Objectives. Acetabular fractures with quadrilateral plate involvement have been shown to have a high rate of complications. Anatomic suprapectineal plating systems have been developed to manage these injuries with good short-term outcomes, however long-term maintenance of anatomical reduction and functional outcomes is yet to be established. Efficacy of maintenance of reduction and functional outcomes at a minimum of 5-years follow-up is the aim of this study. Design and Methods. A retrospective cohort study examining patients aged over 16 years following fixation of acetabular fractures with quadrilateral plate involvement at a trauma centre in the United Kingdom. All patients had acetabular fracture fixation with an anatomically designed suprapectineal plate. Patients were admitted from March 2014 to January 2017. Primary outcomes included objective radiological outcomes such as reduction quality, maintenance of reduction, metalwork failure, complications (such as reoperation, neurological deficit and mortality) and subjective patient-related outcome measures (PROMs) using the Oxford Hip Score and EuroQol EQ5D Score at a minimum of 5-years post-operatively. Results. 16 patients met our eligibility criteria in this cohort. Post-operative mean Oxford Hip Score (OHS) at a minimum of 5-years was 40.5 (SD 11.9) with a median score of 45. Post-operative mean EuroQol EQ-5D scores at a minimum of 5-years were 0.83 (SD 0.25). Comparison of OHS and EQ5D at 1-year and 5-years showed no significant difference (OHS p = 0.27 / EQ5D p = 0.128). Radiographic outcomes were assessed with AP and Judet plain radiographs at a minimum of 5-years follow-up. Rate of conversion to total hip replacement was 6.25%. 56.3% showed some evidence of dome comminution with 18.8% demonstrating dome impaction. 93.7% showed evidence of quadrilateral plate involvement. 12.5% showed evidence of femoral head injury. Conclusion. Maintenance of reduction and functional and patient reported outcomes using anatomically contoured suprapectineal plates do not change significantly between 1 year and 5 years follow-up

In multilevel posterior cervical instrumented fusions, extending the fusion across the cervico-thoracic junction at T1 or T2 (CTJ) has been associated with decreased rate of re-operation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient reported outcomes (PROs) remains unclear. The primary objective was to determine whether extending the fusion through the CTJ influenced PROs at 3 and 12 months after surgery. Secondary objectives were to compare the number of patients reaching the minimally clinically important difference (MCID) for the PROs and mJOA, operative time duration, intra-operative blood loss (IOBL), length of stay (LOS), discharge disposition, adverse events (AEs), re-operation within 12 months of the surgery, and patient satisfaction. This is a retrospective analysis of prospectively collected data from a multicenter observational cohort study of patients with degenerative cervical myelopathy. Patients who underwent a posterior instrumented fusion of 4 levels of greater (between C2-T2) between January 2015 and October 2020 with 12 months follow-up were included. PROS (NDI, EQ5D, SF-12 PCS and MCS, NRS arm and neck pain) and mJOA were compared using ANCOVA, adjusted for baseline differences. Patient demographics, comorbidities and surgical details were abstracted. Percentafe of patient reaching MCID for these outcomes was compared using chi-square test. Operative duration, IOBL, AEs, re-operation, discharge disposittion, LOS and satisfaction were compared using chi-square test for categorical variables and independent samples t-tests for continuous variables. A total of 206 patients were included in this study (105 patients not crossing the CTJ and 101 crossing the CTJ). Patients who underwent a construct extending through the CTJ were more likely to be female and had worse baseline EQ5D and NDI scores (p> 0.05). When adjusted for baseline difference, there was no statistically significant difference between the two groups for the PROs and mJOA at 3 and 12 months. Surgical duration was longer (p 0.05). Satisfaction with the surgery was high in both groups but significantly different at 12 months (80% versus 72%, p= 0.042 for the group not crossing the CTJ and the group crossing the CTJ, respectively). The percentage of patients reaching MCID for the NDI score was 55% in the non-crossing group versus 69% in the group extending through the CTJ (p= 0.06). Up to 12 months after the surgery, there was no statistically significant differences in PROs between posterior construct extended to or not extended to the upper thoracic spine. The adverse event profile did not differ significantly, but longer surgical time and blood loss were associated with construct extending across the CTJ

