The purpose of this study was to compare the effect of hydrolysis time on the fixation strengths of biodegradable Inion Trinion screws, Mitek Clearfix screws and 2-0 polydioxanone sutures. Complete peripheral, vertical, longitudinal lesions in adult bovine medial menisci were repaired with either a Trinion screw, a Clearfix screw, or a 2-0 polydioxanone (PDS) vertical suture. The ultimate tensile strength of the repair was then tested immediately or after 6, 9, or 12 weeks of incubation (N=6/group/time) at 37C in a saline solution containing antibiotics, antimycotics, and protease inhibitors. Immediately after implantation, the mean failure strengths of the Trinion screw (5215 N) and 2-0 PDS suture (646 N) were significantly (P< 0.05) higher than the Clearfix screw (2610 N). At six weeks the maximum failure loads were as follows: Trinion 2611 N; Clearfix 2012 N; and 2-0 PDS suture 71 N. By 9 weeks the PDS suture lost all fixation strength. The mean maximum failure loads for the Trinion and Clearfix screws at 9 weeks (189 N and 2614 N) and at 12 weeks (165 N and 1011 N) were not statistically different (P> 0.05). Conclusions: The fixation strengths of the Trinion screw and the 2-0 polydioxanone vertical suture are significantly higher than the holding power of the Clearfix screw at time zero. Thereafter the fixation strengths of the Trinion screw and the polydioxanone suture start decreasing, and at 6 weeks no significant difference exists between the three groups. The holding power of the Trinion screw is statistically equivalent to the holding power of the Clearfix screw after 6, 9 and 12 weeks of hydrolysis.

Aims

To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery.

Introduction: Muscle strength has been incorporated in the outcome assessment tools of many joints such as the shoulder and the hand. The purpose of this study was to examine the reliability and therefore the suitability of muscle strength around the ankle joint to be incorporated in foot and ankle assessment tools.

Participants: Sixty-nine healthy volunteers participated in this study (35 females and 34 males); the average age was 35 years (range: 21 to 71 years).

Methods: Three measurements of plantar flexion strength and of dorsiflexion strength of each ankle were performed using the Nottingham Mecmesin Myometer. Measurements were repeated at 2 weeks interval. The averages from first and second occasions were statistically compared.

Results: The average plantar flexion strength was 20.2 kg (range 11 to 41 kg). The average dorsiflexion strength was 14.7 kg (range 7 to 26 kg). The ninety five percent limits of agreement were −5.9 (29%) to +5.2 (26%) kg for the planter flexion and −4.9 (33%) to +5.2 (35%) kg for dorsiflexion.

Discussion/Conclusion: Both plantar flexion and dorsiflexion strengths showed repeatability. Nevertheless, the reliability of planter flexion is higher. Furthermore, this reliability is similar to those of grip strength and shoulder abduction strength. Hence, we advise to incorporate ankle planter flexion strength in foot and ankle outcome assessment tools.

The aim was to compare the initial pull out strengths of various interference screw devices used for tibial fixation of hamstring grafts and the effect of concentric or eccentric screw position.

Quadrupled tendon grafts were harvested from freshly killed sheep. The grafts were then prepared and fixed in the distal femur using various devices (Intrafix, RCI screw, Wedge screw +/− transfix pin, screw and post) in both concentric and eccentric positions. A single load to failure test was then performed.

The highest pull out strength was with the Intrafix device inserted concentrically (mean 941N). This was significantly higher than the wedge screw inserted concentrically (737N) (p=0.015). This in turn had significantly greater initial pull out strength than the wedge eccentric with post or pin (p=0.03) and the RCI screw (464N) (p=0.00036).

In this sheep model the Intrafix device inserted concentrically had a significantly greater initial pull-out strength than the other interference screws tested. Concentric positioning of an interference screw gave significantly greater initial pullout strength of a quadruple hamstring graft than eccentric positioning. Addition of a cross pin or post made no difference to initial pullout strength.

Studies comparing the biomechanical properties of different meniscal repair systems are limited, and most have simply investigated load to failure. Meniscal tissue is highly anisotropic, and far weaker under tension in the radial direction. Loading to failure using high radially orientated loads may, therefore, not be the most physiologically relevant in-vitro test for repair of circumferential tears, and determining increases in gapping across repair sites under cyclical loading at lower loads may be of greater importance. This study aimed to determine the load to failure for 4 different meniscal repair techniques, and to assess gapping across repairs under cyclical loading.

