Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility. IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm. We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime. IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation

Abstract. Objectives. To analyse the costs and benefits of sending femoral head specimens for histopathological analysis and whether our practice had changed since the original study five years ago. Methods. The cohort definition was patients who had both undergone hip hemiarthroplasties (HHAs) and had femoral head specimens sent for histopathological analysis at our tertiary care institution from 2013 to 2016. Retrospective review of clinical and electronic notes was performed on these patients for history of malignancy, histopathological diagnosis of femoral head, indication for histopathological examination and radiological studies. The total number of HHAs performed at the centre and the costs involved in analysing each femoral head specimen were identified. Results. A total of 805 HHAs were performed at the centre. We identified 56 femoral head specimens from 56 patients (6.96%) that were sent for histopathological analysis after HHA. 29 patients (51.79%) had a known history of malignancy. Three femoral head specimens (10.34%) were histologically positive for malignancy. Two patients had hip radiographs demonstrating metastasis to the femoral head. The third patient had a PET-CT scan two weeks prior to fracture that did not show signs of metastatic disease. 27 patients (48.21%) had no history of malignancy. None of their femoral head specimens were found to be histologically positive for malignancy. 10 patients had no appropriate indication for histopathological analysis. The cost savings for 27 patients with no previous history of malignancy ranged from €2,295 to €9,504. The cost savings for 10 patients with no appropriate indication ranged from €850 to €3,520. Conclusions. Histopathological analysis of femoral head specimens after HHA has little benefit for patients without a history of malignancy. The practice at our institution had not changed significantly in the past five years. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. Knee alignment affects both the development and surgical treatment of knee osteoarthritis. Automating femorotibial angle (FTA) and hip-knee-ankle angle (HKA) measurement from radiographs could improve reliability and save time. Further, if the gold-standard HKA from full-limb radiographs could be accurately predicted from knee-only radiographs then the need for more expensive equipment and radiation exposure could be reduced. The aim of this research is to assess if deep learning methods can predict FTA and HKA angle from posteroanterior (PA) knee radiographs. Methods. Convolutional neural networks with densely connected final layers were trained to analyse PA knee radiographs from the Osteoarthritis Initiative (OAI) database with corresponding angle measurements. The FTA dataset with 6149 radiographs and HKA dataset with 2351 radiographs were split into training, validation and test datasets in a 70:15:15 ratio. Separate models were learnt for the prediction of FTA and HKA, which were trained using mean squared error as a loss function. Heat maps were used to identify the anatomical features within each image that most contributed to the predicted angles. Results. FTA could be predicted with errors less than 3° for 99.8% of images, and less than 1° for 89.5%. HKA prediction was less accurate than FTA but still high: 95.7% within 3°, and 68.0 % within 1°. Heat maps for both models were generally concentrated on the knee anatomy and could prove a valuable tool for assessing prediction reliability in clinical application. Conclusions. Deep learning techniques could enable fast, reliable and accurate predictions of both FTA and HKA from plain knee radiographs. This could lead to cost savings for healthcare providers and reduced radiation exposure for patients

INTRODUCTION. Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS), decreased narcotic use and are increasingly important in delivering quality, cost savings and shifting appropriate cases to an outpatient setting. The intraoperative use of vasopressors is independently associated with increased length of stay, risk of adverse postoperative events including death and in total hip arthroplasty there is an increased risk for ICU admission. Our aim is to characterize the patient characteristics associated with vasopressor use specifically in total knee arthroplasty (TKA). METHODS. We retrospectively reviewed 748 patients undergoing inpatient primary total knee arthroplasty at a single academic institution by two surgeons from 1/1/17 to 12/21/18. Demographics, comorbidities, perioperative factors and intraoperative medication administration were compared with multivariate regression to identify patients who may require intraoperative vasopressors. RESULTS. Seven hundred-forty eight patients underwent total knee arthroplasty and 439 patients required intraoperative vasopressors while 307 did not require vasopressors. Significant predictors of vasopressor use were male sex (p=0.035), history of prior cerebrovascular event (p=0.041) and older age (p=0.048). NPO time, anesthesia provider level of training, operative time, and intraoperative mean arterial pressure and heart rate were not significant predictors of vasopressor use intra-operatively during total knee arthroplasty. CONCLUSION. In this study, nearly fifty-nine percent of patients undergoing TKA received intraoperative vasopressor support. Male gender, history of stroke and older age were significantly associated with increased intraoperative vasopressor use. Surgical time and case order do not appear to be optimizable factors to minimize the use of vasopressors in TKA. Our results highlight variation in anesthesia practices and an opportunity to standardize vasopressor triggers and identify patients who may require vasopressor support during preoperative optimization and selection of their surgical setting

