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

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

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

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

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

Aim. Periprosthetic Joint Infection (PJI) is a devastating complication in hip and knee joint arthroplasty. The “JS BACH” classification system was developed in 2021 to stratify the complexity of PJI, and more importantly, to act as a tool to guide referrals to specialist centers. The “JS BACH” classification has not been validated in an external cohort. This study aimed to do so using a large prospective cohort from Australia and New Zealand. Method. We applied the JS-BACH classification to the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort. This prospective study of newly diagnosed PJI collected 2-year outcome data from 653 participants enrolled in 27 hospitals. The definition of PJI treatment failure at 24 months was any of the following: death, clinical or microbiological signs of infection, destination prosthesis removed, or ongoing antibiotic use. Results. Individual cases were classified as per JS-BACH into “1 - uncomplicated” (n = 268), “2 - complex” (n = 330), and “3 - limited options” (n = 55). This cohort was similar to the original JS-BACH population in terms of baseline characteristics. However, there was a difference in complexity, with more DAIR procedures, fewer revision procedures, and a higher proportion of uncomplicated patients in the PIANO cohort. The risk of treatment failure correlated strongly with the JS-BACH category, with odds ratios (95% CI [confidence interval]) for category 2 versus 1 of 1.75 (1.24 to 2.47) and for category 3 versus 1 of 7.12 (3.42 to 16.02). Conclusions. Despite the PIANO study population being less complicated than the original derivation cohort, the JS-BACH classification showed a clear association with treatment failure in this large external cohort

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

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

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

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

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

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

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

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

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

Aim

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

Aim

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

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

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

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

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

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

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

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

Introduction:. Total knee replacement (TKR) and total hip replacement (THR) reliably relieve pain, restore function, and ensure mobility in patients with advanced joint arthritis; however these results are not uniform across all patient populations. Moreover, it is well established that knee replacement patients have outcomes inferior to those undergoing hip replacement procedures with lower rates of dissatisfaction with post-operative function and pain relief. We compared baseline demographic and symptom profiles in patients from a US national cohort undergoing primary TKR and THR to determine whether differences in demographic make-up, pre-operative symptoms, or pre-existing co-morbidities might contribute to these differences observed post-operatively. Methods:. A cohort of 2375 patients undergoing primary TKR and THR was identified from the FORCE national research consortium from all surgeries performed between July 1. st. 2011 and March 30. th. 2012. This set of patients was derived from 120 contributing surgeons in 23 US states. Gathered data included patient demographics, comorbidity (Charlson Comorbidity Index), operative joint pain severity (Western Ontario and McMaster Universities Arthritis Index (WOMAC)), physical function (SF-36; Physical Component Score (PCS)), emotional health (SF-36; Mental Component Score (MCS)), and musculoskeletal burden of illness (Hip and Knee Disability and Osteoarthritis Outcome Scores; Oswestry Disability Index). Using descriptive statistics, we compared the baseline demographic characteristics and symptom profiles of patients undergoing TKR (n = 1362) and those undergoing THR (n = 1013). Results:. In this large national sample, patients receiving knee replacements were found to be significantly older (66.5 vs. 64.3 years), more obese (BMI 31.7 vs. 29.3), and less educated (p < 0.005) than those undergoing THR. TKR patients had higher rates of medical comorbidities, specifically diabetes, gastrointestinal ulcers, and cerebrovascular disease (p ≤ 0.006). Conversely, THR patients had significantly worse physical function (PCS 31.6 vs. 33.3), lower back pain (35.6% vs. 30.5% moderate-severe), and operative joint pain, stiffness, and function (p < 0.005) when compared to those undergoing TKR. Conclusions:. US patients undergoing primary TKR are older with more comorbidities, however THR patient baseline functional and musculoskeletal limitations are significantly greater than primary TKR patients. These data may help explain the variability in physical function after primary TKR as compared to primary THR

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

Background The minimum size required for a successful quadrupled hamstring autograft ACL reconstruction remains controversial. The risks of ACL re-tear in younger patients who tend to participate in a higher level of sports activity, and female athletes who have numerous predisposing factors, are poorly defined. Purpose To identify risk factors for graft re-tears within 2 years of ACL surgery. The hypotheses are that female sex, a smaller size graft, and younger patients will increase the odds of failure. Study Design Cohort Study. Level of evidence, 3. A cohort of 503 athletes undergoing primary, autograft hamstring ACL reconstruction, performed by a single surgeon using the same surgical technique and rehabilitation protocol, between September-December 2012, was followed for a total duration of 2 years. Return to play was allowed between 6 and 12 months post-surgery upon completion of functional testing. Exclusion criteria included infections, revisions, double bundle techniques, multi-ligament injuries, non-compliance, BTB/allografts/hybrid grafts. Primary outcome consisted of binary data (ACL graft re-tear or no tear) as measured on physical exam (Lachman and pivot shift) and MRI. Multivariate logistic regression statistical analysis with model fitting was used to investigate the predictive value of sex, age, and graft size on ACL re-tear. Secondary sensitivity analyses were performed on the adolescent subgroup, age and graft size as categorical variables, and testing for interactions among variables. Sample size was calculated based on the rule of 10 events per independent variable for logistic regression. The mean age of the 503 athletes was 27.5 (SD 10.6; range = 12–61). There were 235 females (47%) and 268 males (53%) with a 6 % rate of re-tears (28 patients; 17 females). Mean graft size was 7.9 (SD 0.6; range = 6–10). Univariate analyses of graft size, sex, and age only in the model showed that younger age (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80–0.93; P = .001] and smaller graft size (OR = 0.36; 95% CI = 0.18–0.70; P = .003) were significantly predictive of re-tear. Female sex was correlated with re-tear but was not significant (OR = 1.8; 95% CI = 0.84–3.97; P = .13). Multivariate analysis with all 3 variables in the model showed similar significant results. Graft size < 8 mm (OR = 2.95; 95% CI = 1.33–6.53; P = .008) and age < 25 (OR = 7.01; 95% CI = 2.40–20.53; P = .001) were significantly predictive of re-tear. Entire model was statistically significant (Omnibus test P = .001; Hosmer-Lemeshow statistic P = .68; Receiver Operating Curve [ROC] = 0.8). Surgeons should counsel their patients who are female, younger than 25 and with a graft size less than 8 mm accordingly and consider modifying their surgical or rehabilitation techniques to mitigate these re-tear risks