A quick, portable and reliable tool for predicting ACL injury could be an invaluable instrument for athletes, coaches, and clinicians. The gold standard, Vicon motion analysis, despite having a high sensitivity and risk specificity, is not practical for coaches or clinicians to use on a routine basis for assessing athletes. The present study validated the Kinect device to the currently used method of chart review in predicting athletes at high risk.

A total of 114 participants were recruited from both the men and women McGill Varsity Sports Program. 69 males and 45 female athletes were evaluated to assess the specificity and sensitivity of the Kinect device in predicting athletes at high risk of injury. Each athlete performed three-drop vertical jumps off of a 31cm box and the data was recorded and risk score was generated. Generation of this data is done by our uniquely programmed software that measures landing angles at different time frames and compares live results to previously known data of injured athletes. A chart review was then performed by a clinician, blinded to these risk scores, to risk stratify the same athletes as high or low risk of ACL injury based on their medical charts. Data reviewed incorporated pre-season physical exams along with documented known risk factors for ACL injury, including previous knee injuries, family history of ACL injury, gender, sport, and BMI. Positive risk factors were assigned one point while negative risk factors assigned zero points.

The Kinect device, powered by our software, identified 40 athletes as having a high-risk score (> 55%), and subsequently, five (4.39%) sustained an ACL injury by the end of their respective sport seasons. Two male and two female basketball players along with one male soccer player sustained non-contact ACL injuries. Given that all five of the injured athletes were in the cohort of 40 identified as high risk by the Kinect, this yielded a sensitivity of 100% for the device. As for the specificity, the Kinect computed 35 false positives, yielding a specificity of 68% for the duration of the study. The medical chart review identified 36 athletes as high risk and 60 as being low risk of ACL injury. Four of the athletes that sustained an ACL injury were in the group of 36 identified as high risk by the clinician. However, one of the five participants who sustained an ACL injury was not captured by the medical chart assessment, yielding a sensitivity of 80% and a specificity of 65% for the clinician.

When it comes to injury prediction, it is preferred to have a high sensitivity even if the specificity is slightly lower as this ensures that all athletes who are at risk will be captured. Our data demonstrated that the chart analysis provided one false negative and led to missing one high-risk athlete who ended up sustaining an ACL injury. Based on the comparison of sensitivity and specificity, the Kinect system provides a slightly better predictive analysis for predicting ACL injury compared to chart review.

Objectives

To evaluate the neck strength of school-aged rugby players, and to define the relationship with proxy physical measures with a view to predicting neck strength.

Evidence supporting the use of virtual reality (VR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. We aimed to investigate whether spaced VR training is more effective than massed VR training. 24 medical students with no hip arthroplasty experience were randomised to learning the direct anterior approach total hip arthroplasty using the same VR simulation, training either once-weekly or once-daily for four sessions. Participants underwent a baseline physical world assessment on a saw bone pelvis. The VR program recorded procedural errors, time, assistive prompts required and hand path length across four sessions. The VR and physical world assessments were repeated at one-week, one-month, and 3 months after the last training session. Baseline characteristics between the groups were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the median ± IQR number of procedural errors from 68 ± 67.05 (session one) to 7 ± 9.75 (session four), compared to the weekly group's improvement from 63 ± 27 (session one) to 13 ± 15.75 (session four), p < 0.001. The weekly group error count plateaued remaining at 14 ± 6.75 at one-week, 16.50 ± 16.25 at one-month and 26.45 ± 22 at 3-months, p < 0.05. However, the daily group showed poorer retention with error counts rising to 16 ± 12.25 at one-week, 17.50 ± 23 at one-month and 41.45 ± 26 at 3-months, p<0.01. A similar effect was noted for the number of assistive prompts required, procedural time and hand path length. In the real-world assessment, both groups significantly improved their acetabular component positioning accuracy, and these improvements were equally maintained (p<0.01). Daily VR training facilitates faster skills acquisition; however weekly practice has superior skills retention

