Artificial Intelligence (AI) is becoming more powerful but is barely used to counter the growth in health care burden. AI applications to increase efficiency in orthopedics are rare. We questioned if (1) we could train machine learning (ML) algorithms, based on answers from digitalized history taking questionnaires, to predict treatment of hip osteoartritis (either conservative or surgical); (2) such an algorithm could streamline clinical consultation. Multiple ML models were trained on 600 annotated (80% training, 20% test) digital history taking questionnaires, acquired before consultation. Best performing models, based on balanced accuracy and optimized automated hyperparameter tuning, were build into our daily clinical orthopedic practice. Fifty patients with hip complaints (>45 years) were prospectively predicted and planned (partly blinded, partly unblinded) for consultation with the physician assistant (conservative) or orthopedic surgeon (operative). Tailored patient information based on the prediction was automatically sent to a smartphone app. Level of evidence: IV. Random Forest and BernoulliNB were the most accurate ML models (0.75 balanced accuracy). Treatment prediction was correct in 45 out of 50 consultations (90%), p<0.0001 (sign and binomial test). Specialized consultations where conservatively predicted patients were seen by the physician assistant and surgical patients by the orthopedic surgeon were highly appreciated and effective. Treatment strategy of hip osteoartritis based on answers from digital history taking questionnaires was accurately predicted before patients entered the hospital. This can make outpatient consultation scheduling more efficient and tailor pre-consultation patient education

Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes. We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations. 13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery. With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations

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

The process of gaining informed consent can be a complex and much debated pursuit, especially within a paediatric setting. The role of the trainee surgeon and its explanation to children and their families prior to an operation has not been explored from the resident surgeons' point of view. Ten face-to-face interviews were conducted with orthopaedic surgery trainees at a tertiary level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by 3 reviewers. Three main themes were identified from the interviews. 1) Surgical trainees feel their level of participation and autonomy gradually increases dependent on their observed skills and level of training. 2) Trainees feel the consent process is adequate but acknowledge it is often purposely vague with regards to their intra-operative involvement as this is often unpredictable and it avoids patient/family anxiety. 3) Trainees believe families are aware of their participation however most likely underestimate their role during operations. Trainees in surgical specialties believe their level of autonomy is variable dependent on a number of factors and that this impacts on the ability to be more specific when gaining informed consent. This must be balanced with a family's right to an appropriate understanding of their child's operation and who is performing it. It may be that further patient education regarding trainees and their role in operations would help develop a more thorough and patient centred informed consent process

Aim. Smartphone applications have a great scope for revolutionising the medical field and are becoming increasingly utilised in clinical practice. They are advantageous as they are timesaving and readily available at the touch of a button. We reviewed all the T&O clinically relevant applications available for doctors on Apple's ‘App Store’. Methods. A search was performed using the following terms: Trauma, Orthopaedics, Ortho, Musculoskeletal and Fracture. Applications that were in any language other than English were excluded. The applications were subsequently categorised into: ‘clinical’, ‘learning and reference’, ‘hospital guidelines’ and ‘patient education’. Results. 136 of the 575 were relevant to T&O from the search conducted using the above terms. 18 of these applications were aimed at patient education and 118 were designed for use by doctors. 91 applications were for learning and referencing purposes, 4 were local hospital guidelines and only 23 were designed for use in clinical practice. 2/23 clinical applications were validated by official bodies and only 1/23 was rated by users. Conclusion. It is clear that smartphone use is becoming more popular in clinical practice; however there is a need for developers to create more validated applications of higher quality for T&O surgeons

