Abstract. Introduction. Transforming outpatient services is a key commitment set out in the NHS Long Term Plan, with particular emphasis on digital solutions to reduce outpatient follow-up (FU) by 25%. This study looks at the potential for removing knee arthroscopy FU by providing a bespoke multimedia report for each individual patient, generated using the Synergy™ Surgeon App (Arthrex). Methodology. Single District Hospital using a 3 Phase study. Phase 1 – Assessment of cost and environmental impact of outpatient follow up appointments. Phase 2 – Bench marking of existing pathways and patient experience. Phase 3 – Qualitative assessment of multimedia report feedback of 30 patients. Results. Phase 1 – Impact per year for Trust in released clinician time 135hrs. Cost avoidance £40-£60k. Reduction of the carbon footprint from reduced FU of 3132 KgCo2e2. Phase 2 – Deep dive on 2019 n. 353 procedures. 1206 outpatient appointments required. Average 1.2 post-operative appointments. Phase 3 – 87% of patients who received the e-op report needed no further FU. This compares to only 25% using a traditional post op discussion after surgery. 94% of patients felt the report aided their recovery. Conclusions. Reducing patient FU appointments is crucial to the future of the NHS. Achieving this whilst simultaneously improving the quality of patient communication is achievable as this study has demonstrated. The potential scalability of this project to be applied other arthroscopic procedures is enormous. The study has demonstrated patients are comfortable with modern technology and feel it enhances their understanding whilst decreasing the need for routine post-op FU

Aims. The antidiabetic agent metformin inhibits fibrosis in various organs. This study aims to elucidate the effects of hyperglycaemia and metformin on knee joint capsule fibrosis in mice. Methods. Eight-week-old wild-type (WT) and type 2 diabetic (db/db) mice were divided into four groups without or with metformin treatment (WT met(-/+), Db met(-/+)). Mice received daily intraperitoneal administration of metformin and were killed at 12 and 14 weeks of age. Fibrosis morphology and its related genes and proteins were evaluated. Fibroblasts were extracted from the capsules of 14-week-old mice, and the expression of fibrosis-related genes in response to glucose and metformin was evaluated in vitro. Results. The expression of all fibrosis-related genes was higher in Db met(-) than in WT met(-) and was suppressed by metformin. Increased levels of fibrosis-related genes, posterior capsule thickness, and collagen density were observed in the capsules of db/db mice compared with those in WT mice; these effects were suppressed by metformin. Glucose addition increased fibrosis-related gene expression in both groups of mice in vitro. When glucose was added, metformin inhibited the expression of fibrosis-related genes other than cellular communication network factor 2 (Ccn2) in WT mouse cells. Conclusion. Hyperglycaemia promotes fibrosis in the mouse knee joint capsule, which is inhibited by metformin. These findings can help inform the development of novel strategies for treating knee joint capsule fibrosis. Cite this article: Bone Joint Res 2024;13(7):321–331

Abstract. Introduction. Knee dislocations (KDs) are complex injuries which are often associated with damage to surrounding soft tissues or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system. Methods. A global panel of orthopaedic knee surgery specialists participated in a Delphi process. A list of factors to be included in a KD classification system was formulated by 91 orthopaedic surgeons, which was subsequently prioritised by 27 experts from 6 countries. The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system. Results. The four factors that reached consensus agreement and thus deemed critical for inclusion in a classification system were vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%). Conclusion. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. The Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injuries. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier

Abstract. Introduction. Perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. We investigated (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers to implementing ACL injury prevention program in netball. Methodology. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to this web-based study between 1st May–31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained. Results. Twenty-eight players (77.8%) and 29 coaches (13.2%) completed the questionnaire. Seventeen (60.7%) players and 15 (51.7%) coaches reported female athletes were at greater risk for sustaining ACL injuries. Over 90% of respondents identified netball as high-risk, whilst 89% of players and 76% of coaches reported these injuries to be preventable. Two (7.1%) players and 6 (20.7%) coaches utilised ACL injury prevention programs with lack of time and engagement from coaches and players identified. Majority of respondents indicated that their club has neither promoted, advocated nor demonstrated exercises for ACL injury prevention. Over 90% of respondents would utilise such programs if it minimised players risk with appropriate training and information. Conclusion. Study highlights limited knowledge of female athletes’ increased susceptibility of ACL injuries with lack of communication and education of ACL injury prevention programs between sporting associations, coaches and players. Results demonstrate willingness of players and coaches to implement ACL injury prevention programs in Welsh netball