Glenoid failure remains the most common mode of total shoulder arthroplasty failures. Porous tantalum metal (Trabecular Metal™, Zimmer) have grown in popularity in hip and knee arthroplasty. First-generation porous tantalum metal-backed glenoid components demonstrated metal debris, resulted in failure, and were revised to second-generation glenoid implants. Evidence for second-generation porous tantalum metal implants in shoulder arthroplasty is sparse.1–4 The purpose of this study was to assess clinical and radiographic outcomes in a series of patients with second-generation porous tantalum glenoid components at a minimum two-years postoperative. We retrospectively reviewed the clinical and radiographic outcomes of patients who received a second-generation porous tantalum glenoid component anatomic shoulder arthroplasty between May 2009 and December 2017 with minimum 24 months follow-up. The shoulder arthroplasties were performed by one of two senior fellowship-trained surgeons. We collected postoperative clinical outcome indicators: EQ5D visual analog scale (VAS), Western Ontario Osteoarthritis of the Shoulder (WOOS) Index, American Shoulder and Elbow Surgeons (ASES) Score, and Constant Score (CS). Radiographic review was performed by an independent fellowship-trained surgeon. The Endrizzi metal debris grading system1 was utilized to grade metal debris. We computed descriptive statistics and compared outcome scores between groups via the non-parametric Wilcoxon rank-sum test, with group-wise comparisons defined by: metal debris and humeral head migration (secondary analyses). Thirty-five patients [23 male (65.7%) and 12 female (34.3%)] with 40 shoulder replacements participated in the study. Forty of 61 shoulders (65.6%) had an average of 64 ± 20.3 months follow-up (range 31 to 95). Average BMI was 27.5 ± 4.4 kg/m2 (range 19.5 to 39.1). The average postoperative EQ5D VAS at final follow-up was 74.6 ± 22.5, WOOS Index 87.9 ± 16.6, ASES Score 88.3 ± 10.9, and CS 80.4 ± 13. At final follow-up, 18 of 40 shoulders (45%) had metal debris [15 of 40 (37.5%) Endrizzi grade 1 and three of 40 (7.5%) Endrizzi grade 2], and 22 of 40 shoulders (55%) did not show evidence of metal debris. There was one non-revision reoperation (open subscapularis exploration), one shoulder with anterosuperior escape, three shoulders with glenoid radiolucencies indicative of possible glenoid loosening, and nine shoulders with superior migration of the humeral head (>2mm migration at final follow-up compared to immediate postoperative). When comparing postoperative scores between patients with vs without metal debris, we found no statistically significant difference in the EQ5D VAS, WOOS Index, ASES Score and CS. On further analyses, when comparing superior migration of the humeral head and postoperative outcomes scores, we found no statistically significant difference. We report the longest published follow-up with clinical and radiographic outcomes of second-generation porous tantalum glenoid anatomic shoulder arthroplasties. In this series of patients, 45% of total shoulder arthroplasties with a second-generation porous tantalum glenoid implant had radiographic evidence of metal debris. This metal debris was not statistically associated with poorer postoperative outcomes. Further investigation and ongoing follow-up are warranted

Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41. Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this

The prevalence of gluteal tendinopathy (GT) associated with osteoarthritis of the hip is difficult to determine as it is frequently undiagnosed or misdiagnosed as trochanteric bursitis. Its relationship to total hip arthroplasty (THA) outcomes is currently unknown. The aim of this study was to determine the incidence of GT at the time of hip arthroplasty and examine the relationship between GT and patient reported outcomes (PROMS) before and after THA. Patients undergoing THA for primary osteoarthritis between August 2017 and August 2020 were recruited. Tendinopathy was assessed and graded at time of surgery. PROMS included the Oxford Hip Score (OHS), HOOS JR, EQ-5D, and were collected preoperatively and at one year after THA. Satisfaction with surgery was also assessed at 1 year. 797 patients met eligibility criteria and were graded as Grade 1: normal tendons (n =496, 62%), Grade 2: gluteal tendinopathy but no tear (n=222, 28%), Grade 3: partial/full thickness tears or bare trochanter (n=79, 10%). Patients with abnormal gluteal tendons were older (p=0.001), had a higher mean BMI (p=0.01), and were predominately female (p=0.001). Patients with higher grade tendinopathy had statistically significant inferior PROMS at one year, OHS score (44.1 v 42.9 v 41.3, p 0.001) HOOS JR (89.3 V 86.3 V 85.6 p 0.005). Increasing gluteal tendon grade was associated with a greater incidence of problems with mobility (p=0.001), usual activities (p=0.001) and pain (p=0.021) on EQ5D. There was a 3 times relative risk of overall dissatisfaction with THA in the presence of gluteal tears. This study demonstrated that gluteal tendinopathy was commonly observed and associated with inferior 1-year PROMS in patients undergoing THA for OA. Increasing degree of tendinopathy was a negative prognostic factor for worse functional outcomes and patient satisfaction

