet group (94.1%)) were able to return to sport (p = 0.452). Conclusion. The ABR and AL procedures both obtain satisfactory clinical and functional outcomes in the treatment of anterior glenohumeral instability in adolescents with a low complication rate. However, the ABR is associated with a significantly higher recurrence rate. Cite this article: Bone Jt Open 2024;5(11):1041–1048

Aims. The aim of this study was to compare a bicruciate-retaining (BCR) total knee arthroplasty (TKA) with a posterior cruciate-retaining (CR) TKA design in terms of kinematics, measured using fluoroscopy and stability as micromotion using radiostereometric analysis (RSA). Methods. A total of 40 patients with end-stage osteoarthritis were included in this randomized controlled trial. All patients performed a step-up and lunge task in front of a monoplane fluoroscope one year postoperatively. Femorotibial contact point (CP) locations were determined at every flexion angle and compared between the groups. RSA images were taken at baseline, six weeks, three, six, 12, and 24 months postoperatively. Clinical and functional outcomes were compared postoperatively for two years. Results. The BCR-TKA demonstrated a kinematic pattern comparable to the natural knee’s screw-home mechanism in the step-up task. In the lunge task, the medial CP of the BCR-TKA was more anterior in the early flexion phase, while laterally the CP was more posterior during the entire movement cycle. The BCR-TKA group showed higher tibial migration. No differences were found for the clinical and functional outcomes. Conclusion. The BCR-TKA shows a different kinematic pattern in early flexion/late extension compared to the CR-TKA. The difference between both implants is mostly visible in the flexion phase in which the anterior cruciate ligament is effective; however, both designs fail to fully replicate the motion of a natural knee. The higher migration of the BCR-TKA was concerning and highlights the importance of longer follow-up. Cite this article: Bone Joint J 2023;105-B(1):35–46

Introduction. Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications. Results. 142 patients with 143 fractures were identified, 40 (28%) were open, 94 (66%) were intra-articular, 85 (59%) were tertiary referrals. 32% were type 1, 28%, type 2 and 40% type 3 AO/OTA severity. 139 (97%) of the fractures united (2 non-unions, 1 amputation and 2 delayed unions who remain in frames), at a median of 165 days (range 104 to 429, IQR 136 to 201). 62% united by 6 months, 87% by 9 months and 94% by 1 year. Both non-unions have united with further treatment. Closed fractures united more rapidly than open (median 157 vs 185 days; p=0.003) and true Pilon (43C3) fractures took longer to unite other fractures (median 156 vs 190 days; p<0.001). 34% of patients encountered a problem, 12% an obstacle and 10% a complication. Of the complications, 6 (4%) were minor, 5 (3.5%) major not interfering with the goals of treatment and 4 (3%) major interfering with treatment goals (including the 2 patients with non-union and 1 who underwent amputation as well as 1 significant mal-union). This will increase to 4% if the 2 delayed unions fail to unite. Overall 56% reported good or excellent ankle scores at last report, 28% fair and 16% poor. Closed, extra-articular and non-43C3 fractures had better functional outcome scores than open, intra-articular and 43C3 fractures respectively. Conclusions. This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries. *Judged best paper*

Introduction Pan-talar nailing for ankle arthrodesis has been advocated as a salvage procedure for post-traumatic arthrosis and Charcot’s joint. This study evaluates the outcome of pan-talar nails over a 4-year period.

Method This is a retrospective study of 11 patients (13 ankles) who underwent pan-talar nailing between 2000 and 2004. Various factors including patient demographics, indications for surgery, operation details, complications, time to fusion and need for re-operation were recorded. Nine were reviewed at a mean follow-up of 22 months for clinical and radiological assessment; two patients had died. American Orthopaedic Foot and Ankle (AOFAS) hindfoot and SF-36 scoring systems were also used for evaluation.

