Introduction. A variety of patient reported outcome (PRO) surveys have been established and validated to evaluate the effectiveness of surgical interventions. The Hip Disability and Osteoarthritis Outcome Score (HOOS) has been validated as one method to evaluate the effectiveness of total hip arthroplasty patients. This PRO facilitates the assessment of factors that alter patient outcomes in hip arthroplasty. This retrospective study assesses the effect of psychological post-operative expectations on HOOS in total hip arthroplasty patients. In this pilot study, patient data was collected for 499 patients using the AAOS established Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) [1] and HOOS surveys. Method. Patient data was matched using similar preoperative HOOS scores to allow for comparable room for improvement in HOOS score postoperatively. These patients were placed into groups of high performers and low performers. HOOS is based on a 0 to 100 scale, 100 as the best. High performers were defined as those with a ratio of change in HOOS score between preoperative and postoperative over the highest difference in score possible (reaching a postoperative HOOS of 100) of 1. Low performers were defined as those with the aforementioned ratio, but under the value of 0.3. Using these defined groups we were able to compare the summation of patient specific MODEMS scores using a univariate regression. The HOOS growth ratio is calculated based on the following. HOOS growth ratio = (HOOS postop – HOOS preop)/(100-HOOS preop). A principal component analysis (PCA) was conducted to identify the significant group of factors that could identify changes in the outcome of 41 patients (20 low performers and 21 high performers). Results and analysis. PCA was conducted on 5 items with orthogonal rotation (varimax). The Kaiser–Meyer–Olkin measure verified the sampling adequacy for the analysis, KMO = .0.688, which is well above the acceptable limit of 0.5. Two components had eigenvalues over Kaiser's criterion of 1 and in combination explained 74.487% of the variance. The scree plot demonstrate the two components that were retained in the final analysis. Component 1 represents expected outcome measured on Household activity, sleep comfort, and expected relief; the second component was made of expected outcome based on recreation activity and expected time to return to job. The outcome of the logistic regression model indicated that the factors in the first component group could significantly identify the performance of the patients after surgery. Conclusions. In this study we used MODEMS questionnaire to find the postoperative performance outcome of the patients with THA. MODEMS has shown potential in identifying these individuals however the major component in this questionnaire were expected outcome measured on Household activity, sleep comfort, and expected relief. THis questionnaire can be used for future studies

Computer assisted surgical navigation has played an increasingly central role in total knee arthroplasty (TKA). Given the recognized importance of subtle component position changes in knee function, navigation has emerged as a promising tool for reducing the occurrence of significant malalignment. The ability of this technology to reliably measure multiple parameters intraoperatively allows analysis to possibly identify a correlation between intraoperative computer assisted surgical navigation data and functional outcomes of patients undergoing elective total knee arthroplasty.

Intraoperative navigation data was collected for 121 patients undergoing cemented, posterior stabilized TKA. Three forward stepwise regression analyses were performed to associate intraoperative coronal alignment correction, tibiofemoral external rotation, and alignment under varus and valgus stress with one year outcomes, including range of motion, Oxford and SF-36 scores.

The amount of alignment correction and the maximum flexion achieved intraoperatively were significantly correlated (p <0.05, R-sq = 13%) with clinically measured maximum flexion at one year. Maximum flexion achieved intraoperatively, external tibiofemoral rotation and maximum varus under stress were also significantly associated (p < 0.05, R-sq = 31%) with the physical component of the SF-36 outcome score.

Analyses of computer navigation in TKA to date have primarily focused on precision of sagittal plane correction. Alternatively we have identified four intraoperative parameters that correlate with functional outcome at one year. Correct intraoperative interpretation of navigation data may allow surgeons to make subtle changes in real time to produce superior short-term outcomes for patients.

Pathologies such as Scapho-Lunate Advanced Collapse (SLAC), Scaphoid Non-union Advanced Collapse (SNAC) and Kienbock's disease can lead to arthritis in the wrist. Depending on the articular surfaces that are involved, motion preserving surgical procedures can be performed. Proximal Row Carpectomy (PRC) and Four Corner Fusion (4CF) are tried and tested surgical options. However, prospective studies comparing the two methods looking at sufficient sample sizes are limited in the literature.

The purpose of this study was to prospectively compare the early results of PRC vs 4CF performed in a single centre.

