The modified Hedgehog technique was previously used to reattach pure chondral shear-off fragments in the pediatric knee. In the modified Hedgehog technique, the calcified side of chondral fragments is multiple times incised and trimmed obliquely for an interlocking fit in the defect site. Fibrin glue with or without sutures is subsequently applied to fix the fragment to the defect. This preliminary report further elucidates the potential of the technique by evaluation of its application in young adults using patient reported outcome measures (PROMs) and high-field Magnetic Resonance Imaging (MRI) as outcome measures. Three patients with a femoral cartilage defect (2 medial, 1 lateral), and a concomitant pure chondral corpus liberum were operatively treated by the modified Hedgehog technique. Age at surgery ranged from 20.6–21.2 years, defect size ranged from 3.8–6.0 cm2. Patients were evaluated at three months and one year after surgery by PROMs and 7.0T MRI. PROMs included the Internation Knee Documentation (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale (VAS) questionnaires. 7.0T MRI (Magnetom, Siemens Healthcare, Erlangen, Germany) using a 28-channel proton knee coil (QED, Electrodynamics LLC, Cleveland, OH) included a proton density weighted turbo spin-echo sequence with fat suppression to assess morphological tissue structure andgagCEST imaging to measure the biochemical tissue composition in terms of glycosaminoglycans (GAG). Twelve months after surgery all patients reported no pain and showed full range of motion. While PROMs at three months showed large variability between patients, one year after surgery the scores were consistently improved. Over time, morphological MRI visualized improvements in integration of the cartilage fragment with the surrounding cartilage, which was supported by biochemical MRI showing increased GAG values at the defect edges. Statistics were not applied to the results because of the small sample size. The modified Hedgehog technique in young adults with an acute onset caused by a pure chondral corpus liberum can be considered promising. The improved PROM results over time were supported by 7.0T MRI that visualized improvements in tissue structure and biochemical composition. Inclusion of more patients in future studies would allow statistical analysis and more conclusive results. The etiology of loosening and time between onset of symptoms and surgery for successful graft integration may differ between pediatric and young adult patients and is subject for future studies

Background

Assessment of functional outcome after total hip arthroplasty (THA) often involves subjective patient-reported outcome measures (PROMs) whereas analysis of gait allows more objective assessment. The aims of the study were to compare longitudinal changes of WOMAC function score and ambulatory gait analysis after THA, between patients with low and high self-reported levels of physical function.

Arthroscopic management of femoroacetabular impingement (FAI) has become the mainstay of treatment. However, chondral lesions are frequently encountered and have become a determinant of less favourable outcomes following arthroscopic intervention. The aim of this systematic review and meta-analysis was to assess the outcomes of hip arthroscopy (HA) in patients with FAI and concomitant chondral lesions classified as per Outerbridge. A systematic search was performed using the PRISMA guidelines on four databases including MEDLINE, EMBASE, Cochrane Library and Web of Science. Studies which included HA as the primary intervention for management of FAI and classified chondral lesions according to the Outerbridge classification were included. Patients treated with open procedures, for osteonecrosis, Legg-Calve-Perthes disease, and previous ipsilateral hip fractures were excluded. From a total of 863 articles, twenty-four were included for final analysis. Demographic data, PROMs, and radiological outcomes and rates of conversion to total hip arthroplasty (THA) were collected. Risk of bias was assessed using ROBINS-I. Improved post-operative PROMs included mHHS (mean difference:-2.42; 95%CI:-2.99 to −1.85; p<0.001), NAHS (mean difference:-1.73; 95%CI: −2.23 to −1.23; p<0.001), VAS (mean difference: 2.03; 95%CI: 0.93-3.13; p<0.001). Pooled rate of revision surgery was 10% (95%CI: 7%-14%). Most of this included conversion to THA, with a 7% pooled rate (95%CI: 4%-11%). Patients had worse PROMs if they underwent HA with labral debridement (p=0.015), had Outerbridge 3 and 4 lesions (p=0.012), concomitant lesions of the femoral head and acetabulum lesions (p=0.029). Reconstructive cartilage techniques were superior to microfracture (p=0.042). Even in concomitant lesions of the femoral head and acetabulum, employing either microfracture or cartilage repair/reconstruction provided a benefit in PROMs (p=0.027). Acceptable post-operative outcomes following HA with labral repair/reconstruction and cartilage repair in patients with FAI and concomitant moderate-to-severe chondral lesions, can be achieved. Patients suffering from Outerbridge 3 and 4 lesions, concomitant acetabular rim and femoral head chondral lesions that underwent HA with labral debridement, had worse PROMs. Reconstructive cartilage techniques were superior to microfracture. Even in concomitant acetabular and femoral head chondral lesions, employing either microfracture or cartilage repair/reconstruction was deemed to provide a benefit in PROMs

Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are well-established operative interventions in the treatment of knee osteoarthritis (KOA). However, which of these interventions is more beneficial, to patients with KOA, is not known and remains a topic of much debate. Aims: (i) To determine whether UKA or HTO is more beneficial in the treatment of isolated medial compartment KOA, via an assessment of patient-reported outcome measures (PROMs). (ii) To investigate the relationship between PROMs and radiographic parameters of knee joint orientation/alignment. This longitudinal observational study assessed a total of 42 patients that had undergone UKA (n=23) or HTO (n=19) to treat isolated medial compartment KOA. The PROMs assessed, pre-operatively and 1-year post-operatively, consisted of the: self-administered comorbidity questionnaire; short form-12; oxford knee score; knee injury and osteoarthritis outcome score; and the EQ-5D-5L. The radiographic parameters of knee joint alignment/orientation assessed, pre-operatively and 8-weeks post-operatively, included the: hip-knee-ankle angle; mechanical axis deviation; and the angle of the Mikulicz line. Statistical analysis demonstrated an overall significant (p<0.001), pre-operative to post-operative, improvement in the PROM scores of both groups. There were no significant differences in the post-operative PROM scores of the UKA and HTO group. Correlation analyses revealed that pre-operatively, a more distolaterally angled Mikulicz line was associated with worse knee function (p<0.05) and overall health (p<0.05); a relationship that, until now, has not been investigated nor commented upon within the literature. UKAs and HTOs are both efficacious operations that provide a comparable degree of clinical benefit to patients with isolated medial compartment KOA. To further the scientific/medical community's understanding of the factors that impact upon health-outcomes in KOA, future research should seek to investigate the mechanism underlying the relationship, between Mikulicz line and PROMs, observed within the current study