Abstract. Objectives. Evidence supporting the use of immersive virtual reality (iVR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. This study investigated whether spaced iVR training is more effective than massed iVR training for novices learning hip arthroplasty. Methods. 24 medical students with no hip arthroplasty experience were randomised to learning total hip arthroplasty using the same iVR simulation training either once-weekly or once-daily for four sessions. Participants underwent a baseline physical world assessment to orientate an acetabular component on a saw bone pelvis, and a baseline knowledge test. In iVR, we recorded procedural errors, time, numbers of prompts required and path lengths of the hands and head across 4 sessions. To assess skill retention, the iVR and baseline physical world assessments were repeated at one-week and one-month. Results. Baseline characteristics between the groups were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the mean number of procedural errors from 76.8±37.5 (S1) to 11.1±10.1 (S4), compared to the weekly group improvement from 71.1±19.1 (S1) to 17.2±10.6 (S4), p < 0.001. The weekly group error count plateaued remaining at 16±6.7 at 1-week and 17.5±8.5 at one-month, the daily group however, showed poor retention with error counts rising to 17.8±10.5 at 1 week and becoming higher than the weekly group at one-month to (23.2±13.0 vs 17.5±10.5). A similar effect was noted for procedural time and the number of assistive prompts. In the real-world assessment, both groups significantly improved the accuracy of their acetabular component positioning, these improvements were equally maintained. Conclusions. Daily iVR training facilitates faster skills acquisition, however weekly practice has superior skills retention. Skills learnt using both regimes demonstrate sustained transfer to the real-world

Purpose. Change of the pelvic tilt is an important factor affecting walking after total hip arthroplasty (THA). There are many reports of static evaluation of pelvic tilt by X-ray, however, there are few reports of dynamic evaluation during walking. In this study, we investigated change of pelvic tilt of THA subjects before and after operation during walking using an optical position sensor. Subjects and Methods. 5 normal volunteers (mean age 26.6 years old, Control group) and 10 patients who underwent primary THA due to unilateral osteoarthritis of the hip (mean age 61 years old, THA group) were enrolled. We have measured angle of the hip and inclination of the pelvis in the mid-stance phase of the affected limb during walking using a motion analyzer (MAC3D system) and acquired physical assessment of the hip preoperatively, 3 weeks postoperatively and 3 months postoperatively. The acquired data of inclination of the pelvis was classified as Duchenne or Trendelenburg type compared with that of normal volunteers. Result. Trendelenburg type in 6 patients and Duchenne type in 4 patients were found preoperatively with THA group. Trendelenburg type showed abductor muscle weakness and limited range of motion (ROM) in hip abduction, and Duchenne type showed a limited ROM in hip adduction with physical examination. At 3 weeks after surgery, 9 of 10 THA patients resulted in the Duchenne type. At 3 months after surgery, the inclination angle of the pelvis showed the same as that of healthy subjects in 5 of the 9 patients, in which hip abduction ROM increased and abductor muscle strength recovered among Trendelenburg type and hip adduction ROM increased among Duchenne type (Figure 1). The pelvic inclination returned to preoperative state in 4 patients, in which limitation of hip abduction ROM and abductor muscle weakness remained in Trendelenburg type preoperatively and limitation of hip adduction ROM remained in Duchenne type preoperatively (Figure 2). Discussion. As a risk factor for limping after THA, preoperative limitation of ROM in hip abduction or adduction can be related, leading to necessity of systematical estimation for ROM of the hip with physical assessment and pelvic tilt type in the mid-stance during walking prior to surgery. In addition, preoperative maximum hip adduction angle and abduction muscle strength can be affected to change of the pelvic tilt after THA. It is important to recover of these ROM and muscle strength with physical therapy for prevention of postoperative limping

