Abstract. Objectives. Stem malalignment in total hip arthroplasty (THA) has been associated with poor long-term outcomes and increased complications (e.g. periprosthetic femoral fractures). Our understanding of the biomechanical impact of stem alignment in cemented and uncemented THA is still limited. This study aimed to investigate the effect of stem fixation method, stem positioning, and compromised bone stock in THA. Methods. Validated FE models of cemented (C-stem – stainless steel) and uncemented (Corail – titanium) THA were developed to match corresponding experimental model datasets; concordance correlation agreement of 0.78 & 0.88 for cemented & uncemented respectively. Comparison of the aforementioned stems was carried out reflecting decisions made in the current clinical practice. FE models of the implant positioned in varus, valgus, and neutral alignment were then developed and altered to represent five different bone defects according to the Paprosky classification (Type I – Type IIIb). Strain was measured on the femur at 0mm (B1), 40mm (B2), and 80mm (B3) from the lesser trochanter. Results. Cemented constructs had lower strain on the implant neck, and higher overall stiffness and strain on bone compared to uncemented THA. Strain on the bone increased further down the shaft of the femoral diaphysis, and with progressing bone defect severity in all stem alignment cases. Highest strain on the femur was found at B2 in all stem alignment and bone defect models. Varus alignment showed higher overall femoral strain in both fixation methods. Interestingly, in uncemented models, highest strain was shown on femoral bone proximally (B1-B2) in varus alignment, but distally (B3) in neutral alignment. Conclusion. Varus stem alignment showed overall higher strain on femur compared to neutral and valgus. This highlights the crucial role of stem alignment in long term outcomes of THA. Differences between the two stem types should be taken in consideration when interpreting results from this study

Introduction and Objective. Scaphoid waist fractures (SWF) are notable in upper limb trauma and predominantly occur in young men. Morbidities associated with SWF include fracture non-union, premature arthritis and humpback deformity. Delayed treatment and non-adherence to fracture immobilisation increases likelihood of these complications. There is evidence that men engage in negative health behaviours such as delayed help-seeking. The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) conducted interviews in individuals who had sustained a SWF. Although SWIFFT showed multiple social determinants for the overall injury and healing experience, a key factor this novel study considers is age and sex. This study aimed to analyse interview data from young male participants in SWIFFT to help distinguish the experience of SWF in young men, through exploring the influence of masculinity. Materials and Methods. A purposive sample of 12 young male participants were selected from SWIFFT. These participants were enrolled from a possibility of 13 different centres across Britain. There were 17 semi-structured interviews produced from these participants, and this was thought to be sufficient for data saturation. These interviews were evaluated through deductive thematic analysis with an open-coding approach, with respondents’ experiences being compared against themes documented in men's health literature. The “Braun and Clarke (2006) Six Phases of Thematic Analysis” methodology was adopted to perform this. Results. There were three thematic models developed in the data set, which then were further divided into subthemes. Model 1: Negative Health Behaviour Prior to Treatment, model 2: Feeling Frail and model 3: Need for Speed. Model 1 corroborated that participants were inclined to sustain the injury as a result of risk-taking and would subsequently hesitate to seek treatment. Model 2 indicated that as a result of the injury, respondents were unable to engage in physical activities and activities of daily living. Respondents exercised caution to varying extents after sustaining a SWF. Model 3 highlighted that interviewees were prone to non-adherence with fracture immobilisation and in hindsight resumed employment prematurely. Conclusions. The findings of this study demonstrate that masculinity is significantly influential on the experience of SWF in young men. This was indicated through the results of thematic analysis strongly corresponding with behaviours established in men's health literature. Educational interventions could be of value in addressing behaviours observed in this population group, such as delayed help-seeking and non-compliance with fracture immobilisation. Further work in patient education and concordance with treatment after sustaining a SWF may be beneficial to longer term outcomes. In turn, this may reduce complications associated with SWF in young men