Abstract. Objectives. There is still controversy in the literature over whether Cervical Foraminotomy or Anterior Cervical discectomy and fusion (ACDF) is best for treating cervical Radiculopathy. Numerous studies have focused on the respective complication rates of these procedures and outcome measures with a lack of due consideration to preoperative MRI findings. Proximal foraminal stenosis can theoretically be accessed via either approach. We aimed to investigate whether patient reported outcome measures (PROMs) favoured one approach over the other in patients with proximal foraminal stenosis. Methods. A single centre retrospective review of patients undergoing either ACDF or Cervical foraminotomy over the period 2012 to 2022. VAS, Neck disability index (NDI), EQ5DL and Patient Satisfaction on a Five Point Likert scale were obtained. Patients who had both an ACDF and a Foraminotomy were excluded. Axial MRI images were analysed and the location of the worst clinically relevant disc herniation stratified as follows: Central (1), Paracentral (2) and Foraminal (3). Correlations and average PROMs were analysed in SPSS. Results. PROMs scores were available for 33 ACDF patients and 37 Foraminotomy patients. Average surgery time in ACDF group was 167 minutes while Foraminotomy 142 minutes. Average Length of hospital stay was 6.24 days in the Foraminotomy group and 3.54 days in the ACDF group. 18 patients were excluded due to having both surgeries (2 of which developed CSF leaks postoperatively). Of the included patients there were no postoperative complications. 13 patients in the ACDF had Central or Paracentral stenosis in addition to proximal Foraminal stenosis, 3 patients in the Foraminotomy group had some significant Paracentral herniation just before the Proximal foramen. The majority of patients in both groups had pure proximal Foraminal stenosis (N= 17 (ACDF), 20 (Foraminotomy). The results showed no significant difference in PROMs between patients who received an ACDF or a Foraminotomy for Proximal foraminal stenosis (EQ5DL, NDI, and satisfaction, P= 0.268, 0.253 and 0.327). There was no correlation between location of the stenosis and PROM scores in either group. Conclusions. Our data suggest that Proximal foraminal stenosis can be effectively addressed by either an anterior ACDF or a Foraminotomy with no difference in complication rates. Foraminotomy has the benefit of no implant cost but longer hospital stay. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. Conventional approaches (including Tobit) do not accurately account for ceiling effects in PROMs nor give uncertainty estimates. Here, a classifier neural network was used to estimate postoperative PROMs prior to surgery and compared with conventional methods. The Oxford Knee Score (OKS) and the Oxford Hip Score (OHS) were estimated with separate models. Methods. English NJR data from 2009 to 2018 was used, with 278.655 knee and 249.634 hip replacements. For both OKS and OHS estimations, the input variables included age, BMI, surgery date, sex, ASA, thromboprophylaxis, anaesthetic and preoperative PROMs responses. Bearing, fixation, head size and approach were also included for OHS and knee type for OKS estimation. A classifier neural network (NN) was compared with linear or Tobit regression, XGB and regression NN. The performance metrics were the root mean square error (RMSE), maximum absolute error (MAE) and area under curve (AUC). 95% confidence intervals were computed using 5-fold cross-validation. Results. The classifier NN and regression NN had the best RMSE, both with the same scores of 8.59±0.04 for knee and 7.88±0.04 for hip. The classifier NN had the best MAE, with 6.73±0.03 for knee and 5.73±0.03 for hip. The Tobit model was second, with 6.86±0.03 for knee and 6.00±0.01 for hip. The classifier NN had the best AUC, with (68.7±0.4)% for knee and (73.9±0.3)% for hip. The regression NN was second, with (67.1±0.3)% for knee and (71.1±0.4)% for hip. The Tobit model had the best AUC among conventional approaches, with (66.8±0.3)% for knee and (71.0±0.4)% for hip. Conclusions. The proposed model resulted in an improvement from the current state-of-the-art. Additionally, it estimates the full probability distribution of the postoperative PROMs, making it possible to know not only the estimated value but also its uncertainty

Meniscal tears are the most common injury in the knee, affecting 66/100,000 people/year. Surgical treatment includes arthroscopic meniscectomy or meniscal repair. Little is known regarding medium-term outcomes following these procedures in isolated meniscal tears. This study aims to quantitatively evaluate patients with meniscal tears, and those who have undergone meniscectomy and meniscal repair using validated patient reported outcome measures (PROMs), further exploring factors which affect surgical outcomes. This observational study screened 334 patients who underwent arthroscopic surgery at South Tyneside Hospital since August 2013. 134 patients with isolated meniscal tears were invited to complete postal PROMs. A combination of patient notes and radiological imaging was used to collect information of interest including age, gender, knee-laterality, injured meniscus, tear pattern, procedure performed, complications, and associated injuries. A total of 115 patients (pre-operative patients with current meniscal tear (n=36), meniscectomy (n=63), meniscal repair (n=16)) were included in the analysis with 96% successful PROM completion. Both meniscectomy and meniscal repairs (mean 55-months follow-up) showed better outcomes than pre-operative patients with meniscal tears. Meniscal repairs demonstrated superior outcomes across all PROMs when compared to meniscectomy, with a greater mean overall KOOS score of 17.2 (p=0.009). Factors including higher pre-operative Kellgren-Lawrence Grade, pre-operative articular cartilage lesions and bilateral meniscectomies were shown to negatively influence outcomes. Both meniscectomy and meniscal repair maintain clinical benefit at mean 55-months follow-up, affirming their use for treatment of meniscal tears. When feasible, meniscal repair should be performed preferentially over meniscectomy in isolated meniscal tears. Identified predictive factors allow adequate treatment stratification in specific patient groups