Introduction. Most studies now use Patient Reported Outcome Measures (PROMS) as the preferred and only method for assessing ‘functional outcome’ following surgery. It is thought that these questionnaires accurately reflect the patient's pain and physical function. We hypothesised that comprehensive functional examination would therefore correlate strongly with PROMS following total knee arthroplasty (TKA). Methods. We prospectively assessed the function of 100 consecutive knee replacement patients, pre-operatively, then at 8, 26 and 52 weeks post-operatively. PROMS employed were the Oxford Knee Score (OKS) and the Short Form-36. Additionally, leg strength (Leg Extensor Power Rig(tm)), a validated battery of timed functional tasks (Aggregated Locomotor Function, ALF) and pain scores (numerical rating scale) were also assessed. Statistical analysis was performed using the Minitab version 15 software. Level of significance was set as p = < 0.05. Results. Seven patients were lost to follow-up, leaving 93 data sets available for analysis. All of the individual outcome measures showed statistically significant improvement between each of the assessment periods (paired sample t-test, p = < 0.05). Strong correlation was observed between the two PROMS (r = 0.74). Comparatively small correlations were identified between the PROMS and physical assessments (r = < 0.41). The pain scores correlated modestly well with the OKS (r = 0.61) but comparatively poorly with the physical assessments (r = < 0.37). Conclusion. PROMS correlate well with pain, but less well with function following TKA. These results suggest that PROMS may not fully represent actual physical function, but rather the patient's perception of their function. With the advancement of PROMS as the prime outcome measure of most studies, it is important to acknowledge that the assessment provided may be incomplete and, though a useful means of assessing large cohorts, their limitation in assessing functional outcome should be recognised

Background. There is a recent interest and focus on reducing the length of stay and early discharge after total joint replacement (TJR). However, safety criteria for same-day (SD) or next-day (ND) home discharge are not well defined. We implemented a screening questionnaire to identify patients that qualify for early home discharge. The aim of this study was to assess the efficiency of this questionnaire and short-term outcomes including re-admission and peri-operative complications after TJR. Methods. Between January 2016 and July 2017, 423 consecutive primary hip and knee arthroplasties were performed by the two senior surgeons at our institution. All cases were followed for a minimum of 3-month prospectively after institutional review board approval. Patients were divided based on using a pre-operative questionnaire to determine their disposition after surgery. Group 1 includes 121 cases as control and group 2 includes 302 cases with pre-operative questionnaire. Spinal anesthesia and multimodal pain management including peri-articular injection was used in all cases. The pre-operative questionnaire (PQ, Swiftpath, Inc) included an overall score based on age, comorbidities, body mass index, physical assessment, motivation, comprehension, family support, home setup (i.e. easy access/stairs), proximity to the hospital and lack of serious barriers to early home discharge. Patients were divided into 3 categories based on the score: SD/ND home, regular home discharge and rehabilitation/subacute nursing facility (SNF) discharge. Length of stay (LOS), post-operative complications, readmissions, and discharge destination were assessed. Correlation the questionnaire score and outcomes were assessed. Results. In group 1, 29% of the patients were discharged home after minimum 2 days after surgery with home services and 71% were discharged to short- or long-term rehabilitation center. The mean length of stay was 4.6 ± 2.5 days (range 2 to 7 days). 3% had symptomatic DVT and one patient pulmonary embolism during hospital stay, all after total knee arthroplasty. There was one re-operation for acute periprosthetic infection (0.8%), two cardiopulmonary events (1.6%), and 4 other ER visits for inadequate pain control (3%). In group 2, 51% of the patients were discharged home, 6% of which (10 patients) were same-day discharge. The mean length of stay was 2.2 ± 0.8 days (range 0 to 5 days). One patient (1%) had symptomatic DVT. There were 5 (1.6%) ER visits for wound concerns and pain. There were no acute re-admissions, infections or re-operations. Conclusions. Implementation of a screening questionnaire for SD/ND early discharge is safe and results in significant reduction of length of stay, higher discharge to home, lower rate of DVT/PE/cardiopulmonary complications and less ER visits

Several surgical techniques have been described of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeons experience with a modified surgical technique for the treatment of resistant lateral epicondylitis. Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulate developed in two patients by day ten postoperatively. One patient required further surgery for a synovial fistula which healed with no sequelae. There were no other complications following surgery. The postoperative range of motion improved in all patients but remained reduced in four patients. There was a significantly worse outcome for patients with Worker’s compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain free by twelve weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis

Introduction and Aims: Several surgical techniques have been described for the treatment of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeon’s experience, with a modified surgical technique for the treatment of resistant lateral epicondylitis. Method: Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow-up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Results: Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulae developed in two patients by day 10 post-operatively. One patient required further surgery for a synovial fistula, which healed with no sequelae. There were no other complications following surgery. The post-operative range of motion improved in all patients, but remained reduced in four patients. There was a significantly worse outcome for patients with a Workers’ compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain-free by 12 weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. Conclusion: The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis

Aims

The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected.