Bovine menisci were divided vertically, 5mm from the peripheral edge to simulate a circumferential tear, and then repaired using 1 of 4 techniques: vertical loop sutures using 2-0 PDS, bioabsorbable Meniscal Arrows (Atlantech), T-Fix Suture Bars (Acufex) or Meniscal Fasteners (Mitek). 9 specimens were tested in each group using an Instron 5565 materials testing machine with Merlin control software to determine load to failure. A further 9 specimens in each group were tested by cyclical loading between 5N and 10N at 20mm/min for 25 cycles. Gapping across the repairs under cyclical loading was measured using a digital micrometer and a Differential Voltage Reluctance Transducer.

The peak load to failure values for each repair method did not appear to fit a Gaussian distribution, but were skewed to the left due to some samples failing at lower loads than the main cluster. Results were analysed using the Kruskal-Wallis test, with Dunn’s multiple comparison post test. The results for gapping across the repairs from the cyclical testing all appeared to fit the Gaussian distribution, and these were analysed by Analysis of Variance, with Tukey’s multiple comparison post test. All analysis was performed using Prism (Graph-pad) Software.

The mean loads to failure for each of the repair groups were: Sutures 72.7 N, T-Fix 49.1 N, Fasteners 40.8 N, and Arrows 34.2 N. The load to failure was significantly greater with the Suture group compared to the Arrows (p< 0.01) or the Fasteners (p< 0.05). The mean gapping across the repairs for each of the repair groups after 25 loading cycles were: Sutures 3.29mm, Arrows 2.18mm,Fasteners 3.99mm,andT-Fix 3.47mm.The mean gapping was significantly less for the Arrows compared to the Sutures (p< 0.05), the Fasteners (p< 0.01), or the T-Fix (p< 0.05).

The results confirm that meniscal repair by suturing gives the highest load to failure, but show that Arrows give superior hold under lower loads, with the least gapping across repairs under cyclical loading by this testing protocol.

Background. The purpose of this study is to evaluate the early outcomes with the use of a smartphone-based exercise and educational platform after primary total hip arthroplasty compared to a standard of care control group. Methods. A multicenter prospective randomized control trial was conducted evaluating the use of the mymobility smartphone-based care platform for primary total hip arthroplasty (THA). Patients randomized to the control group (198 patients) received the respective institution's standard of care. Those randomized to mymobility treatment group (167 patients) were provided an Apple Watch and mymobility smartphone application. The application provides pre and postoperative educational content, video directed exercise programs as well as tracks the patient's activity. Patients in the treatment group were not initially prescribed physical therapy, but could be if their surgeon deemed it necessary. Early outcomes assessed included 90-day hip range of motion, HOOS JR scores, 30-day single leg stance (SLS) and time up and go (TUG) test. We also evaluated PT utilization, THA complications associated with readmissions, ER visits not associated with readmissions, urgent care (non standard of care) visits, and physician office visits. Outcome scores include HOOS-Jr, EQ-5D-5L, single stance (SLS), Timed up and go (TUG). Satisfaction scores for the procedure and the mymobility study group were also recorded. Results. The control group was significantly younger by 3.0 years (p=0.007), but no significant difference between groups in BMI, gender or preoperative diagnosis. Postoperative PT utilization was statistically lower in the mymobility group. (P=.001). There were no statistically significant differences in complications, readmissions, or office visits. The 90-day outcomes showed no significant differences in hip flexion between controls (101.3±10.9) and mymobility (99.8 ±12) (p=0.34). HOOS JR scores were not significantly different between control group (84 ±14.5) and mymobility group (81 ±13) (p=0.15). Mean 30-day SLS time was 22.5 ±20 sec in the control group and 19.8 ±19 sec in the mymobility group (p=0.25). Mean TUG time was 14.1 ±27.4 sec for control group and 16.1 ±43.3 sec for my mobility group (p=0.7). Conclusion. The use of the mymobility care platform demonstrated similar early outcomes to traditional care models. This study showed a significant decrease in PTA utilization. Initial findings demonstrated non inferiority of the mymobility platform with regards to complications, readmissions, emergency room and urgent care visits. Strengths of this study include randomized, multicentered study design. Both groups were balanced except for age. Weakness of this study is the lack of preoperative functional testing which may influence postoperative single stance. This technology allows patients to rehabilitate on a more flexible schedule, avoid unnecessary healthcare visits as well as potentially decrease overall healthcare costs

