Introduction. The first VRAS TKA was performed in New Zealand in November 2020 using a Patient Specific Balanced Technique whereby VRAS enables very accurate collection of the bony anatomy and soft tissue envelope of the knee to plan and execute the optimal positioning for a balanced TKA. Method. The first 45 VRAS patients with idiopathic osteoarthritis of the knee was compared with 45 sequential patients who underwent the same TKA surgical technique using Brainlab 3 which the author has used exclusively in over 1500 patients. One and two year outcome data will be presented. Results. One year outcome dataVely Brainlab Significance Oxford 43.4 40.5 P=0.01 WOMAC 8.4 14.1P=0.02 Forgotten Joint Score 72.2 58.3 P=0.01 KOOS ADL91.3 85.8 P=0.04 Normal 83.3 74.2P =0.048 Activity Pain 8.6 18.4 P=0.009 ROM 127 124 P=0.01 Patient Satisfaction 98% 95% P=0.62 Operation again 100% 91% P=0.055 The two year data will be available for the ASM Conclusion: The one year outcome data shows a significantly better Oxford, WOMAC, Forgotten Joint score, KOOS ADL, Normal score and ROM scores and the activity pain is less compared to the authors extensive experience with Brainlab 3

Aims. Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. Methods. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. Results. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was ‘recurrence of osteomyelitis’ (62; 12%). The single-most patient-reported outcome measure was ‘pain’. Conclusion. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies. Cite this article: Bone Jt Open 2023;4(3):146–157

Surgical treatment options for Femoroacetabular impingement (FAI) includes both surgical dislocation and hip arthroscopy techniques. The primary aim of this study was to evaluate and compare the survivorship of arthroscopies (scope) and surgical dislocations (SD) at minimum 5-year follow-up. The secondary aim was to describe differences in functional outcomes between the 2 groups. This was a retrospective, single surgeon, consecutive, case-series from a large tertiary care centre. We evaluated all surgeries that were performed between 2005 and 2011. Our institutional database was queried for any patient undergoing surgery for FAI (pincer (n=23), cam (n=306), or mixed (n=103) types). Patients with childhood pathologies i.e. Legg Calve Perthes and slipped capital femoral epiphysis were excluded. This resulted in 221 hips (169 males, 52 females) who underwent either SD (94, 42.5%) or scope (127, 57.5%). A manual chart review was completed to identify patients who sustained a complication, underwent revision surgery or progressed to a total hip arthroplasty (THA). In addition, we reviewed prospectively collected patient reported outcome measure (PROMs) using (SF12, HOOS, and UCLA). Survivorship outcome was described for the whole cohort and compared between the 2 surgical groups. PROMs between groups were compared using The Mann-Whitney U test and the survival between groups was assessed using the Kaplan-Meier Analysis and the Log-Rank Mantel Cox test. All analyses were performed in SPSS (IBM, v. 26.0). The cohort included 110 SDs and 320 arthroscopies. The mean age of the whole cohort was 34±10; patients in the SD group (32±9) were younger compared to the arthroscopy group (39±10) (p<0.0001). There were 16 post-operative complications (similar between groups) and 77 re-operations (more common in the SD group (n=49) due to symptomatic metal work (n=34)). The overall 10-year survival was 91±3%. Survivorship was superior in the arthroscopy group at both 5- (96% (95%CI: 93 – 100)) and 8- years 94% (95%CI: 90 – 99%) compared to the SD Group (5-yr: 90% (95%CI: 83 – 98); 8-yr: 84% (95%CI:75 – 93)) (p=0.003) (Figure 1). On average HOOS improved from 54±19 to 68±22 and WOMAC from 65±22 to 75±22. The improvement in PROMs were similar between the 2 groups. We report very good long-term joint preservation for the treatment of FAI, which is similar to those reported in hip dysplasia. In addition, we report satisfactory improvement in function following such treatment. The differences reported in joint survival likely reflect selection biases from the treating surgeon; more complex cases and those associated with more complex anatomy were more likely to have been offered a SD in order to address the pathology with greater ease and hence the inferior joint preservation identified in this group. For any figures or tables, please contact the authors directly