Patients with wrist arthritis were prospectively enrolled (2015 to 2021) in a single centre in Vancouver, Canada. Thirty-six patients and a total of 39 wrists underwent either a PRC (n=18) or 4CF (n=21) according to pre-operative clinical, radiographical, and intra-operative assessment. Patient-Rated Wrist Evaluation (PRWE) scores were obtained preoperatively, as well as at six months and one year post operatively. Secondary outcomes were range of motion (ROM) of the wrist, grip strength, reoperation and complication rates. Statistical significance was set at p=0.05

Respectively for PRC and 4CF, the average PRWE scores at baseline were 61.64 (SD=19.62) and 63.67 (SD=20.85). There was significant improvement at the six-month mark to 38.81 (SD=22.95) (p=0.031) and 41.33 (SD=26.61) (p=0.007), then further improvement at the 12month mark to 33.11 (SD=23.42) (p=0.007) and 36.29 (SD=27.25) (p=0.002).

There was no statistical difference between the two groups at any time point.

Regarding ROM, statistical difference was seen in pronation for the PRC group at the 6month mark from an average of 72.18 deg to 61.56 deg and in flexion at the 12 month mark from 47.89 deg to 33.50 deg. All other parameters did not show statistically significant difference post operatively.

For ROM of the 4CF group, only flexion at the 12month mark showed statistically significant change from an average of 48.81 deg to 38.03 deg.

There was no statistical difference in pre-operative ROM between the two groups.

One patient in the 4CF group required a revision for delayed union, and three patients ended up with ulnar sided wrist pain.

Patients undergoing PRC and 4CF showed significant improvement in post operative PRWE scores, this reflects existing literature. For 4CF care must be taken to minimise ulnar sided wrist pain by relatively shortening the unar sided carpal column mass.

ROM analysis showed that patients lost some wrist flexion ROM post-operatively at the 12month mark with both PRC and 4CF. However, other ROM parameters were unchanged

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients

Aim. Decubitus ulcers are found in approximately 4.7% of hospitalized patients, with a higher prevalence (up to 30%) among those with spinal cord injuries. These ulcers are often associated with hip septic arthritis and/or osteomyelitis involving the femur. Girdlestone resection arthroplasty is a surgical technique used to remove affected proximal femur and acetabular tissues, resulting in a substantial defect. The vastus lateralis flap has been employed as an effective option for managing this dead space. The aim of this study was to evaluate the long-term outcomes of this procedure in a consecutive series of patients. Method. A retrospective single-center study was conducted from October 2012 to December 2022, involving 7 patients with spinal cord injuries affected by chronic severe septic hip arthritis and/or femoral head septic necrosis as a consequence of decubitus ulcers over trochanter area. All patients underwent treatment using a multidisciplinary approach by the same surgical team (orthopedic and plastic surgeons) along with infectious disease specialists. The treatment consisted of a one-stage procedure combining Girdlestone resection arthroplasty with unilateral vastus lateralis flap reconstruction, alongside targeted antibiotic therapy. Complications and postoperative outcomes were assessed and recorded. The mean follow-up period was 8 years (range 2-12). Results. Of the 7 patients, 5 were male and 2 were female, with a mean age of 50.3 years at the time of surgery. Minor wound dehiscence occurred in 28.6% of the flap sites, and 2 patients required additional revisional procedures—one for hematoma and the other for bleeding. There were no instances of flap failure, and complete wound healing was achieved in an average of 32 days (range 20-41), with the ability to load over the hip area. No cases of infection recurrence or relapse were observed. Conclusions. An aggressive surgical approach is strongly recommended for managing chronic hip septic arthritis or proximal femur osteomyelitis in patients with spinal cord injuries. A single-stage procedure combining Girdlestone resection arthroplasty with immediate vastus lateralis muscle flap reconstruction proves to be an effective strategy for dead space management and localized antibiotic delivery through the vastus muscle, giving reliable soft tissue coverage around the proximal femur to avoid the recurrence of pressure ulcers. The implementation of a standardized multidisciplinary protocol contributes significantly to the success of reconstruction efforts

Abstract. Aims. Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods. Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results. 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal technique were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion. Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures

The use of cannabis is increasingly medically relevant as it is legalized and gains acceptance more broadly. However, the effects of marijuana use on postoperative outcomes following orthopedic surgery have not been well-characterized. This study seeks to illuminate the relationship between marijuana use and the incidence postoperative complications including: DVT, PE, nonunion, and infection following common orthopedic procedures. This study was conducted using a national orthopaedic claims insurance database. We identified all patients undergoing knee arthroscopy, shoulder arthroscopy, operatively managed long bone fractures (humerus, femur, tibia and/or fibula, and radius and/or ulna), and single-level lumbar fusion. The proportion of patients within each surgery cohort who had a diagnostic code for marijuana dependence was assessed. The rates of DVT, PE, and infection within 90 days were assessed for all patients. The rate of nonunion was assessed for the long bone fracture and lumbar fusion cohorts. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities. We identified 1,113,944 knee arthroscopy, 747,938 shoulder arthroscopy, 88,891 lumbar fusion, and 37,163 long bone fracture patients. Out of the 1,987,936 patients, 24,404 patients had a diagnostic code for marijuana dependence. Within all four surgical subgroups, the marijuana dependence cohort experienced increased rates of infection, PE, and DVT, as well as increased rates of nonunion in the lumbar fusion and long bone fracture populations. In the multivariate analyses controlling for a variety of patient risk factors including tobacco use, marijuana dependence was identified as an independent risk factor for infection within all four surgical subgroups (Knee: OR 1.85, p < 0.001; Shoulder: OR 1.65, p < 0.001; Spine: OR 1.45, p < 0.001; Long bone: OR 1.28, p < 0.001), and for nonunion in the lumbar fusion (OR 1.38, p < 0.001) and long bone fracture (OR 1.31, p < 0.001) subgroups. Our data suggests that marijuana dependence may be associated with increased rates of infection and nonunion following a variety of orthopaedic procedures. During preoperative evaluation, surgeons may consider marijuana use as a potential risk factor for postoperative complications, especially within the context of marijuana legalization. Future research into this relationship is necessary

Abstract. Background. With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods. A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS). Results. 58 patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78cGy (range 11.60 to 156.01cGy) vs 121.09cGy (range 58.01 to 18.03cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow-up was 5.5 months vs 11 months in the SP and IP group respectively. Mean KOOS was 7 (range 0 to 22) at 6 months for the SP group. Conclusion. The semi extended position (SP group) leads to reduced radiation exposure because of ease of imaging. All Patients in the SP group showed improved outcomes, with shorter follow-up and fracture union. The KOOS revealed SP nail patients had minimal pain and good knee function. This study establishes a management and PROMs baseline for ongoing evaluation of SP nails

The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between catastrophizing, anxiety, depression and postoperative pain and functional outcomes following primary TJR. A prospective cohort study of preoperative TJR patients at one academic arthroplasty centre over a one-year period was conducted. Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) at preoperative assessment. Postoperative outcomes at one-year included patient perceived level of hip/knee pain using a visual analogue scale (VAS), subjective perception of function using the Oxford Hip/Knee Scores, and objective function using the Knee Society Score (KSS) and Harris Hip scores (HHS). Median regression was used to assess pattern of relationship between preoperative PCS clinically relevant catastrophizing (CRC), abnormal HADS-A, abnormal HADS-D and postoperative outcomes at one-year. Median difference and 95% confidence interval (CI) were reported. T-tests were performed to determine mean differences in postoperative outcomes among patients with PCS CRC, abnormal HADS-A, and abnormal HADS-D scores versus those with normal scores at preoperative assessment. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). Both the PCS-rumination CRC sub-domain (median difference 1, 95% CI 0.31–1.69, p=0.005) and abnormal HADS-A (median difference 1, 95% CI 0.36–1.64, p=0.002) were identified as significant predictors of one-year VAS pain. PCS-magnification CRC sub-domain was also identified as a significant predictor of KSS/HHS at one-year (median difference 1.3, 95% CI −5.23–0.11, p=0.041). Preoperative VAS pain, Oxford and HHS/KSS scores were significantly inferior in patients who had CRC PCS, abnormal HADS-A, and abnormal HADS-D scores compared to patients with normal scores. At one-year, PCS CRC patients also had significantly inferior VAS pain (p=0.001), Oxford (p < 0 .0001) and KSS/HHS (p=0.025). Abnormal HADS-A and HADS-D patients experienced significantly inferior postoperative VAS pain (HADS-A p=0.025, HADS-D p=0.030), Oxford (HADS-A p=0.001, HADS-D p=0.030), but no difference in KSS/HHS (HADS-A = 0.069, HADS-D = 0.071) compared to patients with normal PCS/HADS scores. However, patients with CRC PCS experienced significantly greater improvement in preoperative to postoperative VAS pain (p < 0 .0001), Oxford (p=0.003) and HHS/KSS (p < 0 .0001). Similarly, patients with abnormal HADS scores showed significant improvement in preoperative to one-year postoperative change scores, as compared to normal patients in VAS pain (HADS-A p=0.011, HADS-D p=0.024), KSS/HHS (HADS-A p=0.017, HADS-D p=0.031), but not Oxford (HADS-A p=0.299, HADS-D p=0.558). Patients who are anxious, depressed or who pain catastrophize have worse preoperative function and pain. Postoperatively, pain and functional outcomes are also inferior in such patients, however they do experience a significantly greater improvement in outcomes. Furthermore, it appears that rumination and anxiety traits predict pain levels postoperatively. Although these patients report higher levels of pain postoperatively, as compared to preoperative, great improvement can be expected following hip and knee TJR