Obesity is a common in individuals undergoing arthroplasty, and the potential for weight loss with improved mobility may be expected by some. The aim of this study was 1. determine the proportion that achieved weight loss after hip or knee arthroplasty, and 2. examine the effect of obesity on patient reported outcomes (PROMS) and satisfaction with surgery. Participants underwent primary TKA or THA between July 2015 and December 2020 and consented to participation in a research database with baseline PROMS, including weight, BMI, Oxford Knee, or Hip Score, and EQ5D. Participants repeated PROMS at 12 months after surgery with additional questions regarding satisfaction with surgery. 3449 patients completed PROMS 1 year after arthroplasty with weight and BMI. There were 1810 THA and 1639 TKA procedures. The mean baseline BMI was higher in TKA (29.8, SD 5.2) compared to THA (27.7, SD 5.0), p=0.001. A higher proportion of TKA were classified as obese class 1 (29% TKA, 19% THA), obese class 2 (11% TKA and 6% THA), and obese class 3 (5% TKA and 2% THA), p=0.001. The mean weight loss after 1 year was 0.4kg and 0.9kg in obese THA subjects and TKA subjects respectively. In the obese >5kg weight loss was achieved in 13% of TKA and 7% of THA (p=0.001). Obese experienced equivalent improvement in Oxford scores, compared to non-obese subjects. Satisfaction with surgery was reported by 95% of THA and 91% of TKA subjects with no significant differences between BMI group grades (p=0.491 THA and p=0.473 TKA). Preoperative obesity was observed in 44% of TKA and 27% of THA subjects. In the obese only 1 in 10 subjects lost 5kg or more over 12 months. Obese patients experienced equivalent improvements in outcome after arthroplasty and rates of satisfaction with surgery to the non-obese

This study aims to correlate Oxford shoulder score (OSS) to EQ5D score in healthy patients presenting to a shoulder clinic with shoulder pain. OSS and EQ5D scores were collected prospectively from 101 consecutive patients presenting with shoulder pain in a shoulder clinic at one specialist centre. Patients with ASA > 2 and other significant joint arthritis were excluded from the study. Scores were collected from electronic patient records. Spearman's rho correlation of oxford shoulder scores and EQ5D scores was completed. Mean age of subjects was 51.8 (range 19.1–81.9) years, 55 of 101 subjects were men (54%). Median OSS was 26 (range 3–48) and median EQ5D score was 0.76 (range 0–0.76). Correlation for all patients was 0.624 (Sig p<0.001). This study demonstrates a strong correlation between Oxford shoulder scoring and EQ5D in a fit and well shoulder surgery clinic population. It is possible that Oxford shoulder scores may be a useful indicator of quality of life in healthy shoulder clinic patients presenting with shoulder pain

Objectives. This study examines variations in knee arthroplasty patient reported outcome measures according to patient age. Methods. We analysed prospectively collected outcome data (OKS, Eq5D, satisfaction, and revision) on 2456 primary knee arthroplasty patients. Patients were stratified into defined age groups (< 55, 55–64, 65–74, 75–84, and ≥85 years). Oxford Knee Score and Eq5D were analysed pre-operatively, and postoperatively at 6 months and 2 years. Absolute scores and post-operative change in scores were calculated and compared between age groups. Satisfaction scores (0–100) were analysed at 6 months post-operatively. Linear, logistic and ordinal regression modelling was used to describe the association between age and outcomes, for continuous, binary and ordinal outcomes, respectively. Kaplan-Meier analysis was performed to describe revision rates at 2 years. Results. Patients aged 65–85 years demonstrated better preoperative status than those aged under 65 (OKS, p=0.03; Eq5D, p=0.048), and over 85 years (OKS, p=0.03). Postoperatively, no significant difference in OKS or Eq5D was observed between age groups. Postoperative change in score showed a linear trend for a greater post-operative change in younger patients at 6-months and 2-years (p< 0.04). Overall satisfaction score was 84.9, but patient satisfaction was significantly lower in those aged < 55 years compared to all other age groups (78.1 Vs. 84.8, p=0.031). Cumulative overall 2-year revision rate was 1.3%. Conclusion. This study demonstrates that good early outcomes, as measured by the OKS and Eq5D, can be anticipated following knee replacement regardless of the patient's age, although younger patients gain greater improvement. However, the lower satisfaction in those aged < 55 years is a concern and suggests that outcome is not fully encapsulated by the OKS and Eq5D alone. This raises the question as to whether the OKS alone is an appropriate measure of pain and function in the younger, more active population