Reduction of length of stay (LOS) without compromising quality of care is a trend observed in orthopaedic departments. To achieve this goal the pathway needs to be optimised. This requires team work than can be supported by e-health solutions. The objective of this study was to assess the impact of reduction in LOS on complications and readmissions in one hospital where accelerated discharge was introduced due to the pandemic. 317 patients with primary total hip and total knee replacements treated in the same hospital between October 2018 and February 2021 were included. The patients were divided in two groups: the pre-pandemic group and the pandemic group. The discharge criteria were: patient feels comfortable with going back home, patient has enough support at home, no wound leakage, and independence in activities of daily living. No face-to-face surgeon or nurse follow-up was planned. Patients’ progress was monitored via the mobile application. The patients received information, education materials, postoperative exercises and a coaching via secure chat. The length of stay (LOS) and complications were assessed through questions in the app and patients filled in standard PROMs preoperatively, at 6 weeks and 3 months. Before the pandemic, 64.8% of the patients spent 3 nights at hospital, whereas during the pandemic, 52.0% spent only 1 night. The median value changed from 3 days to 1 day. The complication rate before the pandemic of 15% dropped to 9 % during the pandemic. The readmission rate remained stable with 4% before the pandemic and 5 % during the pandemic. No difference were observed for PROMS between groups. The results of this study showed that after a hip and knee surgery, the shortening of the LOS from three to one night resulted in less complications and a stable rate of readmissions. These results are in line with literature data on enhanced recovery after hip and knee arthroplasty. The reduction of LOS for elective knee and hip arthroplasty during the pandemic period proved safe. The concept used in this study is transferable to other hospitals, and may have economic implications through reduced hospital costs

Objectives. The patient-rated wrist evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are patient-reported outcome measures (PROMs) used for clinical and research purposes. Methodological high-quality clinimetric studies that determine the measurement properties of these PROMs when used in patients with a distal radial fracture are lacking. This study aimed to validate the PRWE and DASH in Dutch patients with a displaced distal radial fracture (DRF). Methods. The intraclass correlation coefficient (ICC) was used for test-retest reliability, between PROMs completed twice with a two-week interval at six to eight months after DRF. Internal consistency was determined using Cronbach’s α for the dimensions found in the factor analysis. The measurement error was expressed by the smallest detectable change (SDC). A semi-structured interview was conducted between eight and 12 weeks after DRF to assess the content validity. Results. A total of 119 patients (mean age 58 years (. sd. 15)), 74% female, completed PROMs at a mean time of six months (. sd. 1) post-fracture. One overall meaningful dimension was found for the PRWE and the DASH. Internal consistency was excellent for both PROMs (Cronbach’s α 0.96 (PRWE) and 0.97 (DASH)). Test-retest reliability was good for the PRWE (ICC 0.87) and excellent for the DASH (ICC 0.91). The SDC was 20 for the PRWE and 14 for the DASH. No floor or ceiling effects were found. The content validity was good for both questionnaires. Conclusion. The PRWE and DASH are valid and reliable PROMs in assessing function and disability in Dutch patients with a displaced DRF. However, due to the high SDC, the PRWE and DASH are less useful for individual patients with a distal radial fracture in clinical practice. Cite this article: Y. V. Kleinlugtenbelt, R. G. Krol, M. Bhandari, J. C. Goslings, R. W. Poolman, V. A. B. Scholtes. Are the patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) questionnaire used in distal radial fractures truly valid and reliable? Bone Joint Res 2018;7:36–45. DOI: 10.1302/2046-3758.71.BJR-2017-0081.R1