Glenoid failure remains the most common mode of total shoulder arthroplasty failures. Porous tantalum metal (Trabecular Metal™, Zimmer) have grown in popularity in hip and knee arthroplasty. First-generation porous tantalum metal-backed glenoid components demonstrated metal debris, resulted in failure, and were revised to second-generation glenoid implants. Evidence for second-generation porous tantalum metal implants in shoulder arthroplasty is sparse.1–4 The purpose of this study was to assess clinical and radiographic outcomes in a series of patients with second-generation porous tantalum glenoid components at a minimum two-years postoperative. We retrospectively reviewed the clinical and radiographic outcomes of patients who received a second-generation porous tantalum glenoid component anatomic shoulder arthroplasty between May 2009 and December 2017 with minimum 24 months follow-up. The shoulder arthroplasties were performed by one of two senior fellowship-trained surgeons. We collected postoperative clinical outcome indicators: EQ5D visual analog scale (VAS), Western Ontario Osteoarthritis of the Shoulder (WOOS) Index, American Shoulder and Elbow Surgeons (ASES) Score, and Constant Score (CS). Radiographic review was performed by an independent fellowship-trained surgeon. The Endrizzi metal debris grading system1 was utilized to grade metal debris. We computed descriptive statistics and compared outcome scores between groups via the non-parametric Wilcoxon rank-sum test, with group-wise comparisons defined by: metal debris and humeral head migration (secondary analyses). Thirty-five patients [23 male (65.7%) and 12 female (34.3%)] with 40 shoulder replacements participated in the study. Forty of 61 shoulders (65.6%) had an average of 64 ± 20.3 months follow-up (range 31 to 95). Average BMI was 27.5 ± 4.4 kg/m2 (range 19.5 to 39.1). The average postoperative EQ5D VAS at final follow-up was 74.6 ± 22.5, WOOS Index 87.9 ± 16.6, ASES Score 88.3 ± 10.9, and CS 80.4 ± 13. At final follow-up, 18 of 40 shoulders (45%) had metal debris [15 of 40 (37.5%) Endrizzi grade 1 and three of 40 (7.5%) Endrizzi grade 2], and 22 of 40 shoulders (55%) did not show evidence of metal debris. There was one non-revision reoperation (open subscapularis exploration), one shoulder with anterosuperior escape, three shoulders with glenoid radiolucencies indicative of possible glenoid loosening, and nine shoulders with superior migration of the humeral head (>2mm migration at final follow-up compared to immediate postoperative). When comparing postoperative scores between patients with vs without metal debris, we found no statistically significant difference in the EQ5D VAS, WOOS Index, ASES Score and CS. On further analyses, when comparing superior migration of the humeral head and postoperative outcomes scores, we found no statistically significant difference. We report the longest published follow-up with clinical and radiographic outcomes of second-generation porous tantalum glenoid anatomic shoulder arthroplasties. In this series of patients, 45% of total shoulder arthroplasties with a second-generation porous tantalum glenoid implant had radiographic evidence of metal debris. This metal debris was not statistically associated with poorer postoperative outcomes. Further investigation and ongoing follow-up are warranted

