Study design. Retrospective study. Objectives. To identify patient outcomes, in particular employment, >5-years following traumatic thoracolumbar fracture. Methods. 235 patients between the ages of 18–65 were identified from the hospital radiology database having sustained a traumatic thoracolumbar fracture on CT or MRI between 01/01/2013 and 31/01/2017. Questionnaires were sent out via post and available emails, with a reminder letter and phone calls. Retrospective data was gathered about employment status pre-fracture and >5-years post injury. Results. 26 patients had died at follow up leaving 209 patients. 108 (52%) were treated surgically and 101 (48%) conservatively. 106 replies were received with 85 (80%) opting in and 21 (20%) opting out. 68 (80%) patients completed the full questionnaire with 17 (20%) filling out a shortened questionnaire via a phone conversation. 52 (61%) patients underwent surgery and 33 (39%) were treated conservatively. The average follow up was 8 years. Prior to injury 66 (78%) were employed and 19 (22%) unemployed (of which 6 were full time students and 8 were retired). 49 (74%) of the previously employed patients returned to work at follow up with 35 (53%) working the same or increased hours. Regarding employment, there was no significant difference between surgically and conservatively treated patients (P=0.355) or the classification of the fracture (P=0.303). 16 (19%) patients reported back pain prior to their injury whilst 69 (81%) did not. There were 58 (68%) cases of new pain at follow up with the most affected area being the lumbar region in 43 (51%) patients. 32 (38%) patients reported neurological deficit post injury: 19 with subjective symptoms, 9 with objective symptoms and 4 suffered paralysis. Conclusion. >5-years following a traumatic thoracolumbar fracture most individuals return to employment. There was no significant difference between the severity of the fracture or how patients are treated on their employment outcomes

Introduction. Open fractures are complex injuries associated with substantial morbidity. These injuries are associated with harm to both physical and emotional health as well as preclusion of work, social, and leisure activities. Patient reported outcome measures (PROMs) and health related quality of life are critical indicators of successful rehabilitation following open fracture treatment. This study aimed to measure the PROMs for patients with open lower limb fractures and investigate the relationship with injury severity. Materials & Methods. A retrospective cohort study was performed at a single major trauma centre in the UK. All adult patients with an open lower limb fracture were eligible for inclusion. Patients were identified through a search of a local Open Fracture Database. Epidemiological, clinical, and fracture classification data were obtained by reviewing case notes. Lower Extremity Function Scale (LEFS) and EQ5-D were used as PROMs and measured by a postal questionnaire, alongside return to employment data. Results. A total of 73 patients responded to the questionnaire. Median LEFS was 42 (IQR 26.5 – 59.5), and median EQ5-D was 0.69 (IQR 0.48 – 0.89). There was no significant association between open fracture classification and PROMs. Over 40% of patients reported a change in employment due to their injury. Those who changed jobs had a statistically significant reduction in the EQ5-D of 0.12 (p = 0.021); no significant difference existed in LEFS. Conclusions. This study demonstrates the devastating functional impact of open fractures. This cohort of open injuries reported lower functional and quality-of-life measures compared to population norms. Injury classification was not a valuable predictor of PROMs. A substantial proportion of patients were forced to change employment due to their injury, and these patients reported a significantly lower quality of life. Further work is required to understand the factors contributing to open fracture PROMs

Staphylococcus aureus osteo-articular infections (OAI) are frequently accompanied by blood stream infections (BSI) diagnosed by positive blood culture (BC). Microbiological protocols in adults advise prolonged intravenous antibiotics and repeat BC 48-hourly in the presence of a BSI, however evidence to support the systematic employment of these guidelines in paediatric patients is lacking. We aimed to determine whether there was an increased incidence of orthopaedic and systemic complications in patients with s aureus BSI, and whether a shorter duration of intravenous antibiotics was associated with the development of complications. Following ethical approval, the departmental surgical database was searched for patients that underwent surgery for acute OAI over a 5-year period. Patients with no sample taken for BC were excluded, as were those with other or no organisms identified from any site. Demographic and clinical data were captured, including duration of IV antibiotics and development of complications. Statistical significance was set at p<0.05. Following exclusions, 44 patients with a median age of 85 months remained to be analysed. Thirty patients (68%) had a positive BC. A positive BC was associated with a higher rate of systemic complications (p=0.026) but not orthopaedic complications (p=0.159). Patients who had developed any complication had a significantly longer duration of IV antibiotic treatment compared to those without complications (p<0.001). The presenting CRP levels were significantly higher in patients that developed complications (p=0.004). Patients with staphylococcal BSI in association with an OAI are at increased risk of developing systemic complications. In our cohort, a shorter duration of antibiotic use was not associated with the development of complications, which does not support the systematic use of long courses of IV antibiotics in s aureus BSI. Further research will be required to determine the ideal protocol for these patients