Aim. This study assessed quality of life (QoL) in patients having external fixation for treatment of osteomyelitis and fracture-related infection (OM/FRI). Method. Patients who had surgery for OM/FRI and who completed the EuroQoL EQ-5D-5L or EQ-5D- 3L questionnaires, were identified between 2010 and 2020. Patients were followed-up for 2 years after surgery. QoL was compared between patients who had either an Ilizarov frame or a monolateral external fixator with those who did not receive external fixation. Results. 165 patients were included. Of these, 37 (22.4%) underwent application of external fixation which included 23 circular frames and 14 monolateral external fixators. Patients in the frame group had more BACH ‘Complex’ infections (34/37; 91.9%), compared to non-frame patients (57/81; 70.3%). Pre-operatively, the mean EQ-index score for patients planned to receive a frame (0.278 SD 0.427) was worse compared to other treatments (0.453 SD 0.338, p=0.083). At 6 weeks after surgery, the EQ-index score remained significantly lower in frame patients compared to non-frame patients (frame: 0.379 SD 0.363; no frame: 0.608 SD 0.326, p=0.016). By 6 months, 26/37 patients had undergone frame removal. The patients who had frames in situ at 6 months had lower EQ-index scores when compared to patients who had their frames removed (frame in situ: 0.187 SD 0.213; frame removed 0.674 SD 0.206, p=0.076). At one year, 36/37 (97.3%) patients had their frame removed. QoL had greatly improved, to levels similar to non-frame patients (no frame: 0.652 SD 0.357; frame removed: 0.657 SD 0.247, p=0.949). Conclusions. Frame treatment leads to significant improvement in Quality of Life in patients suffering from osteomyelitis, with similar results in EQ5D scores after 1 year compared to patients who did not need an external fixator. These effects cannot be felt until after the frame has been removed with impaired QoL during frame treatment, especially in those patients with frames in situ for more than 6 months. This underlines the need for close and professional patient support during frame treatment for bone infection

Adverse spinopelvic characteristics (ASC) have been associated with increased dislocation risk following primary total hip arthroplasty (THA). A stiff lumbar spine, a large posterior standing tilt when standing and severe sagittal spinal deformity have been identified as key risk factors for instability. It has been reported that the rate of dislocation in patients with such ASC may be increased and some authors have recommended the use of dual mobility bearings or robotics to reduce instability to within acceptable rates (<2%). The aims of the prospective study were to 1: Describe the true incidence of ASC in patients presenting for a THA 2. Assess whether such characteristics are associated with greater symptoms pre-THA due to the concomitant dual pathology of hip and spine and 3. Describe the early term dislocation rate with the use of ≤36mm bearings. This is an IRB-approved, two-center, multi-surgeon, prospective, consecutive, cohort study of 220 patients undergoing THA through anterolateral- (n=103; 46.8%), direct anterior- (n=104; 27.3%) or posterior- approaches (n=13; 5.9%). The mean age was 63.8±12.0 years (range: 27.7-89.0 years) and the mean BMI 28.0±5.0 kg/m. 2. (range: 19.4-44.4 kg/m. 2. ). There were 44 males (47.8%) and 48 females (52.2%). The mean follow-up was 1.6±0.5 years. Overall, 54% of femoral heads was 32 mm, and 46% was 36mm. All participants underwent lateral spinopelvic radiographs in the standing and deep-flexed seated positions were taken to determine lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA) and pelvic incidence (PI) in both positions. Spinal stiffness was defined as lumbar flexion <20° when transitioning between the standing and deep-seated position; adverse standing PT was defined as >19° and adverse sagittal lumbar balance was defined as mismatch between standing PI and LL >10°. Pre-operative patient reported outcomes was measured using the Oxford Hip Score (OHS) and EuroQol Five-Dimension questionnaire (EQ-5D). Dislocation rates were prospectively recorded. Non-parametric tests were used, significance was set at p<0.05. The prevalence of PI-LL mismatch was 22.1% (43/195) and 30.4% had increased standing PT (59/194). The prevalence of lumbar stiffness was 3.5% (5/142) and these patients had all three adverse spinopelvic characteristics (5/142; 3.5%). There was no significant difference in the pre-operative OHS between patients with (20.7±7.6) and patients without adverse spinopelvic characteristics (21.6±8.7; p=0.721), nor was there for pre-operative EQ5D (0.651±0.081 vs. 0.563±0.190; p=0.295). Two patients sustained a dislocation (0.9%): One in the lateral (no ASC) and one in the posterior approaches, who also exhibited ASC pre-operatively. Sagittal lumbar imbalance, increased standing spinal tilt and spinal stiffness are not uncommon among patients undergoing THA. The presence of such characteristics is not associated with inferior pre-operative PROMs. However, when all characteristics are present, the risk of instability is increased. Patients with ASC treated with posterior approach THA may benefit from the use of advanced technology due to a high risk of dislocation. The use of such technology with the anterior or lateral approach to improve instability is to date unjustified as the rate of instability is low even amongst patients with ASCs