Worldwide, it is expected that 6.3 million patients will sustain a hip fracture in 2050. Hemiarthroplasty is commonly practiced for displaced femoral neck fractures. The choice between unipolar (UH) or bipolar (BH) hemiarthroplasty is still controversial. The objective of this study was to assess the effect on hip function of BH compared to UH for a displaced femoral neck fracture in elderly patients. We conducted a systematic review and meta-analysis of randomized controlled trials comparing BH to UH. Data sources were Medline, Embase, Cochrane Library and Web of Science. All data was pooled in Review Manager (RevMan) version 5.3 software. Selection of the studies included, data abstraction, data synthesis, risk of biais and quality of evidence evaluation was done independently by two authors. Our primary outcome was postoperative hip function. Secondary outcomes were health-related quality of life (HRQoL), acetabular erosion and postoperative complications. 13 randomized controlled trials (n=2256) were eligible for the meta-analysis. There was no difference in hip function scores (standardized mean difference of 0.33 [−0.09–0.75, n=864, I. 2. = 87%,]). Patients with bipolar heads had higher Health-Related Quality of Life scores than patients with unipolar heads (mean difference in EQ-5D scores of 0.12 [0.04–0.19, n=550, I. 2. = 44%]). The use of BH decreased the incidence of acetabular erosion (relative risk of 0.37 [0.17–0.83, n=525, I. 2. = 0%]). There was no relative risk difference for mortality, dislocation, revision and infection. Due to the high heterogeneity between the studies included, it is still unclear whether patients undergoing BH have better hip function than patients undergoing UH. Although, health-related quality of life (HRQoL) may be improved. Future research could be conducted to determine whether a BH offers a better quality of life than UH to geriatric patients undergoing surgery. More precise assessment scores could be developed to better evaluate postoperative outcomes

Introduction. With many stakeholders, healthcare decisions are complex. However, patient interests should be prioritized. This maximizes healthcare value (quality divided by cost), simultaneously minimizing costs (objective) and maximizing quality (subjective). Unfortunately, even ‘high value’ procedures like total knee arthroplasty (TKA) suffer from recovery assessment subjectivity (i.e. high assessment variability) and increasing costs. High TKA costs and utilization yield high annual expenditures (∼$22B), including postoperative physical therapy (PT) accounting for ∼10% of total costs (∼$2.3B annually). Post-TKA PT is typically homogenous across subjects ensuring most recover, however recent work shows outcomes unimpacted by PT. Accordingly, opportunities exist improving healthcare value by simultaneously reducing unnecessary PT expenditures and improving outcomes. However, discerning recovery completion relies on discrete ROM measures captured clinically and subjective clinician experience (i.e. intuition about recovery). Accordingly, our goal was developing objective post-TKA performance assessment methods utilizing gait knee ROM and statistical analyses to categorize patient recovery (‘accelerated,’ ‘delayed,’ or ‘normal’). Methods. We first established statistical reasons for current post-TKA rehabilitation including risk-reward tradeoffs between incorrectly ascribing ‘poor recovery’ to well-recovering patients (T1 error) or ‘good recovery’ to poorly-recovering patients (T2 error) using methods described by Mudge et al. and known TKA volumes/rehabilitation costs. Next, previously captured gait ROM data from well-healed patients was utilized establishing standard recovery curves. These were then utilized to assess newly captured patient recovery. Following IRB approval, we prospectively captured gait ROM from 10 TKA patients (3M, 69±13 years) 1-week pre-TKA and 6-weeks immediately post-TKA. Performance was compared to recovery curves via control charts/Shewhart rules (daily performance) as well as standard deviation thresholds (weekly performance) establishing recovery as ‘accelerated,’ ‘delayed,’ or ‘normal.’ The categorization was extrapolated to US TKA population and savings/expenses quantified. Statistical analyses were performed in Minitab with statistical significance set to α<0.05. Results. Current post-TKA approach is as much PT as possible (AMPTAP). AMPTAP was confirmed statistically. Because poor recovery costs are significant, balancing T1/T2 error minimizes risk by removing T1 error risk (α=0.00) via 27 PT sessions for equal cost to one manipulation under anaesthesia (MUA). Previously captured, well-healed subject gait ROM were always normally distributed. Assessing performance via control charts showed serial ‘accelerated’/‘delayed’ recovery and would serially under/over-prescribe PT. Establishing recovery performance via ±1SD thresholds successfully evaluated 3 clinically established “poor recoverers” as ‘delayed’ and the reaming clinically established “good recoverers” as ‘normal’ or ‘accelerated’ throughout recovery. Discussion. Optimization for current AMPTAP approach, while effective reducing poor recovery risk, is a gross misuse of rehabilitation spending. Improved methods are necessary including those rooted with strong statistical foundation. Control charts are likely too fine an assessment as patient performance day-to-day is too variable resulting in clinical rehabilitation prescription over-reactions. In contrast, standard deviation thresholds likely provide a conservative approach that allows clinicians the opportunity to improve postoperative rehabilitation week-after-week throughout recovery. However, PT was not altered herein. Thus, the impact altering PT has on postoperative outcomes remains unknown. Future work should investigate how altering postoperative rehabilitation changes postoperative outcomes. For any figures or tables, please contact authors directly