Motorcycle accident-related traffic accidents contribute significantly to the burden of orthopaedic injuries seen in the South African Healthcare system. Subsequent to the Covid-19 pandemic, there has been an increase in the number of delivery drivers on the roads of South Africa. Many of these delivery drivers have no formal employment contracts. We aim to describe the demographics and injury patterns in motorcyclists involved in time dependent delivery work in South Africa; and to quantify the cost to the state of their orthopaedic surgeries. We performed a consecutive case series study at all of the hospitals draining the study region over the period of one year. Epidemiological, clinical and cost to hospital data was collected from medical records, digital radiographs, theatre invoices and a dedicated patient questionnaire. Provisional. So far 41 delivery drivers were captured by the study over a period of 11 months. All drivers were male and the vast majority foreign nationals. 11 patients were polytraumatised and 5 required admission to an intensive care unit. The most common injury patterns were closed femur fractures (17) followed by tibial shaft fractures (13). The average cost of surgery was R35 049 and average cost of ward stay R44 882 at an average of 10 days admission in a general ward. Overall, an estimated total of R 3.1 million rand was spent on these injuries. Informally employed “app users” performing delivery work on motorcycles in South Africa have added a significant burden to the cost of state healthcare since 2020. The vast majority of these patients are foreign nationals who do not hold South African licences or health insurance. They are sustaining high energy injuries typical of motorcycle-car accidents and many of them are left with lifelong loss of function

With the rising rates, and associated costs, of total knee arthroplasty (TKA), enhanced clarity regarding patient appropriateness for TKA is warranted. Towards addressing this gap, we elucidated in qualitative research that surgeons and osteoarthritis (OA) patients considered TKA need, readiness/willingness, health status, and expectations of TKA most important in determining patient appropriateness for TKA. The current study evaluated the predictive validity of pre-TKA measures of these appropriateness domains for attainment of a good TKA outcome. This prospective cohort study recruited knee OA patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those receiving primary, unilateral TKA completed questionnaires pre-TKA assessing TKA need (WOMAC-pain, ICOAP-pain, NRS-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, prior OA treatment), TKA readiness/willingness (Patient Acceptable Symptom State (PASS), willingness to undergo TKA), health status (PHQ-8, BMI, MSK and non-MSK comorbidities), TKA expectations (HSS KR Expectations survey items) and contextual factors (e.g., age, gender, employment status). One-year post-TKA, we assessed for a ‘good outcome’ (yes/no), defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with TKA results. Multiple logistic regression, stepwise variable selection, and best possible subsets regression was used to identify the model with the smallest number of independent variables and greatest discriminant validity for our outcome. Receiver Operating Characteristic (ROC) curves were generated to compare the discriminative ability of each appropriateness domain based on the ‘area under the ROC curve’ (AUC). Multivariable robust Poisson regression was used to assess the relationship of the variables to achievement of a good outcome. f 1,275 TKA recipients, 1,053 (82.6%) had complete data for analyses (mean age 66.9 years [SD 8.8]; 58.6% female). Mean WOMAC pain and KOOS-PS scores were 11.5/20 (SD 3.5) and 52.8/100 (SD 17.1), respectively. 78.1% (95% CI 75.4–80.5%) achieved a good outcome. Stepwise variable selection identified optimal discrimination was achieved with 13 variables. The three best 13-variable models included measures of TKA need (WOMAC pain, KOOS-PS), readiness/willingness (PASS, TKA willingness), health status (PHQ-8, troublesome hips, contralateral knee, low back), TKA expectations (the importance of improved psychological well-being, ability to go up stairs, kneel, and participate in recreational activities as TKA outcomes), and patient age. Model discrimination was fair for TKA need (AUC 0.68, 95% CI 0.63-0.72), TKA readiness/willingness (AUC 0.61, 95% CI 0.57-0.65), health status (AUC 0.59, 95% CI 0.54-0.63) and TKA expectations (AUC 0.58, 95% CI 0.54-0.62), but the model with all appropriateness variables had good discrimination (AUC 0.72, 95% CI 0.685-0.76). The likelihood of achieving a good outcome was significantly higher for those with greater knee pain, disability, unacceptable knee symptoms, definite willingness to undergo TKA, less depression who considered improved ability to perform recreational activities or climb stairs ‘very important’ TKA outcomes, and lower in those who considered it important that TKA improve psychological wellbeing or ability to kneel. Beyond surgical need (OA symptoms) and health status, assessment of patients’ readiness and willingness to undergo, and their expectations for, TKA, should be incorporated into assessment of patient appropriateness for surgery