One in five patients remain unsatisfied due to ongoing pain and impaired mobility following total knee arthroplasty (TKA). It is important if surgeons can pre-operatively identify which patients may be at risk for poor outcomes after TKA. The purpose of this study was to determine if there is an association between pre-operative measures and post-operative outcomes in patients who underwent TKA. This study included 28 patients (female = 12 / male = 16, age = 63.6 ± 6.9, BMI = 29.9 ± 7.4 kg/m2) with knee osteoarthritis who were scheduled to undergo TKA. All surgeries were performed by the same surgeon (GD), and a subvastus approach was performed for all patients. Patients visited the gait lab within one-month of surgery and 12 months following surgery. At the gait lab, patients completed the knee injury and osteoarthritis outcome score (KOOS), a timed up and go (TUG), and walking task. Variables of interest included the five KOOS sub-scores (symptoms, pain, activities of daily living, sport & recreation, and quality of life), completion time for the TUG, walking speed, and peak knee biomechanics variables (flexion angle, abduction moment, power absorption). A Pearson's product-moment correlation was run to assess the relationship between pre-operative measures and post-operative outcomes in the TKA patients. Preliminary analyses showed the relationship to be linear with all variables normally distributed, as assessed by Shapiro-Wilk's test (p > .05), and there were no outliers. There were no statistically significant correlations between any of the pre-operative KOOS sub-scores and any of the post-operative biomechanical outcomes. Pre-operative TUG time had a statistically significant, moderate positive correlation with post-operative peak knee abduction moments [r(14) = .597, p < .001] and peak knee power absorption [r(14) = .498, p = .007], with pre-operative TUG time explaining 36% of the variability in peak knee abduction moment and 25% of the variability in peak knee power absorption. Pre-operative walking speed had a statistically significant, moderate negative correlation with post-operative peak knee abduction moments [r(14) = -.558, p = .002] and peak knee power absorption [r(14) = -.548, p = .003], with pre-operative walking speed explaining 31% of the variability in peak knee abduction moment and 30% of the variability in peak knee power absorption. Patient reported outcome measures (PROMs), such as the KOOS, do indicate the TKA is generally successful at relieving pain and show an overall improvement. However, their pre-operative values do not correlate with any biomechanical indicators of post-operative success, such as peak knee abduction moment and knee power. Shorter pre-operative TUG times and faster pre-operative walking speeds were correlated with improved post-operative biomechanical outcomes. These are simple tasks surgeons can implement into their clinics to evaluate their patients. Future research should expand these findings to a larger sample size and to determine if other factors, such as surgical approach or implant design, improves patient outcomes

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention. 127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. P<0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI). The number of columns involved in the injury best predicts functional outcomes (FFI, P <0.05, AOFAS, P<0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group. We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes

Aim. To compare outcomes of PJI in relation to treatment method versus classification using the JS-BACH system. Method. Patients having surgery for EBJIS Criteria Confirmed PJI between 2010–2015 were included. Index surgical procedures were 1-stage or 2-stage revision or debridement and implant retention (DAIR). Patients completed the EuroQol EQ-5D-3L questionnaire and were followed clinically to a median of 4.7 years (IQR 2.7–6.7 years). Patients were stratified using the JS-BACH classification1 into either ‘Uncomplicated’, ‘Complex’ or having ‘Limited treatment options’, by two separate classifiers, blinded to clinical outcome. Results. 216 patients met the inclusion criteria. There were 51 patients classified as Uncomplicated (23.6%), 127 (58.8%) as Complex and 38 (17.6%) having Limited treatment options. Patients underwent either DAIR (n=97), 1-stage (n=35) or 2-stage (n=84) revision. Patients classified as Uncomplicated PJI had the lowest risk of recurrence or treatment failure, regardless of index procedure performed. Complex patients were significantly more likely than Uncomplicated patients to have recurrence following 2-stage revision (Odds Ratio 1.85; p=0.040) or DAIR (OR 1.83; p=0.037), but not 1-stage revision (OR 0.518; p=0.675). Limited treatment option patients had the highest recurrence risk regardless of index procedure (1-stage: OR 2.5 p=0.036; 2-stage: OR 3.3 p=0.004; DAIR: OR 3.40 p=0.006). At one year after surgery, Uncomplicated patients had the highest EQ-index scores (a marker of Quality of Life), with all treatments (EQ-5D-3L mean index scores; Uncomp 0.773, Complex 0.512, Limited Options 0.310: p<0.01). Differences in patient-reported outcomes were greater between the JS-BACH classification groups than between any methods of treatment. Conclusions. The JS-BACH classification effectively predicted outcome after three common PJI treatments. Comparing outcomes between treatments, without stratification of the patients, may be misleading as factors other than treatment method have a major effect on outcome. Classification may allow better allocation of individual treatments to provide optimal outcome for patients

Abstract. Background. The primary objective of the study is to determine the function outcome and survivorship of patellofemoral replacement. The secondary aim is to find the determinants of successful/poor outcome. Methods. This retrospective study involved 45 patients who underwent AVON patellofemoral replacement between January 2015 to December 2020 with the minimal follow-up off for 12 months. The functional outcome was measured using Oxford Knee score (OKS), EuroQol five dimension (EQ-5D). IWANO and Kellgren-Lawrence classification was used to analyse radiographs. To identify determinants of outcome, the following subgroups the presence or absence of normal alignment, tibiofemoral arthritis, trochlear dysplasia and previous surgery. Complications and revision rates were also recorded. Results. The mean follow-up period was 41.7 +/− 8.3 months with no patients lost in follow-up. Patellofemoral replacement significantly improved the Oxford Knee score (OKS), EuroQol five dimension (EQ-5D) (p<0.001). Four out of 45(8.9%) patients underwent revision surgery. Patients with normal alignment preoperatively did worse than those with abnormal alignment with patellar instability. Patients with grade two tibiofemoral arthritis, history of previous surgery did significantly worse with poorer functional outcome. Conclusion. Patellofemoral arthroplasty is reliable treatment option which improves patient function and quality of life with good survivorship in isolated patellofemoral arthritis in mid-term follow-up

Little guidance exists in the current literature regarding which patient recorded outcome measures (PROMs) are most clinically appropriate following anterior cruciate ligament reconstruction (ACL) surgery, and what results surgeons should expect or accept. Many PROMs have been validated, but their “ideal” results have not been published, limiting a surgeon's ability to compare their patients’ outcomes with those of their colleagues. We undertook a systematic review of PROMs for ACL to look at common usage and outcomes. After appropriate paper selection, we then undertook a pragmatic meta-analysis (i.e., including all papers that fulfilled the selection criteria, regardless of CONSORT status) and calculated weighted mean outcome scores and standard deviations for the most commonly used PROMs. A comprehensive literature search of all English articles of PubMed and other sources including search terms (‘Patient related outcome measure’ or ‘PROM’) AND ‘anterior cruciate ligament’ (limited to abstract/title) yielded 722 articles. Title review narrowed this to 268, and abstracts review to 151, of which 88 were included in our meta-analysis. Weighted mean and standard deviations were calculated for IKDC, KOOS, Lysholm, Teneger and “VAS Pain” PROMs as the most commonly reported. We identified significant, novel findings relating to selected PROMs and (i) demographics including age, gender and body mass index, (ii) surgical factors including bundle count, strand count, and graft type, and (iii) post operative complications. We clarified the most commonly used PROMs for ACL, and their weighted means and standard deviations. This will allow surgeons to compare results with colleagues, ensuring they meet international levels of quality in PROMs. We have also updated which patient and operative factors have an impact on PROMs scoring to allow for population variance