Abstract. Objectives. Outcomes following different types of surgical intervention for FAI are well reported individually but comparative data is deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyse the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO) and surgical hip dislocation (SHD). Methods. This SR was registered with PROSPERO. An electronic database search of Pubmed, Medline and EMBASE for English and German language articles over the last 20 years was carried out according to the PRISMA guidelines. We specifically analysed and compared changes in patient reported outcome measures PROMs, α-angle, rate of complications, rate of revision and conversion to total hip arthroplasty (THA). Results. A total of 48 articles included for final analysis with a total of 4384 hips in 4094 patients. All subgroups showed a significant correction in mean alpha angle post-operatively with a mean change of 28.8° (95% CI, 21°-36.5°; p <0.01) after AMO, 21.1° (95% CI, 15.1°-27°; p <0.01) after SHD and 20.39° (95% CI, 15.66°-25.12°; p <0.01) after HA. AMO group showed a significantly higher increase in PROMs (3.7; 95% CI, 3.2–4.2; p <0.01) versus arthroscopy (2.47; 95% CI, 2.22–2.73; p <0.01) and SHD (2.4; 95% CI, 1.5–3.3; p <0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. Conclusion. All three surgical approaches offered significant improvements in outcomes and radiological correction of cam deformities. All three groups showed similar rates of revision procedures and SHD had the highest rate of conversion to a THA. Revision rates was similar for all three revision procedures

Introduction and Objective. Platelet-Rich-plasma (PRP) has been used in combination with stem cells, from different sources, with encouraging results both in vitro and in vivo in osteochondral defects management. Adipose-derived Stem Cells (ADSCs) represents an ideal resource for their ease of isolation, abundance, proliferation and differentiation properties into different cell lineages. Furthermore, Stem Cells in the adipose tissue are more numerous than from other sources. Aim of this study was to evaluate the potential of ADSCs in enhancing the effect of arthroscopic mesenchymal stimulation combined with infiltration of PRP. Materials and Methods. The study includes 82 patients. 41 patients were treated with knee arthroscopy, Steadman microfractures technique and intraoperative PRP infiltration, Group A. In the Group B, 41 patients were treated knee arthroscopy, Steadman microfractures and intraoperative infiltration of PRP and ADSCs (Group B). Group A was used as a control group. Inclusion criteria were: Age between 40 and 65 years, Outerbridge grade III-IV chondral lesions, Kellegren-Lawrence Grade I-II. Patient-reported outcome measures (PROMs) evaluated with KOOS, IKDC, VAS, SF-12 were assessed pre-operatively and at 3 weeks, 6 months, 1-year post-operative. 2 patients of Group A and 3 patients of Group B, with indication of Puddu plate removal after high tibial osteotomy (HTO), underwent an arthroscopic second look, after specific informed consent obtained. On this occasion, a bioptic sample was taken from the repair tissue of the chondral lesion previously treated with Steadman microfractures. Results. PROMs showed statistically significant improvement (p <0.05) with comparable results in both groups. The histological examination of the bioptic samples in Group B showed a repair tissue similar to hyaline cartilage, according to the International Cartilage Repair Society (ICRS) Visual Histological Assessment Scale. In Group A, the repair tissue was fibrocartilaginous. Conclusions. According to the PROMs and the histological results, showing repair tissue after Steadman microfractures qualitatively similar to hyaline cartilage, the combination of ADSCs and PRP could represent an excellent support to the arthroscopic treatment of focal chondral lesions and mild to moderate osteoarthritis

Introduction and Objective. An important subset of patients is dissatisfied after total joint arthroplasty (TJA) due to residual functional impairment. This study investigated the assessment of objectively measured step-up performance following TJA, to identify patients with poor functional improvement after surgery, and to predict residual functional impairment during early postoperative rehabilitation. Secondary, longitudinal changes of block step-up (BS) transfers were compared with functional changes of subjective patient reported outcome measures (PROMs) following TJA. Materials and Methods. Patients with end stage hip or knee osteoarthritis (n = 76, m/f = 44/32; mean age = 64.4 standard deviation 9.4 years) were measured preoperatively and 3 and 12 months postoperatively. PROMs were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscore. BS transfers were assessed by wearable-derived measures of time. In our cohort, subgroups were formed based on either 1) WOMAC function score or 2) BS performance, isolating the worst performing quartile (impaired) of each measure from the better performing others (non-impaired). Subgroup comparisons were performed with the Man-Whitney-U test and Wilcoxon Signed rank test resp. Responsiveness was calculated by the effect size, correlations with Pearson's correlation coefficient. A regression analysis was conducted to investigate predictors of poor functional outcome. Results. WOMAC function scores were strongly correlated to WOMAC pain scores (Pearson's r=0.67–0.84) and moderately correlated to BS performance (Pearson's r = 0.31–0.54). Prior to surgery, no significant differences for WOMAC function scores and BS performance were found between the impaired and non-impaired subgroups. One year after TJA, our cohort performed significantly better at WOMAC and BS with largest effect size for the non-impaired subgroups (0.62 and 0.43 resp.) At 12 months postop, 56% of patients allocated to the impaired subgroup defined by WOMAC, represented the impaired subgroup defined by BS. Allocation to the impaired subgroup at 3 months postop, raised the odds for belonging to the impaired subgroup at 12 months for WOMAC with an odds ratio=19.14 (67%) and for BS with an odds ratio=4.41 (42%). Conclusions. Assessment of BS performance following TJA reveals residual functional impairment that is not captured by pain-dominated PROMs. Its additional use may help to early identify those patients at risk for a poor outcome

Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty, particularly for low volume surgeons. The recent introduction of robotic-arm assisted systems has allowed for increased accuracy, however new systems typically have learning curves. The objective of this study was to determine the learning curve of a robotic-arm assisted system for UKA. Methods A total of 152 consecutive robotic-arm assisted primary medial UKA were performed by five surgeons between 2017 and 2021. Operative times, implant positioning, reoperations and patient-reported outcome measures (PROMS; Oxford Knee Score, EuroQol-5D, and Forgotten Joint Score) were recorded. There was a learning curve of 11 cases with the system that was associated with increased operative time (13 minutes, p<0.01) and improved insert sizing over time (p=0.03). There was no difference in implant survival (98.2%) between learning and proficiency phases (p = 0.15), and no difference in survivorship between ‘high’ and ‘low’ usage surgeons (p = 0.23) at 36 months. There were no differences in PROMS related to the learning curve. This suggested that the learning curve did not lead to early adverse effects in this patient cohort. The introduction of a robotic-arm assisted UKA system led to learning curves for operative time and implant sizing, but there was no effect on patient outcomes at early follow- up. The short learning curve was independent of UKA usage and indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons

There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included pain (visual analogue scale VAS), rate of Popeye deformity, and operative time. 860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.14, 95% CI −0.04 to 0.32; p=0.13). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. There was no significant difference for pain (VAS). Tenodesis resulted in a lower rate of Popeye deformity (OR 0.29, 95% CI 0.19 to 0.45, p < 0.00001). Tenotomy demonstrated a shorter operative time (MD 15.21, 95% CI 1.06 to 29.36, p < 0.00001). Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. A large multi-centre clinical effectiveness randomised controlled trial is needed to provide clarity in this area

Introduction and Objective. There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. Materials and Methods. This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included visual analogue scale (VAS), rate of cosmetic deformity (Popeye sign), range of motion, operative time, and elbow flexion strength. Results. 751 patients from 10 RCTs demonstrated (369 tenotomy vs 382 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.17 95% CI −0.02 to 0.36, p=0.09). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. Secondary outcomes including VAS, shoulder external rotation, and elbow flexion strength did not reveal any significant difference. Tenodesis resulted in a lower rate of Popeye deformity (OR 0.27 95% CI 0.16 to 0.45, p<0.00001). Conclusions. Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. This finding was irrespective of the whether the rotator cuff was intact