Results There were seven males and four females, with a mean age of 57 and 71 years, respectively. Eight patients had a pre-operative diagnosis of Charcot’s joint, one avascular necrosis of talus, one fixed deformity with polio, and one following fracture non-union.

All 13 nails were locked at both ends. The average duration of operation was 2 hours and tourniquet time 1 hour 8 minutes. All patients were kept non-weight bearing in cast post-operatively for an average of 6 weeks.

There were two cases of wound infection, one pulmonary embolism and one calcaneal fracture with infected non-union, which was treated with external fixation. There were no cases of nerve damage or septic arthritis.

All nine patients were satisfied with the operation outcome at follow-up with a mean fusion duration of 28 weeks and an average AOFAS score of 75.

Conclusion We conclude from this study that pan-talar nailing when performed for ankle arthrodesis as a salvage procedure produces a high rate of fusion with fewer complications.

Study Design: Retrospective Series.

Objectives: To analyse loss of correction of the anterior wedge angle and the components responsible for the recurrence of kyphosis after surgical stabilisation of dorsolumbar fractures, and to assess the return of functional capacity in these patients.

Materials and Methods: Between January 1998 and March 2003, 34 patients had posterior stabilisation performed with the Universal Spine System (Synthes) for dorsolumbar fracture at a single level with no neurological deficit. There were 26 AO Type A fractures, 5 Type B fractures, and 3 Type C fractures. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The anterior wedge angle, the heights of the discs above and below the fractured vertebra, and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle and posterior). The values were normalised to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up were computed. Short Form 36 (SF-36) was used to assess the functional outcome in each.

Results: The mean follow-up period was 23.6 months (9 to 48 months). The mean anterior wedge angle was 10.1 ± 7.2 degrees in the immediate postoperative period and 17.1 ± 10.9 degrees at latest follow-up (p< 0.001). The mean loss of correction was 7.0 ± 8.5 degrees (−11 to 24) and this showed a linear relationship to the preoperative anterior wedge angle. Furthermore there was a linear increase in the loss of correction of the angle as the follow-up period increased. The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the anterior wedge angle showed significant correlation to the decrease in the anterior segment height at the fractured vertebral body level (Pearson’s coefficient r=0.53 significant at 0.01 level, p=0.001). The mean physical function score from SF-36 was 56.3 and the mean bodily pain score was 49.7. There was no relationship to the angle of kyphosis at follow-up to the physical function score (r=0.12, p=0.50) and the bodily pain score (r=0.14, p=0.44).

Conclusions: There is a progressive loss of correction (increasing kyphosis) after posterior stabilisation with instrumentation that roughly approximates the initial decrease in anterior height of the fractured vertebral body. The degree of loss of correction does not depend on the type of fracture. The loss of correction is related to the preoperative angle of kyphosis.

We report our retrospective multicentre experience of managing periprosthetic knee fractures using locking plates, cemented nails and distal femoral prosthesis. The Aim of this study is to analyze the practicality of management of these injuries using modern methods of fixation or salvation. 62 patients presented to 3 centres between 2003 and 2010. After implementation of inclusion criteria, clinical, radiological and functional outcomes were evaluated in 54 patients, with a minimum follow-up of 6 months. 34 patients were treated with locking plates (10 males, 24 female; mean age 76), 16 with cemented/locking nails (4 males, 12 females; mean age 84.5), and 4 with distal femoral replacement prosthesis (2 males, 2 females; mean age 79). Locking plates which were used with a minimally invasive pattern produced the best outcomes in our study. A statistical significance of p value of less than 0.01 was found in union time between patients operated on with an open technique (6.69±2.69 months) and those operated on with a minimally invasive technique (3.6±0.91 months). Nailing with augmented cement is a useful technique in patients who are not suitable for challenging surgery & rehabilitation programmes. There was a significant difference in mean time to functional weight bearing (p< 0.01) between the plate group (4.79±2.6 months) and the nail group (2.63±0.5 months). Post-operative range of motion was also better for nails (106.36±14.33. O. flexion) compared to plates (93.24±26.8. O. ), a result that approached significance (p=0.065). We recommend minimal invasive plating in uncompromised physiological conditions, as an ideal method of fracture fixation in view of statistically significant union rates. Cemented nailing is recommended in patients where early rehabilitation is essential. Distal Femoral prosthesis replacement is a useful salvage method