Aims. There has been a recent resurgence in interest in combined partial knee arthroplasty (PKA) as an alternative to total knee arthroplasty (TKA). The varied terminology used to describe these procedures leads to confusion and ambiguity in communication between surgeons, allied health professionals, and patients. A standardized classification system is required for patient safety, accurate clinical record-keeping, clear communication, correct coding for appropriate remuneration, and joint registry data collection. Materials and Methods. An advanced PubMed search was conducted, using medical subject headings (MeSH) to identify terms and abbreviations used to describe knee arthroplasty procedures. The search related to TKA, unicompartmental (UKA), patellofemoral (PFA), and combined PKA procedures. Surveys were conducted of orthopaedic surgeons, trainees, and biomechanical engineers, who were asked which of the descriptive terms and abbreviations identified from the literature search they found most intuitive and appropriate to describe each procedure. The results were used to determine a popular consensus. Results. Survey participants preferred “bi-unicondylar arthroplasty” (Bi-UKA) to describe ipsilateral medial and lateral unicompartmental arthroplasty; “medial bi-compartmental arthroplasty” (BCA-M) to describe ipsilateral medial unicompartmental arthroplasty with patellofemoral arthroplasty; “lateral bi-compartmental arthroplasty” (BCA-L) to describe ipsilateral lateral unicompartmental arthroplasty with patellofemoral arthroplasty; and tri-compartmental arthroplasty (TCA) to describe ipsilateral patellofemoral and medial and lateral unicompartmental arthroplasties. “Combined partial knee arthroplasty” (CPKA) was the favoured umbrella term. Conclusion. We recommend bi-unicondylar arthroplasty (Bi-UKA), medial bicompartmental arthroplasty (BCA-M), lateral bicompartmental arthroplasty (BCA-L), and tricompartmental arthroplasty (TCA) as the preferred terms to classify CPKA procedures. Cite this article: Bone Joint J 2019;101-B:922–928

Aims. The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model. Methods. A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution’s standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA). Results. Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121. o. ; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014). Conclusion. The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3–12

Aims. The patient-acceptable symptom state (PASS) is a level of wellbeing, which is measured by the patient. The aim of this study was to determine if the proportion of patients who achieved an acceptable level of function (PASS) after medial unicompartmental knee arthroplasty (UKA) was different based on the status of the anterior cruciate ligament (ACL) at the time of surgery. Methods. A total of 114 patients who underwent UKA for isolated medial osteoarthritis (OA) of the knee were included in the study. Their mean age was 65 years (SD 10). No patient underwent a bilateral procedure. Those who had undergone ACL reconstruction during the previous five years were excluded. The Knee injury Osteoarthritis Outcome Score Activities of Daily Living (KOOS ADL) function score was used as the primary outcome measure with a PASS of 87.5, as described for total knee arthroplasty (TKA). Patients completed all other KOOS subscales, Lysholm score, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Veterans Rand 12-item health survey score. Failure was defined as conversion to TKA. Results. Survivorship at ten years was 97% in both the ACL-deficient and ACL-intact groups. The mean survival was 16.1 years (95% confidence interval (CI) 15.3 to 16.8) for the ACL-deficient group and 15.6 years (95% CI 14.8 to 16.361) for the ACL-intact group (p = 0.878). At a mean of nine years (SD 3.5) in the ACL-deficient group, 32 patients (87%) reached the PASS for the KOOS ADL. In the ACL-intact group, at a mean of 8.6 years (SD 3) follow-up, 63 patients (85%) reached PASS for the KOOS ADL. There was no significant difference in the percentage of patients who reached PASS for all KOOS subscales and Lysholm between the two groups. Conclusion. PASS was achieved in 85% of all UKAs for KOOS ADL, similar to reports for TKA. Fixed-bearing, medial, non-robotically-assisted UKA resulted in 97% survival at ten years in both the ACL-deficient and ACL-intact groups. There was no significant difference in all outcomes between the two groups. Understanding PASS will allow better communication between surgeons and patients to improve the surgical management of patients with single compartment OA of the knee. This study provides mid- to long-term data supporting the use of PASS to document outcomes following UKA. PASS was met in more than 85% of patients with no differences between ACL-deficient and ACL-intact knees at a mean follow-up of nine years. Cite this article: Bone Joint J 2021;103-B(8):1367–1372