Purpose. The purpose of this study was to investigate the rate of return to work after total knee arthroplasty (TKA). Materials and Methods. 105 knees of 80 cases were tested after TKA surgery. 18 knees of 14 cases were men and 87 knees of 66 cases were women. The average age at the time of surgery was 71.5 years, and the average postoperative observation period was 25.5 months. All patients were with osteoarthritis of the knee. The use models were Hi-tech Knee II (Nakashima Medical, Okayama, Japan) CR type 99 knees and PS type 6 knees. The rate of return to work after surgery and employment rate of before and after surgery were examined for all cases. In addition,[1]age at surgery [2]ROM [3]JKOM score(Akai 2006) [4]Knee Society score (KSS Insall 1989) were examined in each case, and found the factors influenced on employment rate after TKA. The occupation was classified using major group of the International Standard Classification of Occupations (ISCO-08) defined by International Labour Organization (ILO) on 2007. Mann-Whitney U test was used for the statistical work. Results. Preoperative and postoperative employment state was shown in the Fig.1. 29 knees of 23 cases were in employment before surgery. In these cases, 22 knees of 18 cases had return to work after surgery (Group I) and 7 knees of 5cases had retired after surgery(Group II). 76 knees of 57cases were unemployed before and after surgery(Group III). Return to work rate was 78.3 percent after TKA. In the Group I, all cases returned to the same occupation before surgery. The average age of the Group III at the time of surgery was significantly higher than Group I and II(Fig.2). Compared KSS, postoperative functional score of the group I was significantly higher than Group II and III(Fig.3). Discussion. The cases employed before TKA were younger than the unemployed cases. In the cases returned to work after TKA, stairs rise-and-fall capability and walking ability were higher than the other cases. Conclusion. (1)The rate of return to work was 78.3 percent after TKA.(2)Age at surgery influenced the preoperative employment.(3)Stairs rise-and-fall capability and walking ability after surgery involved the return to work

Total joint arthroplasty (TJA) is often utilized to improve pain and dysfunction associated with end-stage osteoarthritis. Previous research has suggested that depression may negatively impact patient reported pain and function. The purpose of this study was to determine the effect of pre-operative depressive symptoms, using the Center for Epidemiologic Scale for Depression (CES-D) scale, on patient reported function and pain at one, three and six months following TJA, after controlling for the impact of age, sex, pain, joint replaced, and other comorbidities. This was a secondary analysis of a prospective cohort of 710 patients aged 40 years and older who underwent elective primary TJA in the Edmonton zone. Participants were recruited pre-operatively and reported socio-demographics, comorbid conditions and medications (including depression medications where appropriate), each participant also completed the Western Ontario McMaster (WOMAC) Osteoarthritis Index and the CES-D scale preoperatively. Participants then completed the WOMAC and CES-D scale again at one, three, and six months postoperatively. Risk-adjusted longitudinal data analysis using a linear mixed regression model was performed, controlling for age, sex, joint replaced, chronic pain, comorbidity, social support and employment status. THA participants had a mean age of 65.9±10.1 years and included 175 (57%) female while TKA participants had a mean age of 67.9±10.1 years and included 249 (61%) females. ‘Possible’ depressive symptoms (CES-D score 16–19) were identified in 58 (8.1%) participants while ‘probable’ depressive symptoms (CES-D score ≥20) were identified in 68 (9.6%) participants. The mean WOMAC pain and function scores, when analyzed using the linear mixed regression model, demonstrated improvement from baseline at one, three, and six months (p < 0 .001 for both pain and function models as well as over time). However, in the patients with possible and probable depressive symptoms, WOMAC pain scores were 7.6±1.5 and 11.7±1.3 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, chronic pain, comorbidities and social support. Similarly, WOMAC function scores in the patients with possible and probable depressive symptoms were 8.8±1.4 and 14.2±1.2 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, comorbidities and employment status. Depressive symptoms negatively affect postoperative pain and function measured using WOMAC scales even after risk adjustment up to six-months post TJA. Screening for depressive symptomology both pre- and postoperatively may provide an opportunity to identify and manage depressive symptoms to improve postoperative pain and function