From a cohort of 110 idiopathic clubfeet, 26 feet in 18 children requiring surgery for severe relapse have been studied. Surgery was comprised of a lateral column shortening procedure (Lichtblau) plus or minus a plantarmedial release. Surgery was staged to avoid wound complications.

Pre-operatively, feet were prospectively categorised into one of four grades according to a system reported by Dimeglio. Children were reviewed on two subsequent occasions. At review, feet were again graded. In addition, appearance and functional outcome was analysed and included an assessment of gait, activity and functional limitation.

Three children were lost to follow-up, leaving 22 feet in seven male and eight female patients available for review. The mean age at surgery was 43 months (23–82). The mean time from surgery to first and second reviews was 35 and 56 months, respectively.

There was a significant improvement in grading at first review compared to pre-operative grading (Wilcoxon signed ranks test). Although there remained a significant improvement in grading at second review compared to the preoperative grading, there was a significant reduction in the number of feet in which grading had improved when compared to first review.

There was no significant change in function between the two post-operative reviews (Chi-square tests), with the majority of children experiencing little functional limitation. There were no wound complications.

Relapse surgery, involving a lateral column shortening procedure for severe clubfoot, results in a significant initial improvement when assessed using a grading system. This improvement in grading subsequently decreases over time. However, the functional outcome in such cases remains favourable.

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

The fact that a multitude of procedures exist for the correction of hallux valgus indicates that there is no ideal operation for this problem. Hallux valgus correction can be significantly improved by scarf first metatarsal osteotomy. The surgical technique is versatile and strong internal fixation allows early functional recovery. The aim of our study is to analyse the clinical, radiological and functional outcome after scarf osteotomy for hallux valgus correction. Material and Methods: The scarf osteotomy was performed on 65 feet of 48 patients between 1996 and February 2001. The indication was a symptomatic hallux valgus with increased intermetatarsal angle (IMA). The osteotomy was fixed with one/two 2.3mm screws. Mobilisation was allowed with full weight bearing with forefoot orthesis. Fifty-one cases in 39 female patients (12 bilateral feet) were available for follow-up. The mean follow-up was 14 months (range 3–36 months). Patients were interviewed, clinically examined and standing radiographs of operated foot were taken. They were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalyngeal Inter-phalyngeal clinical rating system in which 100 point are used to compare preoperative and postoperative pain, function and range of motion, shoe wear comfort and activity level and alignment. Results: All osteotomies healed at the time of follow-up. The average value of AOFAS scale was 92 points. Five patients had removal of screws. There were 4 cases of superficial wound infection. All patients have excellent cosmetic and functional results. Conclusion: Our study has demonstrated that scarf osteotomy has proven to offer easy postoperative care and has excellent stable long-term results

Introduction: Terrorist bombings, with catastrophic resultant blast injuries, have been increasing in frequency during past 25 years. Limbs injuries is common among survivors. Four crowded trains were attacked in Madrid on March 11, 2004. Injuries were sustained by 1550 people, 198 of whom died, mostly at the scene. Because the building station did not collapse, as in other attacks, the number of multiple injured patients who survive were high. 509 patients were attended at our Hospital in the emergency unit during the first six hours after the explosions, 80 of whom require hospitalization. Three patients died on arrival. Data about transport from the scene, injury type, diagnostic test and treatment and functional outcome were obtained from the Hospital Trauma Registry.