Introduction. The demands placed upon joint surgeons are perhaps greatest when treating the revision arthroplasty patient, who present with complications demanding skill in diagnosis and evaluation, interpersonal communication and the technical aspects of the revision procedure. However, little information exists identifying which specific tasks in revision arthroplasty are most difficult for surgeons to master, and whether the greatest challenges arise from clinical, cognitive or technical facets of patient treatment. This study was undertaken to identify which tasks associated with revision total knee replacement (TKR) are perceived as most challenging to young surgeons and trainees to guide future efforts in surgical training and curriculum development. Methods. We developed an online survey instrument consisting of 69 items encompassing pre-operative, intraoperative, and post-operative tasks that preliminary studies identified as the essential components of revision TKR. These tasks encompassed 4 domains: clinical decision-making skills (n=9), interpersonal assessment and communication (n=7), surgical decision-making (n=35) and procedural surgical tasks (n=18). Respondents rated the difficulty of each item on a 5-level Likert scale, with an ordinal score ranging from 1 (“very easy”) to 5 (“very difficult”. The survey instrument was administered to a cohort of 109 US surgeons: 31 trainees enrolled in a joint fellowship program (Fellows) and 78 surgeons who had graduated from a joint fellowship program within the previous 10 years (Joint Surgeons). Using appropriate parametric and non-parametric tests, the responses were analyzed to examine the variation of reported difficulty of each of the 69 items, in addition to the nature of the task (cognitive, surgical, clinical and interpersonal), and differences between Fellows and Surgeons. Results. Both Fellows and Surgeons reported a wide variation in the difficulty of performing the tasks identified in each f the 4 domains. Fellows reported a higher average difficulty score than Surgeons (2.94 vs 2.74; p=0.032), corresponding to a greater frequency of tasks entailing some degree of difficulty (34.9% vs 24.4%, p<0.0001). Both groups experienced difficulty in performing tasks involving interpersonal interaction with patients (Fellows: 34.6% vs Surgeons: 34.3%, p=0.93). Fellows also found the technical aspects of revision surgery most challenging with 38.5% of items considered difficult compared to 28.7% for the Surgeon group (p<0.001). Highly significant differences between Fellows and Surgeons were also observed in facility with surgical decision making (p<0.001) and to a lesser extent, clinical decisions relating to patient care (% difficulty: p=0.0251). A compilation of the specific items cited as most difficult by the participants appears in Table 2. Conclusions. The young surgeons surveyed in this study reported difficulty in performing some tasks within both the clinical, cognitive and technical domains of revision knee arthroplasty. The high incidence of difficulty in tasks involving clinical decision-making and operative performance are characterized by a lack of accepted guidelines and the lack of a standard surgical practice. In general, our findings highlight the need for improvements in surgeon training to improve decision-making and procedural skills as part of the comprehensive management of patients undergoing revision knee arthroplasty. For any figures or tables, please contact authors directly

Background. The purpose of this study is to evaluate the early perioperative outcomes after primary knee arthroplasty with the use of a smartphone-based exercise and educational platform compared to a standard of care control group. Methods. A multicenter prospective randomized control trial was conducted evaluating the use of the mymobility smartphone-based care platform for primary total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA). Patients in the control group (224 patients) received the respective institution's standard of care typically with formal physical therapy. Those randomized to mymobility treatment group (192 patients) were provided an Apple Watch and mymobility smartphone application. The treatment group was not initially prescribed physical therapy, but could if their surgeon determined it necessary. Early outcomes assessed included 90-day knee range of motion, KOOS Jr scores, 30-day single leg stance (SLS) time, Time up and Go (TUG) time and need for manipulation under anesthesia (MUA). There was no significant difference in age, BMI or gender between groups. Results. The 90-day knee flexion was not significantly different between controls (118.3±11.8) and mymobility (118.8 ±12) (p=0.7), nor was knee extension (1.6 ±3.5 vs. 1 ±3.1, p=0.16). KOOS Jr scores were not significantly different between control group (74 ±13.1) and mymobility group (71 ±13.3) (p=0.06). 30-day SLS was 22.3 ± 19.5 sec in controls and 24 ± 20.8 sec in mymobility (p=0.2). 30-day TUG times were 16 ± 44.3 sec in control and 15 ± 40.6 sec in mymobility (p=0.84). MUAs were performed in 4.02% of patients in the control group and 2.8% in the mymobility group (p=0.4%). Conclusion. The use of the mymobility care platform demonstrated similar early outcomes to traditional care models, while providing communication and insights into patient engagement with the care plan. There was no significant difference in 90-day range of motion or need for MUA