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods. National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results. The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions. The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings. Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33–36. doi: 10.1302/2046-3758.52.2000506

Carpal tunnel decompression is one of the most commonly performed orthopaedic operations. Last year 160 patients attended our department for surgery. There have been reports in the literature of good results and improved patient satisfaction for wound closure with Vicryl Rapide following Dupuytren's surgery. We looked at 200 consecutive patients who underwent carpal tunnel decompression. Wounds were closed using either non-absorbable monofilament sutures (first 97 patients) or interrupted Vicryl Rapide (next 103 patients). We compared the incidence of wound problems in the early post operative period, scar sensitivity and the number of patients requiring a further outpatient appointment because of ongoing problems associated with these issues. There was a higher incidence of early wound problems (p=0.0359) in patients whose wounds were closed with nylon. There was no difference in the rates of scar tenderness (p=1) or in the number of patients requiring further clinic appointments (p=0.356). There are also potential cost savings in using absorbable sutures as they require fewer sundry items at the dressings clinic. In conclusion there were fewer problems associated with wound closure with interrupted Vicryl Rapide sutures than with nylon in patients undergoing carpal tunnel decompression

Background and purpose. The STarT Back trial demonstrated benefits from a stratified primary care model that targets low back pain (LBP) treatment according to patient prognosis (low-, medium-, or high-risk). The current IMPaCT Back study implemented this approach in everyday primary care to investigate; i) changes in GPs' and physiotherapists' attitudes, confidence and behaviours, ii) patients' clinical outcomes, and iii) cost-effectiveness. Method. This quality improvement study involved 5 GP practices (65 GPs and 34 physiotherapists) with before and after implementation cohorts of consecutive LBP consulters using an intention to treat analysis to compare patient data. Phase 1: Usual care data collection from clinicians and patients (pre-implementation). Phase 2: Introduction of prognostic screening and targeted treatment including a minimal GP intervention (low-risk group), systematic referral to physiotherapy (medium-risk group) and to psychologically informed physiotherapy (high-risk group). Phase 3: Post-implementation data collection from clinicians and patients. Results. 922 patients participated (368 in Phase 1 and 554 in Phase 3) with similar baseline characteristics (mean age 53 v 54 years, disability (RMDQ) 8.7 v 8.4). Significant differences in favour of targeted treatment were demonstrated in clinicians' attitudes and confidence, and RMDQ 6-month change scores (mean difference 0.7 [95% CI 0.1, 1.4]). Health care cost savings were also identified, in addition to an average of 3.5 fewer days off work during study follow-up. Conclusion. A stratified model of LBP management can be successfully introduced into real-life primary care, improving clinicians' attitudes and confidence and patient disability outcomes and reducing the economic burden of LBP. Conflicts of Interest. None. Source of Funding. The Health Foundation. This abstract has not been previously published in whole or substantial part, it has been presented at international meetings in 2011, but not yet a national meeting

Background. One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes. Methods. 1573 adults with back pain (+/− radiculopathy) consulting at 10 general practices in England responded to invitations to attend an assessment clinic, at which 851 eligible participants were randomised (intervention n=568; control n=283). Primary outcome using intention-to-treat analysis was the difference in change in the Roland-Morris Disability Questionnaire (RMDQ) score at 12 months. Secondary outcomes included 4-month RMDQ change between arms overall, and at risk-group level at both time-points. The economic evaluation estimated incremental quality-adjusted life years (QALYs) and back pain-related health care costs. Results. Overall, between-group differences in RMDQ adjusted mean change scores significantly favoured stratified care; 1·8 (95%CI 1·1, 2·6) at 4-months and 1·1 (95%CI 0·3, 1·9) at 12-months. Stratified care was associated with an increase in generic health benefit (0.039 additional QALYs) and cost savings. Low-risk patients had non-inferior outcomes compared with controls, and there were significant between-group differences in RMDQ adjusted mean change scores for medium-risk patients at 4 (1·99 [95%CI 0·75, 3·22]) and 12 months (1·33 [95%CI 0·15, 2·52]), and high-risk patients at 4 months (2·53 [95%CI 0·90, 4·16]). Conclusion. A stratified approach of prognostic screening with treatment matched pathways for patients in primary care with back pain provides significant improvements in clinical and economic outcomes compared to current best practice. Conflicts of Interest. None. Source of Funding. Arthritis Research UK. This abstract has been presented at 3 international conferences but not yet at a national conference. It has also been accepted for publication in the Lancet – but is not yet published