Introduction: Physical activity is a major outcome in total hip arthroplasty (THA) and discharge criterion. Increasing immediate post-op activity may accelerate discharge, enable fast track surgery and improve general rehabilitation. Preliminary evidence (O'Halloran P.D. et al. 2015) shows that feedback via motivational interviewing can result in clinically meaningful improvements of physical activity. It was the aim of this study to use wearable sensor activity monitors to provide and study the effect of biofeedback on THA patients' activity levels. It was hypothesized that biofeedback would increase in-hospital and post-discharge activity versus controls. Methods: In this pilot study, 18 patients with osteoarthritis receiving elective primary THA followed by a rapid recovery protocol with discharge on day 3 after surgery (day 0) were randomized to the feedback group (n=9, M/F: 4:5, age 63.3 ± 5.9 years, BMI 26.9 ± 5.1) or a non-feedback control group (n=9, M/F: 0:9, age 66.9 ± 5.1 years, BMI 27.1 ± 4.0). Physical activity was measured using a wearable sensor and parameters (Time-on-Feet (ToF), steps, sit-stand-transfers (SST), mean cadence (steps/min)) were calculated using a previously validated algorithms (Matlab). For the in-hospital period data was calculated twice daily (am, ca. 8–13:00h and pm, ca. 13–20:00h) of day 1 (D1) and 2 (D2). The feedback group had parameters reported back twice (morning, lunch) using bar charts comparing visually and numerically their values (without motivational instructions) to a previously measured reference group (n=40, age 71 ±7 years, M:F 16:24) of a conventional discharge protocol (day 4/5). Activity measures continued from discharge (D3) until day 5 (D5) at home. Results: Randomization resulted in matched groups regarding age and BMI, but not gender. The first post-op activity assessment (D1am) was identical between groups. Also thereafter similar values with no significant differences in any parameter were seen, e.g. the time-on-feet at D2PM was 59.2 ±31.7min (feedback) versus 62.9 ±39.2min (controls). Also on the day of discharge and beyond, no effect from the in-hospital feedback was measured. For both groups the course of activity recovery showed a distinct drop on day 4 following a highly active day of discharge (D3). On day 5, activity levels only recovered partially. For both groups, all quantitative activity parameters were significantly higher than the reference values used for feedback. Only cadence as a qualitative measure was the same like reference values. Discussion: Biofeedback using activity values from a body-worn monitor did not increase in-hospital or immediate post-op home activity levels compared to a control group when using the investigated feedback protocol. In general, while the day of discharge steeply boosts patient activity, the day after at home results in an activity drop to near in-patient levels before discharge. In a fast track surgery protocol, it may be of value to avoid this drop via patient education or home physiotherapy. Biofeedback using activity monitors to increase immediate post-op activity for fast track surgery or improved recovery may only be effective when feedback goals are set higher, are personalised or have additional motivational context

To assess the outcome of Offloading Knee brace (V-VAS) in the treatment of osteoarthritis of the knee. A total of 147 patients with knee arthritis were included in this study. Eighty six patients were followed up retrospectively and 61 patients were followed up prospectively. Average follow up was about 3.4 years in retrospective group and 1.2 years in prospective group. The Oxford knee score, Pain score, Walking distance and Patient satisfaction were evaluated. Average oxford scores before the brace was 19 and after the brace was 32. The pain scores before and after the brace was 8 and 3 respectively. The walking distance had improved to 900 yards. The patient satisfaction was 78%. Thirteen of eighty six patients in the retrospective group discontinued the brace, of these two had high tibial osteotomy, six patients had total knee replacement, one had unicondylar knee replacement, one patient had dislocation of patella and two elderly patients were house-bound because of medical problems. The Off loading knee brace is effective in the management of osteoarthritis of the knee. Patient satisfaction is high when using the brace. However compliance may be an issue in some of the patients. Education and early appointment for brace re-fitting increases patient compliance. Bracing is a beneficial treatment for severe medial OA of the knee

3D printing and rapid prototyping in surgery is an expanding technology. It is often used for preoperative planning, procedure rehearsal and patient education. There have been recent advances in orthopaedic surgery for the development of patient specific guides and jigs. The logical next step as the technology advances is the production of custom orthopaedic implants. I aimed to use freely available open source software and online cloud 3D printing services to produce a patient specific orthopaedic implant without requiring the input of a university department, specialised equipment or implant companies. Using standard CT scan DICOM data, a 3D surface reconstruction was made of a patient's uninjured radial head using open source DICOM viewer OsiriX. This was then manipulated in other open source software packages called Meshlabs and Netfabb to create a mirror image 3D model of the radial head with a stem to produce a prosthesis suitable to replace the contralateral fractured radial head. This was then uploaded and printed in stainless steel via cloud printing service . Shapeways.com. . The model produced was an exact replication of the patient's original anatomy, except a mirror image suitable for replacement of the contralateral side. The process did not involve any specialist equipment or input from an academic department or implant company. It took a total of 10 days to produce and cost less than £40. From this study I was able to show that production of patient specific orthopaedic implants is possible. It also highlights that the technology is accessible to all, and does not require any special equipment or large investment. It can be achieved quickly and for a very small financial outlay. As a proof of concept it has been very successful