Abstract. Objectives. Intra-articular corticosteroid injections (IACIs) are a well-established non-surgical treatment for the symptoms of osteoarthritis (OA), which can provide short-term improvements in pain, disability and quality of life (QoL). Many patients receive recurrent IACIs as temporary relief of their symptoms. Longer-term outcomes for recurrent IACIs remain less well-researched. This meta-analysis aimed to investigate the longer-term risks and benefits of IACIs beyond 3 months. Methods. We searched MEDLINE, EMBASE, and CENTRAL from inception to January 07, 2021, for randomised controlled trials (RCTs) where patients with OA had received recurrent IACIs. Our primary outcomes were pain and function. Secondary outcomes included QoL, disease progression, radiological changes, and adverse events. Mean differences with 95% confidence intervals were reported. Results. Ten RCTs met eligibility criteria (eight for knee OA [n=378], two for trapeziometacarpal OA [n=57]). Patients received 2–5 injections. Follow-up ranged from 6–24 months. Patients with knee OA showed mild improvement in pain at 3, 6, and 9 months but not at 12 months post-injection compared to baseline. Improvements in function were seen from 3–24 months post-injection, decreasing over time. Improvements in QoL continued at 24 months. For patients with trapeziometacarpal OA, mild improvements in pain, function, and QoL were demonstrated at 3–6 months (and 12 months for pain) compared to baseline. No serious adverse events were recorded. No studies reported on time-to-future interventions, or risk of future periprosthetic joint infection. Conclusions. Only mild improvements in pain, function, and QoL were noted after recurrent IACIs up to 6–24 months post-injection. Existing RCTs on recurrent IACI lacks sufficient follow-up data to assess disease progression and time-to-future interventions. These results will inform the RecUrrent Intra-articular Corticosteroid injections in Osteoarthritis (RUbICOn) study which aims to establish the long-term safety outcomes of IACI through data linkage of clinical practice data, hospital episode statistics, and national PROMs

Summary. Movement analysis (IMA) and activity monitoring (AM) using a body-fixed inertia-sensor can discriminate patients with ankle injuries from controls and between patients of different pathology or post-injury time. Weak correlations with PROMs show its added value in objectifying outcome assessment. Introduction. Ankle injuries often result in residual complaints calling for objective methods to score outcome alongside subjective patient-reported outcome measures (PROMs). Inertial motion analysis (IMA) and activity monitoring (AM) using a body-fixed sensor have shown clinical validity in patients suffering knee, hip and spine complaints. This study investigates the feasibility of IMA and AM 1) to differentiate patients suffering ankle injuries from healthy controls, 2) to compare different ankle injuries, 3) to monitor ankle patients during recovery. Methods. 32 patients suffering ankle problems (ankle sprain, n=17, 42 ±26yrs; operatively managed ankle fracture, n=15, 44 ±17yrs) during short-term recovery (6weeks to 3months post-trauma) were compared to 22 matched healthy controls (41 ±13yrs). Function was measured using IMA: Gait, Sit-Stand (STS) and 10s one-leg Balance test (OLB) were performed while wearing a 3D inertia-sensor at the lower back. Physical activity was measured during 4 successive days using a 3D accelerometer (AM), attached at the upper leg. Validated algorithms were used to derive motion parameters (e.g. speed for gait, bending angle for STS, sway area for OLB, # steps for AM). Moreover three ankle specific questionnaires were completed: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), Foot and Ankle Ability Measure (FAAM), AOFAS ankle-hindfoot score. Data was analysed using paired t-tests, one-way ANOVA and Pearson's r. Results. Both patient groups performed worse in function (IMA), activity (AM) and scales (PROM). Even at 3 months mean walking speed (−26%) and cadence (−9%) were slower while pelvic obliquity during ST (+18%) and sway during OLB (+230%) was higher than in controls (p<0.05). Activity was less regarding step/day (−31%) and sit-stand transfers (−11%, p<0.05). Also PROMs were significantly worse in patients (range 17–37%). Comparing in-between patients, significant differences were found in PROMs and function (IMA) with fracture patients walking slower (−30%) or showing more sway during one-legged balance (+250%). Mean activity scores (steps, bouts, cadence) were also less for fractures (p>0.05). During recovery, PROMs improved significantly, while function (IMA) and activity (AM) only showed small or selective improvements (e.g. 8° reduction in bending angle during ST, 20% increase in cadence). Only weak to moderate correlations were found between PROM, IMA (r-range: 0.32–0.79) and AM parameters (r-range: 0.31–0.71). Discussion & Conclusion. Function, physical activity and PROMs were impaired in patients with ankle injuries compared to healthy subjects, with the fracture group performing worse on IMA and PROMs than the sprain group. In this first study ever to measure activity in ankle patients, it was shown that e.g. fracture patients walk ca. half as many steps and bouts as age-matched controls even though at 6weeks they were unable to walk 20m without walking aids (floor effect of IMA function test). The lack of improvements in IMA and AM during recovery while PROMs improved significantly, together with the few and only weak-to-moderate correlations between PROMs, IMA and AM shows that subjective and objective recovery differ and highlight the added value of IMA and AM for objectifying routine clinical outcome assessment