Summary Statement. A prospective randomised evaluation of primary TKA utilizing patient specific instruments demonstrated great accuracy of bone resection, improved sagittal alignment and the potential to improve functional outcomes and reduce operating room costs when compared to standard TKA instrumentation. Introduction. Patient specific instruments (PSI), an alternative to standard total knee arthroplasty (TKA) technology, have been proposed to improve the accuracy of TKA implant placement and post-operative limb alignment. Previous studies have shown mixed results regarding the effectiveness of PSI. The purposes of this study were (1) to evaluate the accuracy of the pre-operative predicted PSI plan compared to intra-operative TKA resection measurements, (2) to compare patient-reported outcome measures of PSI and standard TKA patients, and (3) to compare the incremental cost savings with PSI. Patients and Methods. This randomised, prospective pilot study of 19 patients undergoing primary TKA with a cruciate-retaining cemented prosthesis (NexGen, Zimmer Inc.) was conducted by a single high-volume arthroplasty surgeon (DCA). Patients were randomised to PSI or standard instrumentation. Patients randomised to the PSI cohort received a pre-operative knee MRI for PSI fabrication using Zimmer proprietary software. 10 standard TKA and 9 PSI TKA were completed. Pre-operative baseline SF-36 and WOMAC scores were collected. Operative data collected included operating room times, implant details, femoral (medial/lateral distal and posterior) and tibial (medial/lateral) cut thicknesses, and number of instrument trays used. Hospitalization data collected included length of stay, blood loss, drain output, and transfusion requirements. Follow-up occurred at 2 weeks, 6–8 weeks, 3 months, 6 months, and 1 year, with SF-36 and WOMAC scores collected at each time point. Routine radiographic analysis was carried out in both cohorts. Extensive financial data was collected including costs of operating room use and anesthesia, implants, and hospitalization. Statistical analyses included t-tests for continuous variables and chi-square tests for categorical variables. Results. All femoral and tibial implant sizes used during TKA matched the component sizes predicted by the PSI software. Flexion gap bone resection (posterior medial/lateral femoral cuts) was extremely accurate (<1 mm on average) when compared with PSI predictions. PSI proximal tibial bone resection was also extremely accurate and within 1 mm on average of predicted values. Sagittal plane tibial component posterior slope in PSI TKA was significantly more accurate (7.33 degrees) in comparison to standard instrumentation (4.20 degrees) (p<0.025). No significant differences in coronal mechanical limb alignment existed between the two cohorts (p>0.05). There were no differences in operating room times, length of stay, or transfusions between the two groups. PSI patients used 4 fewer instrument trays per case (p<0.0001). There were no significant differences in functional outcome scores between the two groups (p>0.05). Discussion/Conclusion. PSI TKA demonstrated outstanding accuracy in bone resection when compared with the custom operative plan. There was no difference in post-operative coronal limb alignment or individual component alignment between the two groups, but an improvement in tibial component alignment in the sagittal plane in the PSI cohort was statistically significant. The number of instrument trays in PSI TKA's were significantly less than standard TKA which led to less cost for instrument sterilization and assembly, and quicker room set-up. PSI instrumentation resulted in accurate bone resection and appropriate limb and component alignment after primary TKA in this prospective randomised evaluation

We performed a biomechanical study to compare the augmentation of isolated fractured vertebral bodies using two different bone tamps. Compression fractures were created in 21 vertebral bodies harvested from red deer after determining their initial strength and stiffness, which was then assessed after standardised bipedicular vertebral augmentation using a balloon or an expandable polymer bone tamp.

The median strength and stiffness of the balloon bone tamp group was 6.71 kN (sd 2.71) and 1.885 kN/mm (sd 0.340), respectively, versus 7.36 kN (sd 3.43) and 1.882 kN/mm (sd 0.868) in the polymer bone tamp group. The strength and stiffness tended to be greater in the polymer bone tamp group than in the balloon bone tamp group, but this difference was not statistically significant (strength p > 0.8, and stiffness p = 0.4).