Summary Statement. We are taking very expensive cutting edge technology, usually reserved for industry, and using it with the help of open source free software and a cloud 3D printing services to produce custom and anatomically unique patient individual implants for only £32. This is approx. 1/100. th. of the traditional cost of implant production. Introduction. 3D printing and rapid prototyping in surgery is an expanding technology. It is often used for preoperative planning, procedure rehearsal and patient education. There have been recent advances in orthopaedic surgery for the development of patient specific guides and jigs. The logical next step as the technology advances is the production of custom orthopaedic implants. Our aim was to use freely available open source software, a personal computer and consumer access online cloud 3D printing services to produce an accurate patient specific orthopaedic implant without utilising specialist expertise, capital expenditure on specialist equipment or the involvement of traditional implant manufacturing companies. This was all to be done quickly, cost effectively and in department. Methods & Materials. Using standard computed tomography (CT) scan and the standard file format of digital imaging and communications in medicine (DICOM) data, a 3D surface reconstruction was made of a cadaveric radial head using the software OsiriX (DICOM image processing software for Apple OS X). This data was then processed in Meshlabs (a system for the processing and editing of unstructured 3D triangular meshes) to create a mirror image 3D model of the radial head with a stem added to produce prosthesis suitable to replace the contra lateral radial head. Both packages are distributed under open-source licensing—Lesser General Public Licence (LGPL)—and are therefore free. This was then uploaded and 3D printed using a process of selective laser sintering (SLS) in stainless steel via the commercial cloud printing service . Shapeways.com. . Results & Conclusions. The model produced was an accurate mirror image replica of the patient's original anatomy (all measurements equal +/− 0.2mm using TS411212 Digital Vernier Expert Caliper 300mm P=0.001 Showing no significant statistical difference. Production from original CT scan took a total of 10 days and the total cost including shipping was £32. This was then re-implanted in to the contra lateral cadaveric radius. We achieved our aims and goals of quick, cost effective and accurate implant creation

Consequent upon a retrospective audit of all acute tibial nail patients within GRI in 2010, it was agreed, due to variable follow-up, imaging and requirement for secondary intervention, a standardised protocol for management of acutely nailed tibial fractures within GRI was to be established. Subsequently, a Nurse Led Tibial Nail Clinic commenced in July 201. The majority of consultants (11 of 13) devolving follow up of these patients to a protocol based algorithm designed on evidence based principles and consensus expert opinion. Aims were to standardise/improve management of tibial nail patients in terms of patient education, weight bearing, imaging, follow-up intervals and also coordinate secondary intervention via a single consultant with an interest in limb reconstruction/non union. A secondary goal was to achieve measureable outcome data for this subgroup of patients. All patients underwent post operative radiographs prior to discharge, review in clinic at 10 days for wound assessment, 6 weeks for physiotherapy and 12 weeks where standard AP and lateral tibial radiographs were repeated. Patients are discharged at 12 weeks if the radiographs confirm bony healing on three cortices or more and fractures are clinically united. If not, repeat x rays are undertaken at 20 weeks. A parallel consultant led limb reconstruction clinic is available to review patients failing to demonstrate satisfactory progression to union with secondary intervention instigated thereafter as appropriate. Since commencement of the Nurse Led Tibial Nail Clinic, 60 patients have been treated with a tibial nail, 44 managed in the Tibial Nail Clinic. The mean number of radiographs has reduced from 6.4 to 3.1 per patient to discharge. Clinic visits are reduced from 6.4 to 3.9 per patient to discharge. Non compliance is low with 4.6% of patients failing to attend. Secondary interventions have been low (13%), confirming a relatively benign course of healing for most patients treated with an IM nail for acute tibial fractures. There has been one non union, no deep infections, two nail removals and one DVT. A protocol based specialist nurse led clinic is safe for patients, cost effective for the NHS and gives increased opportunity for measuring outcome and improving care in a previously heterogenously managed group of patients

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and day two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PTE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Objectives

We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change.