Total joint arthroplasty (TJA) is often utilized to improve pain and dysfunction associated with end-stage osteoarthritis. Previous research has suggested that depression may negatively impact patient reported pain and function. The purpose of this study was to determine the effect of preoperative depressive symptoms, using the Center for Epidemiologic Scale for Depression (CES-D) scale, on patient reported function and pain at one, three and six months following TJA, after controlling for the impact of age, sex, pain, joint replaced, and other comorbidities. This was a secondary analysis of a prospective cohort of 710 patients aged 40 years and older who underwent elective primary TJA in the Edmonton zone. Participants were recruited pre-operatively and reported socio-demographics, comorbid conditions and medications (including depression medications where appropriate), each participant also completed the Western Ontario McMaster (WOMAC) Osteoarthritis Index and the CES-D scale preoperatively. Participants then completed the WOMAC and CES-D scale again at one, three, and six months postoperatively. Risk-adjusted longitudinal data analysis using a linear mixed regression model was performed, controlling for age, sex, joint replaced, chronic pain, comorbidity, social support and employment status. THA participants had a mean age of 65.9±10.1 years and included 175 (57%) female while TKA participants had a mean age of 67.9±10.1 years and included 249 (61%) females. ‘Possible’ depressive symptoms (CES-D score 16–19) were identified in 58 (8.1%) participants while ‘probable’ depressive symptoms (CES-D score ≥20) were identified in 68 (9.6%) participants. The mean WOMAC pain and function scores, when analyzed using the linear mixed regression model, demonstrated improvement from baseline at one, three, and six months (p < 0 .001 for both pain and function models as well as over time). However, in the patients with possible and probable depressive symptoms, WOMAC pain scores were 7.6±1.5 and 11.7±1.3 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, chronic pain, comorbidities and social support. Similarly, WOMAC function scores in the patients with possible and probable depressive symptoms were 8.8±1.4 and 14.2±1.2 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, comorbidities and employment status. Depressive symptoms negatively affect postoperative pain and function measured using WOMAC scales even after risk adjustment up to six-months post TJA. Screening for depressive symptomology both pre- and postoperatively may provide an opportunity to identify and manage depressive symptoms to improve postoperative pain and function

Introduction. Patients undergoing complex limb reconstruction are often under immense physical, psychological and financial stress. We already provide psychological support within our unit. We have identified that patients struggle to obtain proper advice on the financial support to which they are entitled. In September 2019, . rebuildcharity.org. commissioned a Citizens Advice Clinic. One advisor from the local Citizens Advice staffs the clinic. Currently we have no set criteria for referral and patients can be referred by any member of the limb reconstruction team. Although severely affected by the coronavirus pandemic and the disruption of all routine work we were able to run clinics from September 2019 to March 2020 and September 2020 to January 2021. We present our initial results. Materials and Methods. In total 19 patients (68% male) have been seen. There have been 58 clinic appointments which have been a combination of face to face and virtual. The majority (80%) of issues dealt with relate to benefits – including claiming tax credits, universal credits and Personal Independence Payments. Other issues include housing problems, employment and claiming for travel and transport. Results. Through the advice given our cohort of patients have been able to claim back £51,175 in total. The cost for the charity is £11,000 per annum based on one clinic per week. Patient satisfaction is high with 100% expressing satisfaction with the service and reporting decrease levels of stress. 100% of patients are better able to pay for essential bills and 50% to pay for their travel to hospital. Conclusions. Our study identified the difficulties our patients have negotiating the complexities of the benefit system and how Citizens Advice can help. This project is in its early days with an initial slow uptake and then severely affected by the coronavirus pandemic such that no clinics were held for 6 months. Despite this our early results are promising

Introduction. Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy. Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed. Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6 months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07). Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing. Discussion. These results suggest MIC has comparable early results to OC. Larger studies are required to further establish the benefits of MIC. Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open cheilectomy with promising early results. Patient satisfaction with this procedure is very high