Abstract. Background. Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects. Methods. 82 patients (mean age-28.8 years) with recurrent patellar dislocations, who underwent soft-tissue or bony procedures, were divided into 2 matched groups (age, sex, follow-up and type of procedure) of 41 each based on the presence or absence of cartilage defects in patella. Chondroplasty, microfracture, osteochondral fixation or AMIC-type procedures were done depending on the nature of cartilage injury. Lysholm, Kujala, Tegner and Subjective Knee scores of both groups were compared and analysed. Complications and return to theatre were noted. Results. With a mean follow-up of 8 years (2 years-12.3 years), there was a significant improvement observed in all the mean post-operative Patient Reported Outcome Measures (p<0.05) of both the groups, as compared to the pre-operative scores. Comparing the 2 groups, post-operative Lysholm, Kujala and Subjective knee scores were significantly higher in patients operated without cartilage defects (p<0.05). 3 patients operated for PFJ instability with cartilage defects had to undergo patellofemoral replacement in the long term. Odds ratio for developing complications is 2.6 for patients operated with cartilage defects. Conclusion. Although there is a significant improvement in the long term outcome scores of patients operated for recurrent patellar dislocation with cartilage defects, the results are significantly inferior as compared to those without cartilage defects, along with a higher risk of developing complications and returning to theatre. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Acetabular fractures occur as a result of high-velocity trauma and are often associated with other life threatening injuries. Approximately one-third of these fractures are associated with dislocation of the femoral head but there are only few studies documenting the long term outcomes of this group of acetabular fracture. Methods. This was undertaken at the Royal Infirmary of Edinburgh which provides the definitive orthopaedic treatment for all major trauma including all acetabular fractures for the South East of Scotland. We retrospectively reviewed patients who sustained an acetabular fracture associated with a posterior hip dislocation from a prospectively gathered trauma database between 1990 to 2010. Patient characteristics, complications and the requirement for further surgery were recorded. Patient outcomes were measured using the Oxford Hip score and Short Form SF-12 health survey. Results. A total of 99 patients were treated over a 24 year period. The mean age was 41.3 years. The majority were male (75%). Road traffic accidents were the most common mechanism of injury (47%). The most common Letournal & Judet classification was a posterior wall fracture. Complications such as Sciatic Nerve Palsy was 12.1%, DVT 3%, Infection 5%, Heterotopic ossification 6.1%, Avascular necrosis at 11.1% and 19.2% went on to have a total hip replacement. The mean Oxford Score for Native hip was 34.7 and 31.8 for those who converted to hip replacement. SF12 Physical score was was 40.3 and 39 for the native hips and converted hips respectively. And the SF12 Mental score was 45.5 and 44.9 for the native hips and converted hips respectively. Conclusions. This is the first study to present the long term outcomes following an acetabular fracture dislocation. Our study suggests there is considerable disability in this group of patients and the requirement for subsequent THR has inferior patient reported outcomes. Level of Evidence. Cohort study, Level 2B

Background. Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects. Methods. 82 patients (mean age-28.8 years) with recurrent patellar dislocations, who underwent soft-tissue or bony procedures, were divided into 2 matched groups (age, sex, follow-up and type of procedure) of 41 each based on the presence or absence of cartilage defects in patella. Chondroplasty, microfracture, osteochondral fixation or Autologous Matrix-Induced Chondrogenesis(AMIC)-type procedures were done depending on the nature of cartilage injury. Lysholm, Kujala, Tegner and Subjective Knee scores of both groups were compared and analysed. Complications and return to theatre were noted. Results. With a mean follow-up of 8 years (2 years-12.3 years), there was a significant improvement observed in all the mean post-operative Patient Reported Outcome Measures (p<0.05) of both the groups, as compared to the pre-operative scores. Comparing the 2 groups, post-operative Lysholm, Kujala and Subjective knee scores were significantly higher in patients operated without cartilage defects (p<0.05). 3 patients operated for patellofemoral instability with cartilage defects had to undergo patellofemoral replacement in the long term. Odds ratio for developing complications is 2.6 for patients operated with cartilage defects. Conclusion. Although there is a significant improvement in the long term outcome scores of patients operated for recurrent patellar dislocation with cartilage defects, the results are significantly inferior as compared to those without cartilage defects, along with a higher risk of developing complications and returning to theatre

Telemedicine is the delivery of healthcare from a remote location using integrated computer/communication technology. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation particularly during our current pandemic where patient contact is limited. Databases of PubMed, Scopus and CINHAL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools. Twenty studies were included consisting of nine RCTs across numerous orthopaedic subspecialties including fracture care, elective orthopaedics and oncology. Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient reported outcome measures. Telemedicine was reported to be a safe method of consultation. However, studies were of variable methodological quality with selection bias. In conclusion, evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment with high patient/clinician satisfaction. Further work with high quality RCTs is required to elucidate long term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use in the current COVID-19 pandemic and beyond