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Currently, hip implant designs are evaluated experimentally using mechanical simulators or cadavers, and total hip arthroplasty (THA) postoperative outcomes are evaluated clinically using long-term follow-up. However, these evaluation techniques can be both costly and time-consuming. Neither can provide an assessment of post-operative results at the onset of implant development. More recently, a forward-solution mathematical model was developed that functions as theoretical joint simulator, providing instant feedback to designers and surgeons alike. This model has been validated by comparing the model predictions with kinematic results from fluoroscopy for both implanted and non-implanted hips and kinetics from a telemetric hip. The model allows surgical technique modifications and implant component placement under in vivo conditions. The objective of this study was to further expand the capabilities of the model to function as an intraoperative virtual surgical tool (Figure 1). This new module allows the surgeon to simulate surgery, then predict, compare, and optimize postoperative THA outcomes based on component placement, sizing choices, reaming and cutting locations, and surgical methods. This virtual surgery tool simulates the quadriceps, hamstring, gluteus, iliopsoas, tensor fasciae latae, and an adductor muscle groups, as well as the hip capsular ligament groups. The model can simulate resecting, weakening, loosening, or tightening of soft tissues based on surgical techniques. Additionally, the model can analyze a variety of activities, including gait and deep flexion activities. Initially, the virtual surgery module offers theoretical surgery tools that allow surgeons to alter surgical alignments, component designs, offsets, as well as reaming and cutting simulations. The virtual model incorporates a built-in CT scan bone database which will assist in determining muscle and ligament attachment sites as well as bony landmarks. The virtual model can be used to assist in the placement of both the femoral component and the acetabular cup (Figure 2). Moreover, once the surgeon has decided on the placements of the components, they can use the simulation capabilities to run virtual human body maneuvers based on the chosen parameters. The simulations will reveal force, contact stress, and motion predictions of the hip joint (Figure 3). The surgeon can then choose to modify the positions accordingly or proceed with the surgery. This new virtual surgical tool will allow surgeons to gain a better understanding of possible post-operative outcomes under pre-operative conditions or intra-operatively. Simulations using the virtual surgery model has revealed that improper component placement may lead to non-ideal post-operative function, which has been simulated using the model. Further evaluation is ongoing so that this new module can reveal more information pre-operatively, allowing a surgeon to gain ample information before surgery, especially with difficult and revision cases

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Previous studies have indicated that prolonged surgical time may lead to higher rates of infection following total hip arthroplasty (THA). The purpose of this study was to evaluate the influence of surgical time on 30-day complications following THA and to determine if there was a time interval associated with worse outcomes. Patients ≥18 years who underwent THA between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database using procedural codes. Patients with surgical durations >240 minutes were excluded. Patient demographics, operation length, and 30-day major and minor complications were ascertained. Multivariable regression was used to determine if the rate of complications differed depending on length of operation, while adjusting for relevant covariables, and to identify independent predictors of operation length. Covariables of interest included age, sex, American Society of Anaesthesiologists (ASA) class, smoking status, functional status, comorbidities, anesthesia type, and Body Mass Index (BMI). A total of 131,361 THA patients (average age 65 ±12 years) were identified from the database. Of these, 2,177 (1.64%) experienced a major complication, and 3,504 (2.64%) experienced a minor complication within 30-days of the initial procedure. Average operation length was 91.9 minutes (range 20 – 240 minutes). Independent predictors of prolonged operation length included overweight/obese BMI, male sex, cancer, dependent functional status, epidural anaesthetic, lower pre-operative hematocrit, and ASA class II, III or IV vs. I Alternatively, older age, current smoking, and spinal anaesthetic were associated with shorter surgical durations. Unadjusted rates of both major and minor complications were significantly higher for patients whose operation lengths were ≥ 120 minutes (P>0.001). Specifically, patients whose operations lasted ≥ 120 minutes had higher rates of septic shock, sepsis, pulmonary embolism (PE), deep vein thrombosis (DVT), urinary tract infection (UTI), renal insufficiency, surgical site infection(SSI) and wound disruption. After covariable adjustment, surgical durations of 90–119 minutes increased the risk of minor complications by 1.2 (95%Confidence interval [95%CI] 1.1–1.3), while surgical durations of 120–179 minutes increased the risk of major complications by 1.4 (95%CI 1.3 – 1.6), and minor complications by 1.4 (95%CI 1.2 – 1.5), and surgical durations ≥180 minutes increased the risk of major complications by 2.1 (95%CI 1.8 – 2.6), and minor complications by 1.9 (95%CI 1.6 – 2.3). There was no difference in the overall risk of complications for operation times lasting 20 – 39, 40 – 59, or 60 – 89 minutes (P>0.05). In terms of specific complications, operation length ≥90 minutes was determined to be an independent risk factor for deep and superficial incisional SSI, as well as wound disruption, while operation length ≥ 120 minutes was an independent risk factor for sepsis, UTI, and deep, non-incisional SSI and operation length ≥ 180 minutes was an independent risk factor for PE, DVT, and cardiac arrest (p < 0 .05). These data indicate that prolonged surgical durations may be an independent predictor of major and minor complications following THA. This suggests that quality improvements could be made to improve operating room efficiency and surgical times and therefore postoperative outcomes