To assess the efficacy of a combined orthoplastic approach to the management of severe grade III fractures of the lower limb, we looked at the functional and radiological outcome of 100 consecutive fractures from a specialist centre. A prospective analysis was performed on 100 consecutive open tibial fractures (98 patients). An early decision was made by a specialist multidisciplinary team as to whether the injured limb was reconstructable. In the reconstruction group there were 84 Gustilo grade IIIB/C injuries. Definitive skeletal stabilisation was most commonly with a circular frame (60%) or intramedullary nail (20%). The mean time to union was 26 weeks for diaphyseal fractures, 20 weeks for metaphyseal fractures and 10 weeks for ankle fractures. There was one aseptic non-union which is still undergoing treatment. The anterolateral thigh free flap was the most common soft tissue reconstruction used (42%). There were minimal surgical complications and only one free flap failure. Mean time to follow-up was 24 months. The mean limb functional score (modified enneking) was 83% of that of the normal limb and was not influenced by the site of fracture or type of fixation. The mean SF-36 score was 75 and there was a high return to employment (70%). In the primary amputation group there were 16 grade IIIB/C injuries. Mean time to follow-up was 38 months. The mean SF-36 score for the below knee amputees was 58 and there was again a high return to employment (58%). In the reconstruction group there is a 99% limb salvage rate with infection-free union to date and no delayed amputations. A higher return to functional activity/employment was achieved in the reconstruction group compared to the primary amputation group. Our results demonstrate that by using a combined orthoplastic approach in a specialist centre excellent results can be achieved for all patients presenting with severe open lower limb injuries

The patient's subjective experience of disease is an increasing focus in health care delivery. Health-related quality of life (HRQoL) is defined as a “functional effect of a medical condition and its consequent treatment”; it is both self-reported and multi-dimensional. While functional outcome is well researched among the soft tissue sarcoma (STS) population, few studies have focused on HRQoL, which gives a broader understanding of the psychological, somatic, social and physical toll of cancer and its treatment from the patient's viewpoint. The biologic and anatomic heterogeneity of sarcomas are considerable, just as the treatments are diverse, we surmise that the indicators of patient HRQoL differ and are not captured in existing generic HRQoL tools for cancer. The study objectives were to explore the domains of HRQoL and functioning in adult patients diagnosed with extremity STS from the patient's perspective from active care through survivorship through qualitative inquiry, so as to form the basis for the development of a patient-derived, sarcoma-specific, preference based HRQoL tool. Study design is a sequential exploratory mixed methods study of patient experience in localized or metastatic adult extremity STS (2007 and 2017). The study was conducted at a high-volume sarcoma centre. Qualitative descriptive design was grounded in an integrated knowledge translation approach and aimed at identifying HRQoL domains through in-person and electronic focus groups, and individual semi-structured interviews in both English and French (N=28). The interview guide topics were selected based on existing knowledge about PROs and HRQoL life, including (a) impact of diagnosis on employment or acquisition of academic/vocational skills; (b) physical and psychological functioning; (c) symptom burden; (d) treatment preferences; (e) knowledge of and use of existing resources; (f) impact on family time and resources; and (g) overall experience. Data was analyzed using inductive thematic networks approach using the qualitative software N-Vivo 12. Codes were generated by 2 independent qualitative experts capturing key concepts of HRQoL that is impacted by STS. Basic themes were clustered into organizing themes, and merged into global domains. Attention was paid to deviant cases and within-group dynamics during focus group discussion analysis. Discrepancies or inconsistencies in coding were resolved in consensus meetings. Final sample size was determined when data saturation was reached and no new themes emerged. Qualitative reduction of identified items to reach a consensus framework was facilitated by a moderator during multi-disciplinary panel meetings comprised of sarcoma experts, patient partners, allied health staff and other stakeholders. Twenty-nine patients with biopsy-proven localized or metastatic STS of the extremity participated (69% lower extremity STS; mean age 56 years, 25% with local recurrence, 21% metastatic, 18% amputation). Inductive thematic network analysis revealed five function-related domains HRQoL for patients with STS. The functional domains were mapped to the Wilson & Cleary Model and experience domains were mapped to the Picker Institute's Through Patient's Eyes model. This is a critical step toward developing disease specific outcome measures. Patient-centered research is crucial to understanding the impact of surgery, adjuvant therapy and the associated complications for patients with extremity STS, and thereby improving the quality of care provision. This study offers a unique perspective on what domains and sub domains are most impactful on HRQoL and provides the basis for our on-going development of a disease-specific, preference-based HRQoL measure