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

Introduction. Patients-reported outcome measures (PROMs) have been reported as the important methods to evaluate clinical outcomes in total knee arthroplasty (TKA). The patient satisfaction score in Knee Society Score (KSS-2011) has been used in the recent literatures. Patient satisfaction was subjective parameter, and would be affected by multiple factors including psychological factors and physical conditions at not only affected joint but also elsewhere in the body. The question was raised regarding the consistency of patient satisfaction score in KSS-2011 to other PROMs. The purpose of this study was to investigate the correlation of patient satisfaction in KSS-2011 to other categories in KSS-2011 and to other PROMs including Forgotten Joint Score (FJS-12), EuroQol-5 Dimensions (EQ-5D) and 25-questions in Geriatric Locomotive Function Scale (GLFS-25). Material & Method. 83 patients over 65 years old with osteoarthritic knees were involved in this study. All patients underwent CR-TKAs (Persona CR. R. ). The means and ranges of demographics were as follows: age; 74.5 years old (65–89), Hip-Knee-Ankle (HKA) angle; 12.4 (−6.2–22.5) in varus. We asked patients to fulfill the questionnaire including KSS-2011, FJS-12, EQ-5D and GLFS-25 at 1-year postoperative follow-up visit. KSS-2011 consisted of 4 categories of questions; patient satisfaction (PS), symptoms, patient expectations (PE), functional activities (FA). We evaluated the correlation of PS to other PROMs using simple linear regression analyses (p<0.001). Results. The means and standard deviations of 1-year postoperative scores were as follows: PS; 28.5 ± 7.0, symptoms; 19.1 ± 4.3, PE; 11.2 ± 2.9, FA; 71.5 ± 16.6, FJS-12; 51.5 ± 18.6, EQ5D; 0.69 ± 0.10, GLFS-25; 25.7 ± 16.9. PSs were moderately positively correlated to other categories in KSS-2011(correlation coefficient (r): symptoms; 0.69, PE; 0.73, FA; 0.69). PSs were positively correlated to both FJS-12 and EQ5D (r: FJS-12; 0.72, EQ-5D; 0.67) and negatively correlated to GLFS-25(r; −0.74). Discussions. Patient satisfaction score positively correlated to the symptoms, patient expectation and functional activities in KSS-2011 with moderately high correlation coefficient. This meant the better pain relief and functional outcome improved patient satisfaction. Although there had be reported preoperative higher expectation would lead to poor patient satisfaction postoperatively, we interestingly found positive correlation between patient satisfaction and expectation at 1 year after TKA. Patient with the higher satisfaction tended to expect more in the future, on the other hand, unsatisfied patient with residual pain and/or poor function would resign themselves to the present status and reduced their expectation in our patient population. We have found patient satisfaction score in KSS-2011 significantly correlated to FJS-12 and GLFS-25 with strong correlation coefficient. This meant patient satisfaction could be considered consist to other PROMS in relatively younger patient with better functional status in this study. Conclusion. The patient satisfaction score in KSS-2011 was found to be consistent with moderately high correlations coefficient to other categories in KSS-2011 and other PROMs including FJS-12, EQ-5D, GLFS-25 at 1 year after (CR)-TKA. For any figures or tables, please contact authors directly

Background. In the late 1980's Michael Freeman conceived the idea that knee replacement would most closely replicate the natural knee joint, if the medial Tibio-Femoral articulation was configured as a “ball-in-socket”. Over the last three decades, medial rotation and medial pivot designs have proved successful in clinical use. Freeman's final iteration of the medial ball-in-socket concept was the Medial Sphere knee. We report the three-year survivorship, clinical outcomes, patient reported outcome measures (PROMs) and radiographic analysis of this implant in a multi-centre, multi-surgeon, prospective observational study. Methods. Patients awaiting total knee replacement were recruited by four centres. They had no medical contraindication to surgery, were able to provide informed consent and were available for follow-up. Primary outcome was implant survival at six months, one, two, three and five years. Secondary outcomes were patient reported outcome measures: Oxford Knee Score (OKS), Euroqol (EQ-5D), International Knee Society Score (IKSS), IKSS Functional score and Health State score, complications and radiographic outcomes. Radiographic analysis was undertaken using the TraumaCad software and data analysis was undertaken using SPSS. Results. To date, 328 female and 202 male patients with a mean age 66.9 years and mean body mass index 30.0 were recruited. Three year Kaplan-Meier survivorship analysis of cumulative failure showed an implant survival of 99.46% (95% confidence interval 100 – 96.74), when deaths and withdrawals were treated as censored data. Twelve patients withdrew (2.26%), seven died (1.32%) and two knees were revised (0.38%). The mean EQ5D, Health State Scores, OKS, IKSS & IKSS Function scores at three years improved significantly from pre- operative scores (Health State Score: 9.91 (65.59 pre-op to 75.50); OKS: 18.82 (19.90 pre-op to 38.72); IKSS: 39.87 (44.39 pre-op to 92.09); IKSS Function Score: 35.03 (49.42 pre-op to 84.45). The mean improvement of EQ5D at three years was: 0.34 (0.48 pre-op to 0.82). Discussion. Survival of the GMK Sphere to three years in this study was over 99%. Risk of revision compares favourably with UK National Joint Registry (NJR) data. The improvements that are seen in patient reported outcome measures reflect an enhancement in patient function and quality of life. Conclusion. At three years follow-up, the implant demonstrates satisfactory survival and outcomes. Patient matching and evaluation of more cases, at more time points will allow outcome comparison with other implant options