The day at the Hospital:

The first patient arrived at 08:00, when the daily clinical meeting for the trauma admissions began. During the first hour, an effort was made in order to triage victims and organize the requirements for operating room and ICU treatment. All scheduled operations were aborted and six orthopaedic trauma teams were prepared to start operations immediately. A separate area in the Hospital was established to treat minor injuries. All patients were operated within the first 8 hours.

Injury characteristics: 39 patients admitted with an ISS higher than 9 presented the most severe injuries. A study group was made with these patients. Mean age were 33,6. The mean RTS were 6,87, mean ISS 21,94, and mean NISS 26,15, revealing the high frequency of multisistemic injuries. The most frequently injury in these group were pulmonary blast injury, with a mean AIS for thorax of 2,7 points.74% of patients had some type of pulmonary blast injury.

Limb injuries: 12 (25%) patients had open fractures, combined in all cases with pulmonary blast. Open Gustilo IIIb and IIIc occur in seven patients. Soft tissue injuries caused by small fragments were also frequent. Two patients presented SCIWORA like injuries of the thoracic medullary cord. All patients were operated in the first six hours after the explosion. A detailed description of the injuries, treatment and functional outcome will be presented. Functional outcome were analyzed by physical and psychological scales at six and twelve months after the attack. Scales used were SF-36(short form 36), EQ-5D (Euroqol), CES-D( Center for Epidemiologic Studies Depression Scale) and AVS. Comparison with a similar general trauma group revealed poorer functional outcome at six months for the study group.

Conclusions: The bombing attack in Madrid was the first massive attack over civilian population in Europe since WW II. Functional outcomes were worse than expected in patients with skeletal injuries. In spite of the good results of initial treatment in our experience, we think that there is no country prepared sufficiently to treat this new type of massive casualties.

Back pain screening clinics are established to clinically screen patients with back pain for organic lumbar pathology. The aim of this study is to assess the relationship between clinical signs of organic pathology and the level of disability as measured by functional outcome scores. Methods: Notes from 581 consecutive patients who were seen in the back screening clinic was analyzed. Sixty-nine patients who were found to have clinical signs of organic pathology and 69 age and sex-matched patients from 512 patients who were found to have no signs of organic pathology in the same time period in the back pain screening clinic were selected. The Oswestry disability, Short form-36 and visual analogue (pain) scores between the two groups were statistically analyzed.

The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed. Results: Although there was a signiþcant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). We also found a strong relationship between psychological disability and the duration of back symptoms. Conclusions: High level of disability is associated with organic pathology. Acute back pain should be treated promptly to reduce it impact on the psychological disability.

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

Introduction. Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Methods. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined. Results. Between January 2019 and August 2023, 50 MPFL reconstructions were performed in 37 children using partial thickness quadriceps autograft. Patient age at time of surgery ranged from 5 to 17 years (median age 13 years). The technique was utilised for a variety of indications including recurrent traumatic and habitual patellofemoral instability, fixed dislocations, and revision MPFL reconstruction. Conclusion. Partial thickness quadriceps tendon autograft can be used safely to primarily reconstruct the medial patellofemoral ligament in paediatric population, including those children with open growth plates. It also has utility in revision cases following previous failed hamstring MPFL reconstruction. We have noted that the younger the child, the more distal to the physis lies the femoral point of isometricity, rendering this a safe and reproducible treatment in this age group. Use of this technique has increased in our unit as we have observed that patients seem to be satisfied with their clinical and functional outcomes with a low incidence of short- and medium-term complications

Aim. The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. Method. All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. Results. We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n=6), free vascularized fibular graft (n=5), cancellous bone graft (n=1)) to reconstruct the bone defect. The median follow-up was 32.3 (P. 25. -P. 75. : 23.9–51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P. 25. -P. 75. : € 7.953–23.798) per patient. Conclusion. FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. Overall, the outcome of patients treated for FRI of the clavicle is good, when management of this complication is performed by using a multidisciplinary team approach. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Expert opinion considers factors such as the size of the bone defect, the condition of the soft tissue, and patient demand to guide surgical decision making