Introduction. The management of young patients with painful medial compartment osteoarthritis remains controversial. Opening wedge medial high-tibial osteotomy using a locking plate has shown good results in selected patients. This cohort of patients has high physical demands and previous studies have warned against operating on patients with increased body mass index (BMI). Patients and Methods. Thirty five patients undergoing valgus high tibial osteotomy between Oct 2004 and Feb 2010. Surgical outcome was assessed using Oxford Knee score, pre- and post-operative pain scores, change in employment and patient satisfaction. Results. Mean age at the time of surgery was 41 (22 to 62), mean BMI was 30.9 (21 to 43) and mean Oxford score was 37/48 (16 to 48). Patients rated their overall satisfaction as 7.9/10. Three patients were lost to follow-up, two patients died of unrelated disease. Fifteen (50%) patients had heavy manual jobs and of these 12 (80%) returned to their previous employment post-operatively within 6 months. Seven patients had a BMI > 35 (Mean 39) with a mean weight of 126 Kg (105Kg to 144Kg). These patients had a mean Oxford Score of 42/48 and overall satisfaction of 90%. Pain improved from 8.4/10 pre-op to 1.5/10 post-op (P < 0.0001). None had further procedures. Conclusion. Opening wedge high-tibial osteotomy offers a successful alternative treatment of medial osteoarthritis in young patients with high BMI who place high demands on their knees

Study design. Economic evaluation alongside a prospective, randomised, controlled trial from a two-year National Health Service (NHS) perspective. Objective. To determine the cost-effectiveness of Titanium Cages (TC) compared to Femoral Ring Allografts (FRA) in circumferential lumbar spinal fusion. Summary of background data. A randomised controlled trial has shown the use of TC to be clinically inferior to the established practice of using FRA in circumferential lumbar fusion. Health economic evaluation is needed to justify the continued use of TC, given that this treatment is less effective and, all things being equal, is assumed more costly than FRA. Methods. Eighty-three patients were randomly allocated to receive either the TC or FRA between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF-6D) was administered pre-operatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs) for the trial period. Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness. Results. A significant cost difference of £1,942 (95% CI £849 to £3,145) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of -0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 in favour of FRA. Conclusion. From an NHS perspective, this data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was both cheaper and generated greater QALY gains. FRA patients also reported a greater return to work rate

Introduction. Uncemented porous coated acetabular components have gained more research emphasis in recent years compared to their cemented counterparts, largely owing to the natural biological fixation they offer. Nevertheless, sufficient peri-prosthetic bone ingrowth is essential for long-term fixation of such uncemented acetabular components. The phenomenon of bone ingrowth can be predicted based on mechanoregulatory principles of primary bone fracture healing. Literature review reveals that the surface texture of implant plays a major role in implant-bone fixation mechanism. A few insilico models based on 2-D microscale finite elements (FE) were reported in literatures to predict the influence of surface texture designs on peri-prosthetic bone ingrowth. However, most of these studies were based on FE models of dental implants. The primary objective of this study, therefore, is to mechanobiologically predict the influence of surface texture on bone- ingrowth in acetabular components considering a novel 3-D mesh-shaped surface texture on the implant. Materials/Methods. The 3-D microscale model [Fig.1] of implant-bone interface was developed using CATIA. ®. V5R20 software (DassaultSystèmes, France) and was modelled in ANSYS V15.0 FE software (Ansys Inc., PA, USA) using coupled linear elastic ten-noded tetrahedral finite elements. The model consists of cast-inbeaded mesh textured implant having finely meshed inter-bead spacing. Linear, elastic and isotropic material properties considering Young's modulus of 210 GPa and Poisson's ratio of 0.3 for stainless steel implant were employed in the model. Boundary of bone was assumed to be rich in Mesenchymal Stem Cells(MSC) with periodic boundary conditions at contralateral surfaces. The linear elastic material properties in the model were updated iteratively through a tissue differentiation algorithm that works on the principle of mechanotransduction driven by local mechanical stimuli, e.g. hydrostatic pressure and equivalent deviatoric strain. Results. Results indicate that bone ingrowth is inhibited upon increasing the inter-bead spacing and upon decreasing the bead aspect ratio. It has been observed that there is a predominant influence of bead spacing diameter on the peri-acetabular bone ingrowth. The increase in bead spacing diameter has led to increased bead height that is found to promote higher bone ingrowth with an increase in average Young's modulus of neo-tissue layer. Conclusions. The present study focussed on the development of a new texture on the implant surface and to study the influence of surface texture on bone-ingrowth in acetabular components. Since there is a promising increase in average Young's modulus of the newly formed tissue layer, it predicts the increase in stiffness of the newly formed tissue. The increase in tissue stiffness reveals that, there is not much inhibition in bone ingrowth after the employment of the acetabular implant. The numerical study based on mechanoregulatory algorithm considering the appropriate mechanical stimuli responsible for bone ingrowth, reveals that, compared to hemispherical beaded surface texture, mesh shaped surface texture provides an improved fixation of the acetabular component. For any figures or tables, please contact the authors directly