Background. The JOURNEY™ II Cruciate-Retaining Total Knee System (JIICR) and the JOURNEY™ II Bi-Cruciate Stabilized Total Knee System (JIIBCS) (both, Smith & Nephew, Memphis, TN, USA) are used for the treatment of end-stage degenerative knee arthritis. Belonging to the JOURNEY family of knee implants, the relatively new devices are designed to provide guided motion. Studies suggest that long-term outcomes of robotic-assisted navigation in total knee arthroplasty (TKA) are superior to the classical approach. This is the first report describing early postoperative outcomes of the NAVIO® robotic-assisted surgical navigation using the JOURNEY™ II family of knee implants. Materials & Methods. In this ongoing study, six investigational sites in the US prospectively enrolled 122 patients (122 TKAs, 64 JIIBCS and 58 JIICR). Patients underwent TKA using the NAVIO system (Figure 1), a next-generation semi-autonomous tool that uses handheld miniaturized robotic-assisted instrumentation that the surgeon manipulates in 6 degrees of freedom, but restricts cutting to within the confines of the pre-designated resection area of the patient's bone. The primary outcome was postoperative mechanical alignment on long leg X-ray at one month postoperative compared to operative target alignment. Alignment within ±3 degrees of the target alignment was considered a success. Results. Average age was 65.7 years (range, 39–79); 60.7% were females. All patients underwent patella resurfacing. Two patients had revision prior to the one-month follow-up visit; two patients withdrew from the study. 95% (112/118) attended the one-month follow-up. Four patients were missing either baseline or follow-up long leg X-ray, resulting in 108 evaluated TKAs. Overall, 92.6% (100/108) of TKAs were within 3 degrees of the target alignment. Of these, 24.1%, 39.8-, 19.4%, and 9.3% were at 0, 1, 2, and 3 degrees of the target alignment, respectively. There were two revisions, one at 18 days postoperative and the second at 27 days postoperative. Discussion. At the one-month follow-up, the NAVIO™ Robotic Assisted TKA procedures resulted in a very high success rate of 92.6% in achieving planned mechanical alignment compared to standard instruments as historical control (73.4%) based on literature. 1. This demonstrates the improved accuracy and reliability of the NAVIO™ Robotic Assisted Surgical System for TKA procedures. For any figures or tables, please contact the authors directly

Introduction. Previous research defines the existence of a “safe zone” (SZ) pertaining to acetabular cup implantation during total hip arthroplasty (THA). It is believed that if the cup is implanted at 40°±10° inclination and 15°±10° anteversion, risk of dislocation is reduced. However, recent studies have documented that even when the acetabular cup is placed within the SZ, high incidence dislocation and instability remains due to the combination of patient-specific configuration, cup diameter, head size, and surgical approach. The SZ only investigates the angular orientation of the cup, ignoring translational location. Translational location of the cup can cause a mismatch between anatomical hip center and implanted cup center, which has not been widely explored. Objective. The objective of this study is to define a zone within which the implanted joint center can be altered with respect to the anatomical joint center but will not increase the likelihood of post-operative hip separation or dislocation. Methods. A theoretical forward solution hip model, previously validated by telemetric devices and fluoroscopy data of existing implants, was used for analysis. The model allows for modifications of implant geometries/placement and soft tissue resection to simulate various surgical conditions. For the baseline simulation, the cup center was matched to the anatomical hip joint center, calculated as the center of the best fit sphere mapping the acetabulum, and the orientation of the cup was 40°/15° (inclination/anteversion). Keeping cup orientation the same, the location of the cup was moved in 1 mm increments in all directions to identify the region where a mismatch between the two centers did not lead to separation or instability in the joint. Results. During both swing and stance phase, when the acetabular cup was placed within the optimal conic with a slant height of 5±1 mm, no hip instability or dislocation risk occurred. As the acetabular cup was translated to the boundary of the optimal conic, hip instability increased. When the acetabular cup was placed at the boundary of the optimal conic, up to 2 mm of hip separation in the lateral direction occurred during swing phase, resulting in a decrease in contact area and an increase in contact stress. As the cup was placed outside the optimal conic, severe edge loading and hip separation up to 3.5 mm occurred during swing phase. In general, this resulted in large increases in cup stress, resulting in increased risk of wear leading to early complications. Discussion. This study introduces the concept of an optimal conic in the hip joint space to reduce the incidence of dislocation and hip instability after THA. Placing the cup center within the optimal conic reduces hip instability. Moving the cup further from the anatomical hip center increases the occurrence of hip instability. Cup placement within the optimal conic and angular SZ can lead to better postoperative outcomes. For any figures or tables, please contact authors directly