The purpose of this study was to examine the influence of weight-bearing on the measurement of in vivo wear of total knee replacements using model-based RSA at 1 and 2 years following surgery. Model-based RSA radiographs were collected for 106 patients who underwent primary TKR at a single institution. Supine RSA radiographs were obtained post-operatively and at 6-, 12-, and 24-months. Standing (weight-bearing) RSA radiographs were obtained at 12-months (n=45) and 24-months (n=48). All patients received the same knee design with a fixed, conventional PE insert of either a cruciate retaining or posterior stabilized design. Ethics approval for this study was obtained. In order to assess in vivo wear, a highly accurate 3-dimensional virtual model of each in vivo TKA was developed. Coordinate data from RSA radiographs (mbRSA v3.41, RSACore) were applied to digital implant models to reconstruct each patient's replaced knee joint in a virtual environment (Geomagic Studio, 3D Systems). Wear was assessed volumetrically (digital model overlap) on medial and lateral condyles separately, across each follow-up. Annual rate of wear was calculated for each patient as the slope of the linear best fit between wear and time-point. The influence of weight-bearing was assessed as the difference in annual wear rate between standing and supine exams. Age, BMI, and Oxford-12 knee improvement were measured against wear rates to determine correlations. Weight bearing wear measurement was most consistent and prevalent in the medial condyle with 35% negative wear rates for the lateral condyle. For the medial condyle, standing exams revealed higher mean wear rates at 1 and 2 years, supine, 16.3 mm3/yr (SD: 27.8) and 11.2 mm3/yr (SD: 18.5) versus standing, 51.3 mm3/yr (SD: 55.9) and 32.7 mm3/yr (SD: 31.7). The addition of weight-bearing increased the measured volume of wear for 78% of patients at 1 year (Avg: 32.4 mm3/yr) and 71% of patients at 2 years (Avg: 48.9 mm3/yr). There were no significant (95% CI) correlations between patient demographics and wear rates. Volumetric, weight-bearing wear measurement of TKR using model-based RSA determined an average of 33 mm3/yr at 2 years post-surgery for a modern, non-cross-linked polyethylene bearing. This value is comparable to wear rates obtained from retrieved TKRs. Weight-bearing exams produced better wear data with fewer negative wear rates and reduced variance. Limitations of this study include: supine patient imaging performed at post-op, no knee flexion performed, unknown patient activity level, and inability to distinguish wear from plastic creep or deformation under load. Strengths of this study include: large sample size of a single TKR system, linear regression of wear measurements and no requirement for implanted RSA beads with this method. Based on these results, in vivo volumetric wear of total knee replacement polyethylene can be reliably measured using model-based RSA and weight-bearing examinations in the short- to mid–term. Further work is needed to validate the accuracy of the measurements in vivo

Purpose. The purpose of this study was to examine the influence of weight-bearing on the measurement of in vivo wear of total knee replacements using model-based RSA at 1 and 2 years following surgery. Methods. Model-based RSA radiographs were collected for 106 patients who underwent primary TKR at a single institution. Supine RSA radiographs were obtained post-operatively and at 6-, 12-, and 24-months. Standing (weight-bearing) RSA radiographs were obtained at 12-months (n=45) and 24-months (n=48). All patients received the same knee design with a fixed, conventional PE insert of either a cruciate retaining or posterior stabilized design. Ethics approval for this study was obtained. In order to assess in vivo wear, a highly accurate 3-dimensional virtual model of each in vivoTKA was developed. Coordinate data from RSA radiographs (mbRSA v3.41, RSACore) were applied to digital implant models to reconstruct each patient's replaced knee joint in a virtual environment (Geomagic Studio, 3D Systems). Wear was assessed volumetrically (digital model overlap) on medial and lateral condyles separately, across each follow-up. Annual rate of wear was calculated for each patient as the slope of the linear best fit between wear and time-point. The influence of weight-bearing was assessed as the difference in annual wear rate between standing and supine exams. Age, BMI, and Oxford-12 knee improvement were measured against wear rates to determine correlations. Results. Weight bearing wear measurement was most consistent and prevalent in the medial condyle with 0–4% of calculated wear rates being negative compared to 29–39% negative wear rates for the lateral condyle. For the medial condyle, standing exams revealed higher mean wear rates at 1 and 2 years; supine, 16.3 mm. 3. /yr (SD: 27.8) and 11.2 mm. 3. /yr (SD: 18.5) versus standing, 51.3 mm. 3. /yr (SD: 55.9) and 32.7 mm. 3. /yr (SD: 31.7). The addition of weight-bearing increased the measured volume of wear for 78% of patients at 1 year (Avg: 32.4 mm. 3. /yr) and 71% of patients at 2 years (Avg: 48.9 mm. 3. /yr). There were no significant (95% CI) correlations between patient demographics and wear rates. Discussion and Conclusion. This study demonstrated TKA wear to occur at a rate of approximately 10 mm. 3. /year and 39 mm. 3. /year in patients imaged supine versus standing, respectively, averaged over 2 years of clinical follow-up. In an effort to eliminate the effect of PE creep and deformation, wear was also calculated between 12 and 24 months as 9.3 mm. 3. (standing examinations), This value is comparable to wear rates obtained from retrieved TKRs. Weight-bearing exams produced better wear data with fewer negative wear rates and reduced variance. Limitations of this study include: supine patient imaging performed at post-op, no knee flexion performed, and unknown patient activity level. Strengths of this study include: large sample size of a single TKR system, linear regression of wear measurements and no requirement for implanted RSA beads with this method. Based on these results, in vivo volumetric wear of total knee replacement polyethylene can be reliably measured using model-based RSA and weight-bearing examinations in the short- to mid–term. For any figures or tables, please contact authors directly