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Total hip arthroplasty (THA) is among the most successful interventions in all of medicine and has recently been termed “The Operation of the Century”. Charnley originally stated that “Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip joint that will last 30 years and at some time in this period enable the patient to play football.” and he defined an appropriate patient as generally being over 65 years of age. Hip rating scales developed during this time were consistent with this approach and only required relief of pain and return to normal activities of daily living to achieve a perfect score. Since this time, however, hip arthroplasty has been applied to high numbers of younger, more active individuals and patient expectations have increased. One recent study showed that in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled following THA. The current generation metal-metal hip surface replacement arthroplasty (SRA) has been suggested as an alternative to standard THA which may offer advantages to patients including retention of more native bone, less stress shielding, less thigh pain due to absence of a stem, less limb length discrepancy, and a higher activity level. A recent technology review by the AAOS determined that currently available literature was inadequate to verify any of these suggested potential benefits. The potential complications associated with SRA have been well documented recently. The indications are narrower, the implant is more expensive, the technique is more demanding and less forgiving, and the results are both highly product and surgeon specific. Unless a clinical advantage in the level of function of SRA over THA can be demonstrated, continued enthusiasm for this technique is hard to justify. To generate data on the level of function of younger more active arthroplasty patients, a national multicenter survey was conducted by an independent university medical interviewing center with a long track record of conducting state and federal medical surveys. All patients were under 60, high demand (pre-morbid UCLA score > 6) and had received a cementless stem with an advanced bearing surface or an SRA at one of five major total joint centers throughout the country. The detailed questionnaire quantified symptoms and function related to employment, recreation, and sexual function. Patients with SRA had a higher incidence of noises emanating from the hip than other bearing surfaces although this was transient and asymptomatic. SRA patients were much more likely to have less thigh pain than THA, less likely to limp, less likely to perceive a limb length difference, more likely to run for exercise, and more likely to run longer distances. In another study of over 400 THA and SRA patients at two major academic centers, patients completed pain drawings that revealed an equivalent incidence of groin pain between THA and SRA, but an incidence of thigh pain in THA that was three times higher than in SRA in young active patients. While some or most of the observed advantages of SRA over THA may be attributable to some degree of selection bias, the inescapable conclusion is that SRA patients are demonstrating clinical advantages that warrants continued utilization and investigation of this procedure

One out of every five total knee arthroplasty (TKA) recipients is unhappy with the outcome of their surgery. As the number of TKA candidates continues to increase, so, too, will the dissatisfied patient population. These statistics should not be acceptable to the surgeons, hospitals, and patients implicated in this elective procedure. There are many contributing factors to patient dissatisfaction, paramount among them being post-operative levels of functionality and pain. Therefore, in an attempt to increase function and decrease pain levels through soft-tissue management, sensor-assisted TKA outcomes were compared with manual TKA outcomes. One hundred and fourteen primary TKA patients were evaluated: 57 sensor-assisted TKA patients; 57 manual TKA patients. All procedures were performed by the same surgeon. In order to reduce confounding variables, all patients were matched for: age, gender distribution, BMI, marital status, smoking proclivity, pre-operative ROM, pre-operative alignment, and employment status. Outcomes scores were captured pre-operatively, and at the 6-month interval, including Knee Society Score metrics and the Oxford score, as well as 6-month ROM. The sensor device used in this analysis is inserted into the tibial component, during the trialing, and displays loading values in the medial and lateral compartments (lbf.), and also displays the medial and lateral center of load location. In the sensor-assisted TKA group, balance was achieved for all patients, as previously described in literature. There was a statistically significant rate of improvement, for all outcomes measures, in the sensor-assisted TKA group when compared with the manual group (Figure 1). In addition to rate of improvement, there was also a significant trend towards a significance in ROM in the sensor-assisted group, as a stand-alone dependent variable (P = 0.002). By the 6-month follow-up interval, patients in receipt of a sensor-assisted TKA reported greater improvement in function and less pain than the patients in the manual TKA group. This data suggests that soft-tissue balance may contribute to faster recovery, as reported by the patient. Because pain and function play an integral role in patient satisfaction, further follow-up might yield higher satisfaction in the sensor-assisted patient group, which is consistent with previously published observations