Flexible fixation techniques combined with anatomic (open) syndesmosis reduction have demonstrated improved functional outcomes and rates of malreduction. Suture-button devices allow physiologic motion of the syndesmosis without need for implant removal, which may lower the risk of recurrent syndesmotic diastasis. There is limited longer-term assessment of the maintenance of reduction between static and flexible syndesmotic fixation using bilateral ankle CT evaluation. This is an a priori planned subgroup analysis of a multi-centre, randomized clinical trial comparing static syndesmosis fixation (two 3.5 mm screws) with flexible fixation (single knotless Tightrope) for patients with AO- OTA 44-C injuries. Patients who completed bilateral ankle CT scans at 3- and 12-month follow-up were included. The primary outcome measure was syndesmotic malreduction based on bilateral ankle CT scans, using the uninjured, contralateral ankle as a control. Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance were calculated to measure syndesmosis reduction. Secondary outcomes included re-operation, adverse events and functional outcomes including the EQ5D, Olerud-Molander Ankle Score (OM), Foot and Ankle Disability Index (FADI), and Work Productivity Activity Impairment Questionnaire (WPAI). Paired samples t-tests were used to compare injured to control ankles (R, v 3.5.1). 42 patients (24 Group S, 18 Group T) were included. ASD for Group T was 5.22mm (95%CI 4.69–5.77) at 3 months compared to 4.26mm (95%CI 3.82–4.71; p=0.007) in controls and 5.38mm (95%CI 4.72–6.04) at 12 months compared to 4.44mm (95%CI 3.73–5.16; p=0.048) in controls. ASD for Group S was 4.63mm (95%CI 4.17– 5.10) at 3 months compared to 4.67mm (95%CI 4.24–5.10; p=0.61) in controls, but significantly increased to 5.73mm (95%CI 4.81–6.66) at 12 months compared to 4.65mm (95%CI 4.15–5.15; p=0.04) in controls. MSD results were similar; Group T had a larger MSD than control ankles at 3 months (p=0.03) and 12 months (p=0.01), while the MSD in Group S was not different at 3 months (p=0.80) but increased at 12 months (p=<0.01). 88% (21/24) of Group S had broken or removed screws by 12 months. Unplanned re-operation was 15% in Group S and 4% in Group T (p=0.02), with an overall re-operation rate of 30% in Group S. There was no significant difference between treatment groups for EQ-5D, OM, FADI or WPAI at 3- or 12-month follow-up. Tightrope fixation resulted in greater diastasis of the ASD and MSD compared to contralateral, uninjured ankles at 3- and 12-months post-fixation. Group S initially had syndesmotic reduction similar to control ankles, but between 3- and 12-months post-fixation, there was significantly increased syndesmosis diastasis compared to controls. The majority of Group S (88%) had either broken screws or scheduled screw removal, which may explain the increased tibio-fibular diastasis seen at 12-months