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

Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. A common belief of having ≥20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. We examined clinico-radiological outcomes in patients with intra-femoral tunnel graft lengths <20 and ≥20mm. Primary outcomes were knee scores at 1-year. Secondarily, graft revascularization was compared using magnetic resonance imaging (MRI). We hypothesized that outcomes would be independent of intra-femoral tunnel graft lengths. This prospective, single-surgeon, cohort study was conducted at a tertiary care teaching centre between 2015–2018 after obtaining ethical clearances and consents. Eligible arthroscopic ACL reconstruction patients were sequentially divided into 2 groups based on the intra-femoral tunnel graft lengths (A: < 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those > 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively examined and scored (Lysholm and modified Cincinnati scores) at 3, 6 and 12 months. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using MRI. Statistical significance was set at p<0.05. Age and sex-matched patients of both groups were followed to 1 year (1 dropout in each). Mean femoral and tibial tunnel diameters (P =0.225 and 0.595) were comparable. Groups A (<20mm) and B (≥20mm) had 27 and 25 patients respectively. At 3 months, 2 group A patients and 1 group B patient had grade 1 Lachman (increased at 12 months to 4 and 3 patients respectively). Pivot shift was negative in all patients. Lysholm scores at 3 and 6 months were comparable (P3= 0.195 and P6= 0.133). At 1 year both groups showed comparable Cincinnati scores. Mean ROM was satisfactory (≥130 degrees) in all but 2 patients of each group (125–130 degrees). MRI scans at 3 months and 1 year observed anatomical tunnels in all without any complications. Femoral tunnel signals in both groups showed a fall from 3–12 months indicating onset of maturation of graft at femoral tunnel. Our hypothesis, clinical and radiological outcomes would be independent of intra-tunnel graft lengths on the femoral aspect, did therefore prove correct. Intra-femoral tunnel graft lengths of <20 mm did not compromise early clinical and functional outcomes of ACL reconstructions. There seems to be no minimum length of graft within the tunnel below which suboptimal results should be expected

Aims. Intraoperative pressure sensors allow surgeons to quantify soft-tissue balance during total knee arthroplasty (TKA). The aim of this study was to determine whether using sensors to achieve soft-tissue balance was more effective than manual balancing in improving outcomes in TKA. Methods. A multicentre randomized trial compared the outcomes of sensor balancing (SB) with manual balancing (MB) in 250 patients (285 TKAs). The primary outcome measure was the mean difference in the four Knee injury and Osteoarthritis Outcome Score subscales (ΔKOOS. 4. ) in the two groups, comparing the preoperative and two-year scores. Secondary outcomes included intraoperative balance data, additional patient-reported outcome measures (PROMs), and functional measures. Results. There was no significant difference in ΔKOOS. 4. between the two groups at two years (mean difference 0.4 points (95% confidence interval (CI) -4.6 to 5.4); p = 0.869), and multiple regression found that SB was not associated with a significant ΔKOOS. 4. (0.2-point increase (95% CI -5.1 to 4.6); p = 0.924). There were no significant differences between groups in other PROMs. Six-minute walking distance was significantly increased in the SB group (mean difference 29 metres; p = 0.015). Four-times as many TKAs were unbalanced in the MB group (36.8% MB vs 9.4% SB; p < 0.001). Irrespective of group assignment, no differences were found in any PROM when increasing ICPD thresholds defined balance. Conclusion. Despite improved quantitative soft-tissue balance, the use of sensors intraoperatively did not differentially improve the clinical or functional outcomes two years after TKA. These results question whether a more precisely balanced TKA that is guided by sensor data, and often achieved by more balancing interventions, will ultimately have a significant effect on clinical outcomes. Cite this article: Bone Joint J 2022;104-B(5):604–612

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

Aims. Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods. This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination. This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(5):411–418