Meniscal tears commonly co-occur with ACL tears, and many studies address their side, pattern, and distribution. Few studies assess the patient's short-term functional outcome concerning tear radial and circumferential distribution based on the Cooper et al. classification. Meniscal tears require primary adequate treatment to restore knee function. Our hypothesis is to preserve the meniscal rim as much as possible to maintain the load-bearing capacity of the menisci after meniscectomy. The purpose of this study is to document the location and type of meniscal tears that accompany anterior cruciate ligament (ACL) tears and their effect on patient functional outcomes following arthroscopic ACL reconstruction and meniscectomy. This prospective cross-sectional observational study was conducted at AL-BASRA Teaching Hospital in Iraq between July 2018 and January 2020 among patients with combined ipsilateral ACL injury and meniscal tears. A total of 28 active young male patients, aged 18 to 42 years, were included. All patients were subjected to our questionnaire, full history, systemic and regional examination, laboratory investigations, imaging studies, preoperative rehabilitation, and were followed by Lysholm score 6 months postoperatively. All 28 patients were males, with a mean age of 27 ± 0.14 years. The right knee was the most commonly affected in 20/28 patients (71.4%). The medial meniscus was most commonly injured in 11 patients, 7 patients had lateral meniscal tears, and 10 patients had tears in both menisci. The most common tear pattern of the medial meniscus was a bucket handle tear (36.4%), while longitudinal tears were the most frequent in the lateral meniscus (71.4%) (P-value = 0.04). The most common radial tear location was zone E-F (5/28, 17.8%), and the most common circumferential zone affected was the middle and inner third, reported in 50% of tears. Good and excellent outcomes using the Lysholm score after 6 months were obtained in 42.9% and 17.9% of patients, respectively. Better functional scores were associated with lateral meniscal tears, bucket handle tears, tears extending to a more peripheral vascular area, and if no more than one-third of the meniscus was resected (P-value = 0.002). Less favourable outcomes were reported in smokers, posterior horn tears, and when surgery was delayed more than 1 year (P-value = 0.03). We conclude that there is a negative correlation between the amount of meniscus resected and functional outcome. Delayed ACL reconstruction increases the risk of bimeniscal tears. Bucket handle tears are the most common tears, mostly in the medial meniscus, while longitudinal tears are most common in the lateral meniscus. We recommend performing early ACL reconstruction within 12 months to reduce the risk of bimeniscal injuries

Aims. The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature. Methods. A bibliometric search of journals’ online archives and multiple databases was undertaken in March 2024, to identify articles using qualitative research methods in the top 12 trauma and orthopaedic journals based on the 2023 impact factor and SCImago rating. The bibliometric search was conducted and reported in accordance with the preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO). Results. Of the 7,201 papers reviewed, 136 included qualitative methods (0.1%). There was no significant difference between the journals, apart from Bone & Joint Open, which included 21 studies using qualitative methods, equalling 4% of its published articles. Conclusion. This study demonstrates that there is a very low number of qualitative research papers published within trauma and orthopaedic journals. Given the increasing focus on patient outcomes and improving the patient experience, it may be argued that there is a requirement to support both quantitative and qualitative approaches to orthopaedic research. Combining qualitative and quantitative methods may effectively address the complex and personal aspects of patients’ care, ensuring that outcomes align with patient values and enhance overall care quality