Physical outcome following total knee arthroplasty is variable. Satellite cells are undifferentiated myogenic precursors considered to be muscle stem cells. We hypothesised that; the recovery of muscle strength and physical function following knee arthroplasty would be influenced by the underlying number of muscle satellite cells. 16 patients provided a distal quadriceps muscle biopsy at time of surgery. Satellite cells were identified with a primary mouse antibody for Pax7 – a cytoplasmic protein marker, and the myonuclei with DAPI. Positive cells were identified on the basis of immunofluorescent staining in association with nuclear material, and confirmed by position under the basal lamina. Patient function was assessed using a validated physical assessment protocol, the Aggregated Locomotor Function (ALF) score, muscle strength assessed using the leg extensor power-rig, and clinical outcome assessed with the Oxford Knee Score (OKS) pre-operatively and at 1 year post operatively. Muscle satellite cell content varied amongst the patient group (Positive Staining Index 3.1 to 11.4). Satellite cell content at time of surgery correlated with change in outcomes between pre-operative and 1 year assessments in all assessed parameters (ALF, r = 0.31; muscle power, r = 49; OKS, r = 0.33). Regression analysis employing a forward stepwise selection technique employed satellite cell volume in models of pre-operative to 1 year change for all outcome parameters. Physical function (satellite cell content, patient age and pre-operative ALF score) adjusted R2 = 0.92; Muscle power (pre-operative power and satellite cell content) adjusted R2 = 0.38; Clinical outcome (pre-operative OKS and satellite cell content) adjusted R2 = 0.28. Muscle satellite cell content influences recovery of muscle power and physical function following total knee arthroplasty. Importantly it is also associated with change in clinical scores; suggesting it to be a biomarker for patient outcomes

Purpose and Background:. Clinical interpretations of Degenerative Lumbar Disc Disease are not described in the literature. The purpose of this study was to establish a consensus of expert clinical opinion in order to fuel further research. Methods:. A reliable and valid electronic survey was designed to include theoretical constructs relating to training and education, general knowledge, assessment and management practices. Clinicians from the Society of Back Pain Research U.K. were invited to take part. Quantitative data was collated and coded using Bristol on-line survey software, and content analysis was used to systematically code and categorize qualitative data. Results:. Respondents represented a wide range of clinical specialties. The majority graduated in the U.K. (87%), were clinically active and had greater than 9 years postgraduate clinical experience (84%). MRI (36%) and physical assessment (21%) were cited as the most important clinical assessment tools. Reduction in disc height (92%) and disc dehydration (90%) were reported as the most important variables with respect to DLDD diagnosis. The most effective treatment approaches varied from education and reassurance, pain management, cognitive behavioural approaches to core stability training and group activity. Health professionals viewed the future of care advancement in terms of improvements in patient communication (35%) and education (38%). Treatment stratification (24%) and advancing evidence based management practices through research were also regarded as essential (27%). Conclusion:. Spinal clinical experts have clear views on DLDD assessment. In terms of management the results are varied suggesting inconsistency and uncertainty

Like athletes, musicians are vulnerable to musculoskeletal injuries that can be career ending or have a severe negative financial impact. All ages are affected, with a peak incidence in the third and fourth decades. Women are slightly more likely to be affected than men. It is incumbent upon orthopaedic surgeons to be able to complete a thorough physical assessment, be aware of the risk factors associated with musculoskeletal symptoms in musicians, and have a detailed knowledge of the specific syndromes they suffer and their appropriate treatment. In this paper we review the common hand injuries that afflict musicians and discuss their treatment. Cite this article: Bone Joint J 2013;95-B:146–50

Aims

Although periacetabular osteotomies are widely used for the treatment of symptomatic dysplastic hips, long-term surgical outcomes and patient-reported outcome measures (PROMs) are still unclear. Accordingly, we assessed hip survival and PROMs at 20 years after transpositional osteotomy of the acetabulum (TOA).