Metal on metal total hip arthroplasty (MoM THA) provides the potential improvement in articular wear. However, several adverse events including pseudotumor had been reported. Magnetic resonance imaging (MRI) was considered to be the proposal tool for detection of pseudotumor after MoM THA. In this study, we performed the screening of pseudotumor after MoM THA using the MRI. We studied 43 patients with M2a Magnum® (Biomet) and 34 patients with M2a Taper® (Biomet) of MoM THA from December 2009 to December 2011 with follow-up of 2.5 years (2.0–4.0 years) after surgery. MRI assessments were performed at a mean of 2.1 years postoperatively. Pseudotumor findings were graded using Anderson classification (Skeletal Radiol, 2011: 40; 303). Age, sex, height, weight, Harris Hip Score, EQ5D satisfaction score, UCLA activity score, and blood metal ion levels were evaluated. The prevalence of pseudotumor was 27.2%; 56 normal (Type A), 13 mild (C1), 8 moderate (C2) and none were graded severe (C3). Weight and BMI in the mild group was significantly higher than those in normal. There was no significant difference in age, sex and height among these groups. With regard to Harris Hip score, pain and ROM score in moderate group was significantly lower than that in normal and mild group. EQ5D satisfaction score and UCLA activity score showed not significant differences among groups. 3.01±3.32 μg/L of blood cobalt ion levels in the moderate groups was significantly higher than 0.97±0.64 μg/L in normal group. Blood cobalt ion levels of 1 mild and 2 moderate were over the threshold of 7 μg/L. These patients were implanted with M2a Taper, not M2a Magnum. 14% of the prevalence in the patients with M2a Magnum was significantly lower than 41% in the patients with M2a Taper. No revision surgeries were required. The patients with no pseudotumor did not show the increase of blood metal ion. Contrarily, several patients showed the increase of blood metal ion in case of detecting pseudotumor. MRI assessments were useful for screening of pseudotumor after MoM THA and blood metal ion should be investigated for patients with mild and moderate pseudotumor in MoM THA

Intro. Across much of medicine, activity levels predict life expectancy, with low levels of activity being associated with increased mortality, and higher levels of activity being associated with longer healthier lives. Resurfacing is a technically demanding procedure that has suffered significant fallout from the failure of a couple of poorly performing designs. However strong evidence associates resurfacing with improved life expectancy in both the short and longer term following surgery. We wondered if there was any relationship between the function of hips following surgery and the extent of that surgery. Could a longer stem inside the femur be the reason for a slightly reduced step length? We proposed the nul hypothesis that there was no clinically relevant difference between stem length and gait. Method. After informed consent each subject was allowed a 5 minute acclimatisation period at 4km/hr on the instrumented treadmill (Kistler Gaitway, Amherst, NY). Their gait performance on an increasing incline at 5, 10 and 15%. At all 0.5km incremental intervals of speed, the vertical component of the ground reaction forces, center of pressure and temporal measurements were collected for both limbs with a sampling frequency of 100Hz over 10sec. They were also asked to log onto our JointPRO website and report their function using Oxford, EQ5D, and Imperial scores. Owing to current restrictions in indications, the patient groups selected were not comparable. However, from our database of over 800 patients who have been through the gait lab. 82 subjects were tested from 2 diagnostic groups (29 conventional THR, 27 hip resurfacing) and compared with a slightly younger group of 26 healthy controls. Patients were excluded if less than 12 months postop, or with any other documented joint disease or medical comorbidities which might affect gait performance. Body weight scaling was also applied to the outputted mechanical data to correct for mass differences. All variables for each subject group were compared to each other using an analysis of variance (ANOVA) with Tukey post hoc test with significance set at α=0.05. Results. The experimental groups were reasonably matched for sex, height and BMI, although the controls were rather younger, and the hip replacements rather older (young hip resurfacings were excluded for lack of good controls). Any differences did not reach significance. Oxford hip scores and EQ5D were almost identical for the two experimental groups. The THR group walked 10% slower than control (1.8 (±0.2)m/sec vs 2.0 (±0.1)m/sec). while the HRA group walked 5% faster (2.1(±0.2)m/sec). The difference between THR and control was significant (p<0.05). (See Figure 1). Discussion. This data records a 15% difference in top walking speed between THR and HRA, far exceeding the 5% threshold of clinical relevance. We therefore consider this improved functional outcome to be clinically relevant, and report with increasing confidence that hip resurfacings is an effective intervention in the treatment of hip disease with clinically relevant superiority over THR, even in a group with an average age of 60