Background. In the adolescent population, operative management of hallux-valgus is controversial. Operations may be less successful than in adults and post-operative recurrence is more common before full skeletal maturity. This study assesses the radiographic, functional and qualitative outcomes of surgical Hallux Valgus correction in adolescents. Methods. Three independent reviewers retrospectively analysed pre and post-operative radiological markers of hallux valgus severity for 44 operations on patients age 13–18. The patient cohort were also asked the Manchester-Oxford foot questionnaire (MOXFQ) to assess functional outcome via telephone interview and patient notes were reviewed for any evidence of complications. Results. There was no evidence of NICE recognised complications from any of the operations performed, however there was persistence or recurrence in 20.8%, requiring a second operation in 10.3%. Radiologically, all operations performed resulted in a reduction in hallux valgus severity. The hallux valgus angle showed a mean reduction of 18.0 degrees (16.3–19.7) and the inter-metatarsal angle by 7.3 degrees (6.55–8.14). 93% of operations resulted in a good MOXFQ outcome score of less than 20 out of a possible 80 negative functional outcome points. This score worsened with age in a statistically significant manner (p=0.03) but had no significant correlation with BMI. Conclusion. Surgical correction of adolescent hallux valgus reduces the radiographic severity, which correlates with good long term outcome. This surgery provides beneficial results to the patient, however there is a high recurrence rate, correlating with younger age and this must be taken into account

Introduction. High-volume image guided injections (HVIGI) followed by structured rehabilitation have been shown to be effective in various musculoskeletal conditions including Achilles tendinopathy and shoulder impingement syndrome. The aim was to explore the effect of a HVIGI in Hoffa's fat pad impingement, a common cause of anterior knee pain. Materials and Methods. 100 consecutive subjects who received a HVIGI followed by a standardised physiotherapy rehabilitation regime for Hoffa's fat pad impingement (diagnosed using clinical history, examination and magnetic resonance imaging) at one specialist MSK centre were sent a follow-up questionnaire. The questionnaire collected demographics, symptom length and the percentage improvement in symptoms following the HVIGI. All had received HVIGI consisting of 10ml of 0.5% Marcaine and 50mg of hydrocortisone followed by a structured rehabilitation programme with a focus on lower limb alignment control, flexibility, hip and knee strengthening in line with best practice. Data was analysed using SPSS version 20 at this interim stage; data collection is continuing. Results. The response rate at this point is currently 28%. Of the twenty-six subjects (9 female; 19 male; average age 37.8 ± 13.4) who completed the questionnaire 82% had had anterior knee pain symptoms for >6 months prior to receiving a HVIGI. The average percentage improvement in anterior knee pain was 45 ± 36.5% (range 0–100%). 48% of subjects reported a >6 month improvement in symptoms. No adverse effects were reported and no subject required anytime off work. Discussion. HVIGI with a structured rehabilitation programme should be considered in the short term management of Hoffa's fat pad impingement. Future research should be prospective, to improve the response rate, and consider longer term outcomes

Purpose and background. Effective reassurance is an essential element of treatment for conditions that do not require further investigations, referrals and on-going monitoring. However, research defining what reassurance should consist of and how to deliver it is scarce. The aim of this review was to identify consultation-related processes that improved patients' outcomes, in order to build an evidence-based model of effective reassurance in primary care. Method and results. A literature search identified prospective observational studies that explicitly measured consultation-related factors in appropriate primary care patient groups. The findings from empirical studies were combined with theoretical and systematic reviews to develop a model of effective reassurance. Scrutiny of 8193 Abstracts yielded 29 empirical studies fitting inclusion criteria, and 64 reviews. The majority of studies measured patient satisfaction. Clinical outcomes (e.g. health status / symptom reduction) appear to improve with patients' active participation in the consultation. Behavioural outcomes (e.g. adherence/ health care utilization) were only measured in a handful of studies, but may improve when information was given in the final stage of the consultation. Psychological outcomes (e.g. health concerns) were consistently improved by patient-centred approaches. Conclusion. The synthesis of empirical evidence and theory resulted in a model with two distinct stages: Affective reassurance, which focuses on eliciting patient concerns empathically and leads to trust in the clinician. Cognitive reassurance should then follow, involving iterative and interactive education, leading to enablement and impacting on medium and long term outcomes. Conflicts of Interest. None. Source of Funding. None