Aims

The aim of this study was to compare any differences in the primary outcome (biphasic flexion knee moment during gait) of robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) at one year post-surgery.

Purpose: The aim of this study was to see if there is any relationship between a positive hamstring shift test, which is a measure of knee flexion deformity after eliminating pelvic tilt with anterior pelvic tilt during the gait cycle. Methods: We included all patients with cerebral palsy who had a gait analysis and a full physical assessment including measurement of the popliteal angle and hamstring shift test between August and December 05. The difference in measurement of knee flexion between the popliteal angle at 90 degrees and the hamstring shift test was termed hamstring length (HL). There were 33 patients of which 9 [18 limbs] were selected who fulfilled the criteria of a significant positive hamstring shift [> 10 degrees difference]. Maximum dynamic hip extension and average pelvic tilt were estimated from the gait analysis graph. SPSS13.0 was used to analyse the data. Results: Mean HL was found to be 15.28 degrees. 6 (33.3%) patients had average pelvic tilt < 5 degrees, 8 (44.4%) was between 5–10 degrees and 4 (22.2%) patients had pelvic tilt of more than 10 degrees. The data had a normal distribution. There was no co relation between HL and pelvis tilt [p value:0.363 and r= −0.228.] or between average anterior pelvic tilt and the hip fixed flexion deformity. (p=0.361). However, it was found that maximum dynamic hip extension had strong negative association with average pelvic tilt (p=0.05, r = −0.455). Conclusion: This study suggests that hamstring shift test does not have any correlation with pelvic tilt. In patients with a positive hamstring shift test, correcting the pelvic tilt will not correct the flexion deformities of the knee

Aims

The aim of this study was to compare the clinical outcomes of robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) during the first six weeks and at one year postoperatively.

Aims

We aimed to determine hip-related quality of life and clinical findings following treatment for neonatal hip instability (NHI) compared with age- and sex-matched controls. We hypothesized that NHI would predispose to hip discomfort in long-term follow-up.

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve.

Cite this article: Bone Joint Open 2020;1-6:272–280.

Introduction: The purpose was to present a new osteotomy technique (trochleoplasty) and its preliminary results for the treatment of femoral trochlear dysplasia with recurrent patellar dislocation. Methods: Between 1990 and 2002, 59 knees of 51 patients (mean age 224 years) with recurrent patellar dislocation due to femoral trochlear dysplasia were treated uniformly at a single institution with a new osteotomy technique developed by the senior author. A distally connected osteochondral flake is released from the dysplastic trochlea and refixed after the osseous trochlear groove has been reconstructed. 44 patients with 50 involved knees returned at a mean follow-up of 37 months (range 6 to 139) for a physical examination, assessment of knee pain and function, radiographic examination of the knee, and in selectived cases for CT scan, MR imaging and follow-up knee arthroscopy. Results: Postoperative complications were limited to hemarthros-1, arthrofibrosis-1, and sudeck‘s disease-1. Postoperatively, no further patellar dislocations were reported. All patients experienced a sensation of significantly improved knee stability resulting in higher levels of activity. Retropatellar pain as found in 34 knees preoperatively was better-24, unchanged-7, worse-6 (3 additional cases) after surgery. Positive apprehension sign, as preoperatively found in all patients, turned negative in all cases. Radiographically, osseous healing of the reconstructed trochlea was noted without evidence of subsequent arthrosis. MRI and knee arthroscopy including histological analysis of osteochondral biopsies did not provide any evidence for osteonecrosis or chondropathia. Conclusion: Recurrent patellar dislocation due to femoral trochlear dysplasia can be treated successfully using the presented technique of trochleoplasty