Background. Patient specific instrumentation (PSI) for total knee replacement (TKR) has demonstrated mixed success in simplifying the operation, reducing its costs, and improving limb alignment. Evaluation of PSI with tools such as radiostereometric analysis (RSA) has been limited, especially for cut-through style guides providing mechanical alignment. The primary goal of the present study was to compare implant migration following TKR using conventional and PSI surgical techniques, with secondary goals to examine whether the use of PSI reduces operative time, instrumentation, and surgical waste. Methods. The study was designed as a prospective, randomized controlled trial of 50 patients, with 25 patients each in the PSI and conventional groups, powered for the RSA analysis. Patients in the PSI group received an MRI and standing 3-foot x-rays to construct patient-specific cut-through surgical guides for the femur and tibia with a mechanical alignment. All patients received the same posterior-stabilized implant, with marker beads inserted in the bone around the implants to enable RSA imaging. Intraoperative variables such as time, number of instrumentation trays used, and mass of surgical waste were recorded. Patients underwent supine RSA exams at multiple time points (2&6 weeks, 3&6 months and yearly) with 6 months data currently available. Migration of the tibial and femoral components was calculated using model-based RSA software. WOMAC, SF-12, EQ5D, and UCLA outcome measures were recorded pre-operatively and post-operatively. Results. There were no demographic differences between groups. One patient in the PSI group was revised for infection, and three patients required manipulation, with no revisions or manipulations in the conventional group. There was no difference in maximum total point motion between groups for the tibia (mean 0.50 vs. 0.50 mm, p = 0.98) or femur (mean 0.46 vs. 0.48 mm, p = 0.87). The PSI group displayed greater tibial posterior tilt (p = 0.048, Fig. 1) and greater femoral anterior tilt (p = 0.01) and valgus rotation (p = 0.04, Fig. 2) than the conventional group, but there were no other differences in migrations. The PSI group required less instrument trays than the conventional group (mean 4.8 vs. 8.1 trays, p < 0.0001), but procedure time was equivalent (mean 79 vs. 74 min, p = 0.06). The PSI group produced less recyclable waste (mean 0.3 vs. 1.4 kg, p < 0.001), but total waste (Fig. 3) was equivalent between groups (mean 10.1 vs. 10.6 kg, p = 0.32). At 6 months there was no difference between groups for SF-12, WOMAC, EQ5D, or UCLA scores. Discussion. At early RSA follow-up, the two groups were broadly similar in implant fixation except for small rotational changes in the tibial and femoral components. The PSI group provided minimal or no advantage over the conventional group for operative time, instrumentation used, or surgical waste produced. The observed increase in manipulations in the PSI group is concerning, and requires additional investigation. Further radiographic and economic analysis is underway to determine if there is any benefit to the use of PSI for TKR during the perioperative and early follow-up period. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Up to 20 percent of patients remain dissatisfied after primary total knee arthroplasty (TKA) surgery. Understanding the reasons for dissatisfaction post TKA may allow for better patient selection and optimized treatment for those who remain dissatisfied. The association between function, mobility and satisfaction are not well understood. The purpose of this study was to investigate the association between post-TKA satisfaction and i) pre-operative, ii) post-operative, and iii) change in knee joint function during gait. Thirty-one patients scheduled to receive primary TKA for knee osteoarthritis (OA) diagnosis were recruited and visited the Dynamics of Human Motion laboratory for instrumented walking gait analysis (using a synchronized NDI Optotrak motion capture system and AMTI force platforms in the walkway) at two time points, first within the week prior to their surgery, and second at approximately one year after surgery. At their post-operative visit, patients were asked to indicate their satisfaction with their knee prosthesis on a scale from zero to 100, with zero being totally unsatisfied and 100 being completely satisfied. Knee joint mechanics during gait at both time points were characterized by discriminant scores, the projection of their three-dimensional knee angles and moments during gait onto an existing discriminant model that was created to optimize separation of severe knee OA and healthy asymptomatic gait patterns. This discriminant model was created using data from 73 healthy participants and 73 with severe knee OA, and includes the magnitude and pattern features (captured with principal component analysis) of the knee adduction and flexion moment, and the magnitude of the knee flexion angle during gait. Larger discriminant scores indicate improved function toward healthy patterns, and smaller scores indicate more severe function. Associations between post-operative satisfaction and pre, post and change in discriminant scores were examined using Pearson correlation analyses. We also examined associations between satisfaction and pre-operative BMI, EQ5D and Oxford 12 scores, as well as changes in these scores from pre to post-TKA. Discriminant scores representing knee joint function during gait significantly improved on average after surgery (P =0.05). While overall knee joint function improved after primary TKA surgery, the amount of improvement in function was not reflected in post-operative patient satisfaction. However, the pre-operative function of the patient was negatively associated with satisfaction, indicating that patients with higher pre-operative function are overall less satisfied with their TKA surgery, regardless of any functional improvement due to the surgery. Interestingly, the only significant association with post-operative satisfaction was knee joint function, and the relationship between function and patient satisfaction following TKA appears to relate only to the baseline functional state of the patient, and not with functional improvement. This suggests that dissatisfaction post-surgery is more likely reflecting the unmet expectations of a higher functioning patient, and has implications for the need for improved understanding of pre-operative patient functional variability in TKA triage and expectation management

Purpose. The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods. Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results. The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p>0.05), sex (p>0.05), energy of injury (p>0.05), number of open fractures (p>0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p< 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p< 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion. There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results for delayed intervention in those who become symptomatic appear comparable