Introduction. In recent years, online patient portals have been developed to offer the potential of an enhanced recovery experience. By offering videos, communication tools and patient-reported outcomes collection, online portals encourage patient's engagement in their care. In the total joint arthroplasty population, portals may also offer online physical therapy, allowing TJA patients to reach functional goals while reducing costs. Although technology may offer the potential of an enhanced recovery experience, disparities may exist between the comfort level of use and communication preferences of different patient populations. Our study aimed to analyze the utilization of an internet based patient portal, and quantify the impact of usage on patient reported outcome measures. Methods. 4,458 patients who underwent TJA across 8 major academic centers within one healthcare system were analyzed. Patients who scheduled surgery were registered for the online portal by the surgical coordinator. Upon registration, patients opt-in by signing a license agreement, and data is collected on their utilization of the portal including logins, exercise and educational videos watched, messages sent and PROs completed. Age was compared to utilization, opt-in rates, total videos watched, and messages sent. Two separate patient cohorts were identified to distinguish between active and non-active users. Anyone who opted-in and viewed over 5 preoperative videos or had at least 5 preoperative logins were considered active users. Patients’ postoperative KOOS-JR and HOOS-JR score improvements from baseline were compared between the active vs. non-active groups. Results. Of 4,458 total TJA patients, TKA and THA comprised 2670 and 1788, respectively, with an average age of 65.9 years (range 16–96 years). On average, patients logged into the portal 3.7 times preoperatively and 6.8 times postoperatively, and sent 2.29 messages. On average, 13 videos were watched preoperatively and 17 videos were watched postoperatively. Of all TJA patients, 72% opted-in to the portal. When looking solely at the TKA cohort, there was a significant difference in age between those patients that provided an email and those who didn't. The mean age of those who did provide an email was 66.3 years old, patients who didn't were on average 69.7 years old (p =.001). There was no significant impact of age on total preoperative or postoperative logins when considering both TKA and THA patients. There was a significant difference between age and preoperative or postoperative logins in the TKA group, with older patients tending to log in less (p =.001) and send fewer messages to the care team (p =.0001). Total videos watched preoperatively and postoperatively as well as preoperative logins did not impact change of HOOS JR scores at 6 weeks, 12 weeks, 6 months or 1 year. In the TKA cohort, the active user cohort correlated to greater improvement in KOOS-JR scores at 6 weeks, and 12 weeks postoperatively (p=.02, .018 respectively). Conclusion. While older TKA patients tended to be less engaged, the usage of the online portal overall was not impacted by age in the TJA population. As the average age of patients undergoing TKA continues to decrease, surgeons will be faced with a younger patient population that communicates heavily through technology. Previously published literature has proven online PT is as effective as traditional PT, making online portals a promising option to improve care while decreasing costs. As seen in our TKA population, patients experienced greater improvement in KOOS-Jr scores with greater activity and use of the portal

Aims

The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

We present a case in which the growth of an intraosseous cyst arising from the proximal tibiofibular joint appeared to have been increased by polyethylene wear particles from a medial unicompartmental knee replacement. Histological examination of the cyst wall showed a histiocytic response associated with numerous polyethylene wear particles. This case demonstrates that there is a direct communication between the joint cavity and the cyst. Such communication is probably through openings in the articular cartilage large enough to allow the passage of these particles

We report a patient with a subperiosteal ganglion cyst of the tibia which was imaged by radiography, arthrography, CT and MRI. The images were correlated with the arthroscopic surgical and histological findings. Spiculated formation of periosteal new bone on plain radiographs led to the initial suspicion of a malignant tumour. Demonstration of the cystic nature of the tumour using cross-sectional imaging was important for the precise diagnosis. Communication between the ganglion cyst and the knee was shown by a delayed arthrographic technique, and the presence of this communication was confirmed at arthroscopy and surgically

Aims

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians’ management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications.

Aims

The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Aims

The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis.

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

Aims

The aim of this study was to perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).

Aims

This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.