Total hip arthroplasty is among the most successful interventions in all of medicine and has recently been termed “The Operation of the Century”. Charnley originally stated that “Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip joint that will last 30 years and at some time in this period enable the patient to play football.” and he defined appropriate patient as generally being over 65 years of age. Hip rating scales developed during this time were consistent with this approach and only required relief of pain and return to normal activities of daily living to achieve a perfect score. Since this time, however, hip arthroplasty has been applied to high numbers of younger, more active individuals and patient expectations have increased. One recent study showed that in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled following THA. The current generation metal-metal hip surface replacement arthroplasty (SRA) has been suggested as an alternative to standard THA which may offer advantages to patients including retention of more native bone, less stress shielding, less thigh pain due to absence of a stem, less limb length discrepancy, and a higher activity level. A recent technology review by the AAOS determined that currently available literature was inadequate to verify any of these suggested potential benefits. The potential complications associated with SRA have been well documented recently. The indications are narrower, the implant is more expensive, the technique is more demanding and less forgiving, and the results are both highly product and surgeon specific. Unless a clinical advantage in the level of function of SRA over THA can be demonstrated, continued enthusiasm for this technique is hard to justify. To generate data on the level of function of younger more active arthroplasty patients, a national multicenter survey was conducted by an independent university medical interviewing center with a long track record of conducting state and federal medical surveys. All patients were under 60, high demand (pre-morbid UCLA score > 6) and had received a cementless stem with an advanced bearing surface or an SRA at one of five major total joint centers throughout the country. The detailed questionnaire quantified symptoms and function related to employment, recreation, and sexual function. Patients with SRA had a higher incidence of noises emanating from the hip than other bearing surfaces although this was transient and asymptomatic. SRA patients were much more likely to have less thigh pain than THA, less likely to limp, less likely to perceive a limb length difference, more likely to run for exercise, and more likely to run longer distances. In another study of over 400 THA and SRA patients at two major academic centers, patients completed pain drawings that revealed an equivalent incidence of groin pain between THA and SRA, but an incidence of thigh pain in THA that was three times higher than in SRA in young active patients. While some or most of the observed advantages of SRA over THA may be attributable to some degree of selection bias, the inescapable conclusion is that SRA patients are demonstrating clinical advantages that warrants continued utilisation and investigation of this procedure

Introduction. The project of a modular, double-conicity stem is born from the need to obtain primary stability and correct osseointegration in patients with developmental hip dysplasia, or proximal femoral dysmorphisms requiring a femoral shortening osteotomy or presenting characteristics of non-adaptability to single-conicity or straight stems. Such an implant could also be employed in femoral nail failures, or lateral femoral neck fractures requiring prosthetic substitution. Aim of the study. To assess implantability of the new double-conicity stem in cadaver femurs, determining “fit and fill” and the behaviour of femoral cortical bone by means of Rx, CT and pre- and post-implantation mechanical testing. Methods. Seven double-conicity stems with anti-rotation fins were implanted in cadaver femurs of various sizes. All femurs underwent pre- and post-implantation radiological assessment for evaluation of fit and fill at the 2 levels corresponding to the 2 conicities, fins penetration, possible microfractures and stem positioning. Prior to implantation, templating was carried out to define the correct size of the stem to be implanted. Modular necks with cervico-diaphyseal angle of 125° or 135° (short or long) were implanted, to preserve the correct rotation center and femoral offset. In 2 femurs, mechanical testing was performed before and after implantation, in order to assess, by means of strain gauges, the variation of the tensional state of cortical bone under dynamic loading (gait cycle simulation). In 2 femurs, 3 cm chevron shortening osteotomies were performed and stabilized with the stem alone. Results. Implanted stems respected pre-operative planning. In the 2 cases in which shortening osteotomies were performed, the stem allowed for good meta-diaphyseal stability without the employment of fixation devices. Radiographic assessment evidenced a valid “fit and fill”. In 4 cases the stem was correctly aligned; in 2 cases it was positioned in 1° varus and in 1 case in 1° valgus. In the 2 osteotomy cases, penetration of the fins was good at the proximal level and slight distally. In the remaining 4 cases penetration at both levels ranged from slight to good. No microfractures, either intraoperative or following stress testing, were evidenced. Mechanical tests showed that stem implantation reduced deformation of the femoral cortical bone undergoing cyclic loading, in comparison with the pre-implantation situation. Conclusions. The double-conicity prosthetic stem showed good implantability, with the capacity to allow for stability in case of femoral shortening osteotomies without the use of plates or cerclage fixation. Mechanical testing also showed a correct load distribution, and a reduction of stress on femoral cortical bone in comparison with the state before implantation. Prospective clinical studies are necessary to assess efficacy and dependability from a clinical and radiographic viewpoint