Primary traumatic anterior dislocations of the shoulder are common injuries which are complicated by persistent instability in a high proportion of patients. Surgery is successful and has been well described in the literature. Current controversies centre on the role of open and arthroscopic techniques. We describe the outcomes of a new mini-incision surgical (MIS) technique which was developed within our institution. 27 patients with traumatic shoulder instability (2 bilateral) were prospectively entered into a database between June 1998 and March 2008. The mean age was 31 years and the mean follow up period was 53 months. 29 shoulders underwent diagnostic shoulder arthroscopy and mini-incision surgery using a delto-pectoral approach and 3 bio-absorbable anchors. Patients reported no re-dislocation in 24 shoulders (83%). 5 shoulders, including one with a bony Bankart lesion, re-dislocated with additional trauma. One shoulder required revision to a Bristow-Latarjet. Satisfaction was very good in 16 and good in 9 shoulders (83%). 19 patients had minimal or no pain. 8 patients experienced moderate shoulder pain with the other two complaining of severe pain. QuickDASH scores were encouraging. Our technique combines the ability to appreciate all shoulder pathology arthroscopically with the visualisation gained in open Bankart surgery. Functionally, patients do well. The higher than expected re-dislocation rate is concerning. We advise that long term outcomes are needed

Introduction. This study sought to determine whether the functional outcome of two common spinal operations could be improved by a programme of post-operative rehabilitation and/or an educational booklet each compared with usual care. Methods. This was a multi-centre, factorial, randomised controlled trial on the post operative management of spinal surgery patients, with randomisation stratified by surgeon and operative procedure. The study compared the effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with “usual care” using a 2 × 2 factorial design, randomising patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analogue scale measures of back and leg pain. An economic analysis was also performed. Results. 338 patients were recruited into the study with outcomes preformed pre-operatively, and postoperatively at 6 weeks, 3, 6, 9 and 12 months post-operatively. At the one year review the effect of rehabilitation on ODI was −2.7 (95% CI −6.8 to 1.5) and the effect of booklet was 2.7 (95% CI −1.5 to 6.9). There were no significant differences in costs or outcomes associated with either intervention and neither intervention was cost-effective. Discussion. This study found that neither intervention had a significant impact on long term outcome or cost. There was some evidence to suggest that the impact of the interventions was different between patients undergoing discectomy and those having spinal decompression. Conflicts of Interest. None. Source of Funding. Arthritis Research UK. Previously presented at International Society for the Study of the Lumbar Spine 2011

Summary Statement. Pedicle screws provide robust fixation and rigid immobilization. There has been no attempt to correlate the anatomic dimensions of thoracic and lumbar pedicles with the accuracy of navigated insertion. This study demonstrates that comparable accuracy using this technique. Introduction. Pedicle screws provide robust mechanical fixation, which makes their use attractive; their use enables fixation of the three spinal columns. There remains concern about the potential both for misplacement; various investigators have studied the accuracy of pedicle screw insertions, comparing different techniques. What is not clear, however, is whether there is any relation between the variables of pedicles’ anatomic dimensions, screw dimensions and accuracy. This study aims to elucidate the relationship between these variables. Patients & Methods. We conducted a retrospective review of consecutive pedicle screws that were inserted in the thoracic and lumbar spine at our institution. Screws were inserted using the navigated method (Stealth Station® TREON™, Medtronic, Louisville, CO). The accuracy of the screw insertion was measured using the classification system developed by Gertzbein and Robbins; pedicle dimensions were measured from post-operative computed tomography scans. The corresponding pre-operative scans were then used to measure the pedicle dimensions at the other levels. The magnitude of a cortical breach in the pedicle was represented by a letter: A (no breach), B (<2mm), C (>2mm, <4mm), D (>4mm, <6mm) and E (>6mm). In addition, measurements were made of the anatomic dimensions of the pedicles. The combination of these two measures allowed for direct correlation to be made between the accuracy of screw insertion, screw dimensions and pedicle anatomy. We then computed the proportion of each pedicle (width) occupied by a screw. Results. A total of 765 screws were reviewed, 493 were in the thoracic spine and 272 in the lumbar spine. Of the screws in the thoracic spine, 472 (96%) were either fully in the pedicle or less than 2mm beyond the cortex (within the A+B classification); when considered separately, 323 (66%) were completely within the pedicle (A) and 149 (30%) were less than 2mm beyond the cortex. A total of 21 (4%) screws were beyond 2mm but within 6mm (C+D). In the lumbar spine, 270 (99%) were either completely within the cortex or less than 2mm exposed (classified as A or B). The nadir of pedicle width was at T4. From L1 to L5, measured pedicle width also rose. This pattern was followed, although it was less profound, when screw diameter was measured in the lumbar spine (and even less so in the thoracic vertebrae). The height of pedicles was noted to progressively increase, peaking at the thoraco-lumbar junction. The mid thoracic region was associated with screws occupying the greatest proportion of pedicle diameter. Discussion/Conclusion. The use of pedicle screws in the thoracic and lumbar spine remains relatively safe. The accuracy of navigated insertion was found to compare well to previous series’. Although there is some association between the anatomical dimensions of pedicles and the dimensions of screws, this doesn't seem to be a strong association. Based on the findings in this series, future studies that relate the long term outcome (e.g. failure or screw loosening) with proportion of pedicle diameter taken up by a screw may be warranted