Osteoarthritis (OA) is the most common form of arthritis and one of the ten most disabling diseases in developed countries. Total joint replacement (TJR) is considered by far as the most effective treatment for end-stage OA patients. The majority of patients achieve symptomatic improvement following TJR. However, about 22% of the TJR patients either do not improve or deteriorate after surgery. Several potential non-genetic predictors for the TJR outcome have been investigated. However, the results were either inconclusive or had very limited predictive power. The aim of this study was to identify genetic variants for the poor outcome of TJR in primary OA patients by a genome-wide association study (GWAS). Study participants were total knee or hip replacement patients due to primary OA who were recruited to the Newfoundland Osteoarthritis Study (NFOAS) before 2017. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess pain and functional impairment pre- and 3.99±1.38 years post-surgery. Two non-responder classification criteria were used in our study. One was defined by an absolute WOMAC change score. Participants with a change score less than 7/20 points for pain were considered as pain non-responders; and those with less than 22/68 points for function were classified as function non-responders. The second one was the Outcome Measures in Arthritis Clinical Trials and the Osteoarthritis Research Society International (OMERACT-OARSI) criteria. Blood DNA samples were genotyped using the Illumina GWAS microarrays genotyping platform. The quality control (QC) filtering was performed on GWAS data before the association of the genetic variants with non-responders to TJR was tested using the GenABEL package in R with adjustment for the relatedness of the study population and using the commonly accepted GWAS significance threshold p < 5*10. −8. to control multiple testing. In total, 316 knee and 122 hip OA patients (mean age 65.45±7.62 years, and 58% females) passed the QC check. These study participants included 368 responders and 56 non-responders to pain, and 364 responders and 68 non-responders to function based on the absolute WOMAC point score change classification. While 377 responders and 56 non-responders to pain, and 366 responders and 71 non-responders to function were identified by the OMERACT-OARSI classification criteria. Interestingly, the same results were obtained by both classification methods, and we found that the G allele of rs4797006 was significantly associated with pain non-responders with odds ratio (OR) of 5.12 (p<7.27×10. -10. ). This SNP is in intron one of the melanocortin receptor 5 (MC5R) gene on chr18. This gene plays central roles in immune response, pain sensitivity, and negative regulation of inflammatory response to antigenic stimulus. The A allele of rs200752023 was associated with function non-responders with OR of 4.41 (p<3.29×10. -8. ). The SNP is located in intron three of the RNA Binding Fox-1 Homolog 3 (RBFOX3) gene on chr17 which has been associated with numerous neurological disorders. Our data suggested that two chromosomal regions are associated with TJR poor outcomes and could be the novel targets for developing strategies to improve the outcome of the TJR

The Cierny and Mader classification assists with decision-making in the management of osteomyelitis by strafying the host status and the pathoanatomy of disease. However the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08– 8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistical significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months)). This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time

Introduction. The Cierny and Mader classification assists with decision-making by stratifying host status and the pathoanatomy of the disease. However, the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. Materials & Methods. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Results. Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08–8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistically significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months)). Conclusions. This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time

Aim. The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. Method. All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. Results. We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n=6), free vascularized fibular graft (n=5), cancellous bone graft (n=1)) to reconstruct the bone defect. The median follow-up was 32.3 (P. 25. -P. 75. : 23.9–51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P. 25. -P. 75. : € 7.953–23.798) per patient. Conclusion. FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. Overall, the outcome of patients treated for FRI of the clavicle is good, when management of this complication is performed by using a multidisciplinary team approach. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Expert opinion considers factors such as the size of the bone defect, the condition of the soft tissue, and patient demand to guide surgical decision making

Introduction. There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population. Materials & Methods. A range of key PROMs was selected (n=32). Systematic and hand-searches were employed to find studies assessing content validity of these PROMs in the adult LLR population, along with PROM content and development information. A systematic review of content validity of the measures was carried out following ‘COnsensus-based Standards for the selection of health Measurement Instruments’ (COSMIN) guidance, alongside conceptual mapping of the content of the PROMs against the PROLLIT conceptual framework. Results. The searches uncovered very few content validity studies assessing the PROMs when applied in adult LLR patients. The COSMIN review found that these measures lacked content validity when applied in this population. The conceptual mapping found that PROMs did not capture all concepts identified as important and relevant in the PROLLIT framework. Conclusions. Existing PROMs applied in the adult LLR population lack content validity and fail to adequately capture relevant outcomes for this patient group. There is a need for a new, dedicated PROM designed for adult LLR patients