Objectives. The purpose of this study was to evaluate the impact of multi-radius (MR, n=20) versus gradually reducing radius (GR, n=18) knee design on the kinematics and kinetics of the knee during level ground walking one year after total knee arthroplasty. Materials and Methods. Thirty-eight knees with end-stage knee osteoarthritis were examined before and one year after total knee arthroplasty. The groups consisted of subjects who had undergone total knee arthroplasty with a representative MR designed implant (B Braun-Aesculap Vega. ®. Knee System) and a representative GR designed implant (Depuy Attune. ®. Knee System) (Figure 1). The kinematic and kinetic parameters of knee varus angle, first peak knee adduction moment, sagittal plane knee excursion and extensor moment were evaluated during gait, as well as the spatiotemporal gait outcomes of walking speed, stride length, cadence, step length, the percentage of stance phase. Comparisons of preoperative and postoperative outcomes were done by the paired t-test. Independent t-test was also done to compare the postoperative outcomes of MR designed implant and GR designed implant. Results. In spatiotemporal parameters of GR implant group, there was an increase in walking speed, stride length and cadence (all p<0.05) and no change in step length and the percentage of stance phase postoperatively. GR implant group showed large reductions in varus angle and adduction moment (all p<0.001), a significant increase in extensor moment (p=0.01), and a small reduction in sagittal plane excursion (p=0.04) after surgery. In comparison of two groups at one year after surgery, there were no significant differences of all spatiotemporal, kinematic and kinetic parameters between two groups except varus angle. GR implant group showed more reduction in varus angle than MR implant group (p=0.01). Conclusions. Total knee arthroplasty performed with gradually reducing radius knee design reduces frontal plane loading patterns of knee varus angle and adduction moment and provided improvement in spatiotemporal parameters. Post-operatively there were no statistical differences between the MR implant group and the GR implant group in any of the kinematic and kinetic measures except knee varus angle during level ground walking

Background of study. Medial patellofemoral ligament (MPFL) reconstructions are often performed using gracilis autografts, this can be associated with donor site morbidity and complications. The use of synthetic material can circumvent a harvest operation and have previously been demonstrated to be effective in other types of reconstructive procedures and may be effective in MPFL reconstruction. We report our experience and clinical results with the use of FiberTape (FT) in MPFL reconstruction and compare it to the same surgical technique using standard autografts. Materials and Methods. Data were collected prospectively in 50 MPFL reconstructions. The first 27 underwent reconstruction using autograft; the following 23 patients were treated with FT. All patients were clinically and radiologically assessed and underwent pre- and post-operative scoring using the Kujala score, Bartlett score, Modified Tegner activity rating scale, SF 12 score and Lysholm score. Statistical significance was tested between groups using ANOVA with repeated measures. Results. There was no significant differences in the pre-operative scores between the FT and GT groups (p>0.05). Both groups showed significant improvement across all scoring modalities between pre- and post-operative periods 12, 24 and 48 months of follow-up (p<0.05). There were no significant differences in knee function scores between the GT and FT groups. Conclusion. The use of FT in MPFL reconstruction is safe and effective, it significantly improved patient's quality of life and related postoperative outcome measures. There were no significant differences in all knee scores compare to GT autografts. Tendon harvesting is unnecessary and FT is a feasible option for MPFL reconstruction