Patient reported outcomes have become validated objective measures of success in research studies. They take time and effort to develop and administer. However, to remain relevant and universal PROMS should be gathered routinely and used to manage evidence-based change in healthcare systems. To ensure that they are adopted individual clinician involvement is key however a framework for comparison and relevance promotes engagement. Several examples will be presented of system change using PROMS and PREMS as well as using routine data to defend patient selection. How and what we present depends on whom we are expecting to influence

Background. Total Knee Replacement (TKR) is an effective treatment for knee arthritis. One long held principle of TKRs is positioning the components in alignment with the mechanical axis to restore the overall limb alignment to 180 ± 3 degrees. However, this view has been challenged recently. Given the high number of replacements performed, clarity on this integral aspect is necessary. Our objective was to investigate the association between malalignment and outcome (both PROMs and revision) following primary TKR. Metod. A systematic review of MEDLINE, CINHAL, and EMBASE was carried out to identify studies published from 2000 onwards. The study protocol including search strategy can be found on the PROSPERO database for systematic reviews. Results. From a total of 2107 citations, 18 studies, comprising of 2,214 patients, investigated the relationship between malalignment and PROMs. Overall 41 comparisons were made between a malalignment parameter and a PROM. Eleven comparisons (27%) demonstrated an association between malalignment and worse PROMs, with 30 comparisons (73%) demonstrating no association. Eight studies investigated the relationship between malalignment and revision. Four studies found an association between a measure of coronal alignment and revision rate, with four not demonstrating an association. Only one study examined axial and sagittal alignment and found an association with revision rates. Conclusion. When considering malalignment in an individual parameter, there is an inconsistent relationship with outcome. Malalignment may be related to worse outcome, but if that relationship exists it is weak and of dubious clinical significance. However, this evidence is subject to limitations mainly related to the methods of assessing alignment post operatively and by the possibility that the premise of traditional mechanical alignment is erroneous. Larger longitudinal studies with a standardised, timely, and robust method for assessing alignment outcomes are required. Level of evidence. 2a

Abstract. Objectives. 1. To investigate the effect of revision total knee replacement (TKR) on gait kinematics in patients with a primary TKR and instability.2. To compare gait kinematics between patients with a well-functioning TKR and those with a primary TKR and symptoms of instability. Methods. This single-centre observational study is following patients who have had a revision TKR due to knee instability. Data was collected pre- and post-operatively at 8–12 week follow-up. The data was compared to a control group of 18 well-functioning TKR patients. Kinematic gait data was collected during routine clinics using a treadmill-based infrared 3D system (Vicon, Oxford, UK) and a published lower limb marker-set. Patients performed 15 strides at three different speeds: 0.6mph, self-selected, and a ‘slow walk’ normalised to leg length (Froude number 0.09). PROMs questionnaires were collected. NHS ethical approval was obtained. Results. Data was collected for 18 well-functioning TKR patients and 8 revision TKR patients pre- and post-operatively, but only 5 could walk at the normalised speed. When walking at a normalised speed (Froude 0.09), patients with a TKR with instability had reduced range of knee flexion (52° (sd 14)) compared to those with a well-functioning TKR (59° (sd 11)). Short term follow-up after a revision TKR operation demonstrated a stiffer knee (45° (sd 12)). However, those with revision TKR had a more flexed knee during stance phase. Conclusions. At short-term follow-up, this cohort of revision TKR patients appear to have reduced flexion range, while remaining more flexed during stance. This may represent a less efficient gait pattern, which may also adversely affect the implant[1]. Longer term follow-up may demonstrate whether this normalises with post-operative rehabilitation. 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