Aim. Pin site infection (PSI) is a common complication of external fixators. PSI usually presents as a superficial infection which is treated conservatively. This study investigated those rare cases of PSI requiring surgery due to persistent osteomyelitis (OM), after pin removal. Method. In this retrospective cohort study we identified patients who required surgery for an OM after PSI (Checketts-Otterburn Classification Grade 6) between 2011 and 2021. We investigated patient demographics, aetiology of the OM, pathogen and histology, treatment strategies and complications. Infection was confirmed using the 2018 FRI Consensus Definition. Successful outcome was defined as an infection-free interval of at least 24 months following surgery, which was defined as minimum follow-up. Results. Twenty-seven patients were treated due to a pin site infection with an osteomyelitis (22 tibias, 2 humeri, 2 calcanei, 1 radius). 85% identified as male and the median age was 53.9 years. Eighteen infections followed external fixation of fractures, with 4 cases after Ilizarov deformity correction, 2 cases followed ankle fusion and 3 after traction pin insertion. Fifteen patients were classified as BACH Uncomplicated and 12 were BACH Complex. The median follow-up was 3.99 years (2.00–8.05 years). Staphylococci were the most common pathogens (16 MSSA, 2 MRSA, 2 CNS). Polymicrobial infections were present in 5 cases (19%). All surgery was performed in a single stage following the same protocol at one institution. This included deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. Seven patients required flap coverage (6 local, 1 free flap), which was performed in the same operation. 25 (93%) patients had a successful outcome after one surgery. Two had recurrence of infection which was successfully treated by repeat of the protocol. One patient suffered a fracture through the operated site after a fall. This healed without infection recurrence. Wound leakage after local antibiotic treatment was seen in 3/27 (11%) of cases. All resolved without treatment. After a minimum of 2 years follow up, all patients were infection free at the site of the former osteomyelitis. Conclusions. OM after PSI is uncommon but has major implications for the patient as 7 out of 27 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections require appropriate surgery, not just curettage. All patients in our cohort were infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective

Introduction. Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures. Materials & Methods. A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Results. 247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames. Conclusions. Orthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation

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

Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

Background. Prospective study to compare patient reported outcome measures (PROM) for sacroiliac joint (SIJ) fusion using HA-coated screw (HACS) vs triangular titanium dowel (TTD). First study of its kind in English literature. Methods. 40 patients underwent percutaneous SIJ stabilisation using HACS and TTD was used in 70 patients. Patients were followed up closely and outcome scores were collected prospectively. PROMs were collected preoperatively and 12 months after surgery. Short Form (SF)-36, Oswestry Disability Index, EuroQol-5D-5L and Majeed Pelvic Scores were collected. Shapiro-wilk test was used to determine normality of data. Mann-whitney U test was used to compared non-parametric data and Independent sample T test for parametric data. Results. 33 patients in HACS group and 61 in TTD group completed follow-up. There was no significant difference in all preoperative PROMs in both groups hence the data was considered comparable. All postoperative PROMs were significantly higher in the TTD group. In the HACS group, 21 patients (63%) had lysis around the screw and a sub-group analysis showed that improvement in PROMs was significantly less in patients with lysis around the screw. 4 patients with lysis around the screw were offered revision due to ongoing pain. Revision was successful in only 1 patient. In TTD group only 5 patients (8.2 %) patients had radiological evidence of lysis. Relative risk of developing lysis was 6.7 times higher in HACS group. Conclusion. Percutaneous SIJ fixation procedure has been shown to have good clinical outcomes and TTD leads to significantly better patient reported outcomes compared to HACS. There is a 6.7 time higher risk of lysis with use of HACS and lysis is a risk factor for poor outcomes