Introduction. Patients with knee osteoarthritis (OA) often tell us that they put extra load on the joints of the opposite leg as they walk. Multiple joint OA is common and has previously been related to gait changes due to hip OA (Shakoor et al 2002). The aim of this study was to determine whether patients with medial compartment knee OA have abnormal biomechanics of the unaffected knee and both hips during normal level gait. Methods. Twenty patients (11 male, 9 female), with severe medial compartment knee OA and no other joint pain were recruited. The control group comprised 20 adults without musculoskeletal pain. Patients were reviewed, x-rays were examined and WOMAC and Oxford knee scores were completed. A 12 camera Vicon (Vicon, Oxford) system was used to collect kinematic data (100Hz) on level walking and the ground reaction force was recorded using three AMTI force plates (1000Hz). Surface electrodes were placed over medial and lateral quadriceps and hamstrings bilaterally to record EMG data (1000Hz). Kinematics and kinetics were calculated using the Vicon ‘plug-in-gait’ model. A co-contraction index was calculated for the EMG signals on each side of the knee, representing the magnitude of the combined readings relative to their maximum contraction during the gait cycle. Statistical comparisons were performed using t-tests with Bonferroni's correction for two variables and ANOVA for more than two variables (SPSS v16). Results. The mean age of the patients was 69 (SD 8.8). Mean gait speed was 0.95m/s (study group) and 1.44m/s (control group). Peak adduction moments for the OA group [OA Knee; Unaffected Knee; Ipsilateral Hip; Contralateral Hip; in Nm/Kg(±95% CI)] were: 0.55(0.06); 0.47(0.06); 0.73(0.09); 0.73(0.08). Control values for peak moments were 0.64 (0.06) for the knee and 0.81(0.07) at the hip. Mid-stance adduction moments for the OA group (listed as before) were: 0.44(0.08); 0.33(0.06); 0.64(0.06); 0.61(0.08). Control values for mid-stance moments were 0.14(0.03) and 0.40(0.04). [OA group vs. Controls: p=NS for peak moments at all 4 joints; p<0.01 for mid-stance moments at all joints]. Co-contraction indices for hamstrings and quads, [OA knee medial; and lateral; unaffected knee medial; and lateral; control medial; and lateral; 0<X. Discussion. Although the affected subjects all had only single joint OA, abnormal moments were present in the hips and knees of both legs during normal level gait, despite the reduced gait speed of the OA cohort. Abnormal hamstring and quadriceps co-contraction occurs bilaterally in patient with single joint OA. Increased trunk sway is a recognised compensation in knee OA and may be the cause of the abnormal hip and contra-lateral knee loading found in this study. Further investigation is warranted and may lead to improvements in the long term outcome for these patients. Acknowledgement. The study was funded by the North Wales NHS Trust

Background. Autologous Chondrocyte Implantation (ACI) is a procedure which is gaining acceptance for the treatment of cartilage defects in the knee with good results and a long term durable outcome. Its use in other joints has been limited, mainly to the ankle. We aimed to assess the outcome of ACI in the treatment of chondral and osteochondral defects in the hip. Methods. Fifteen patients underwent ACI for chondral or osteochondral defects in the femoral head with a follow up of upto 8 years (mean of 2 years) in our institution with a mean age of 37 years at the time of operation. Pre-operatively hip function was assessed by using the Harris Hip Score and MRI. Post-operatively these were repeated at 1 year and hip scores repeated annually. Failure was defined as a second ACI to the operated lesion or a conversion to a hip resurfacing or replacement. Results. The mean pre-op Harris Hip Score (HHS) was 55 which increased to 63 at 1 year and 70 at the latest follow up. Patients who underwent ACI for cartilage defects secondary to trauma (four) were better with a mean HHS of 69 at a mean follow up of 3.5 years. Six patients underwent THR at a mean of 32 months and were classed as failures. Five patients had evidence of avascular necrosis (AVN) of the femoral head post operatively of which four AVN pre-op. Conclusion. These early results suggest that ACI could be a viable option for the treatment of isolated chondral defects in the hip. The presence of AVN or bone cysts pre-op may be a predictor of failure