Training time in Trauma & Orthopaedics is pressured. In this action research project, we develop a feedback/self-reflection model for trainers and trainees, emphasising the contribution both groups make to training, to maximise cohesion and efficacy. Starting in 2013, trainees completed anonymous feedback forms after each 6-month post. The 18-point quantitative questionnaire covers four training domains: WBA engagement, teaching/feedback, research/audit, operative training. Consultant trainers completed a once-off corresponding 18-point self-reflection questionnaire. Additionally, trainers were asked for their expectations of and advice for trainees. Individual trainer profiles were generated from trainee feedback questionnaires, allowing comparison between trainer-group-average, trainer-specific and trainer-self-reflection scores across 18 fields. Trainer profiles were uploaded to ISCP and used for recognition of trainer status for SOAR. This data provided basis for local service provision review with amendments to maximise training efficacy. Results of thematic analysis of trainer feedback was shared with the trainee group. This and subsequent group self-reflection formed the basis of our ‘Trainee Charter’. Trainee feedback illustrates high levels of satisfaction with local training (average global score 4.2/5). Strengths included ‘feedback’ and ‘operative teaching’; relative weaknesses included ‘research time’ and ‘OPD teaching’. The ‘Trainee Charter’ details specific desirable behaviours that embody eight trainee-qualities consistently identified by trainers as important, including ‘honesty’ and ‘being organised’. The charter emphasises trainee contribution to training. For the first time, trainers have the benefit of serial and individualised feedback. Trainees are better informed and empowered in relation to maximising their own training. Most importantly, both halves of the training-team are explicitly acknowledged

Introduction: Physical challenges and a long term treatment for Perthes disease can affect patients’ behaviour in their adolescence. We carried out a study to assess the long term psychosocial development of children treated non-operatively using abduction cast and brace. Methodology: 104 patients treated for Perthes disease between 1992 and 2001 were recruited for a retrospective study. Besides clinical review, patients and their main carers were asked to fill in Strengths and Difficulties Questionnaires (SDQ). SDQ included scores for total difficulties, emotional symptoms, conduct problems, hyperactivity, peer problems, social behaviour and total impact. 70 controls, matched for age and sex, attending the clinics for other unrelated pathology were requested to fill in the same questionnaires along with their main carers. Results: Data from 91 patients was available for assessment. Age at diagnosis was 1.9 to 7.3 years (median 3.9 years). Follow-up duration was 5.6 to 15.1 years (median 8.7 years). The age of subjects at final follow up was 8.9 to 20.4 years (median 15.3 years). The mean duration of treatment in abduction cast or brace was 2.4 years. 57 controls and 69 subjects were found to be low risk for emotional disorder (p> 0.05). Similarly 58 control and 74 subjects were predicted to be low risk for behavioural disorder. 16 controls and 18 subjects had medium or high risk for hyperactivity or concentration disorder (p> 0.05; student t test). There was no significant difference between the self report and parent questionnaires for difficulties or their impact. Conclusion: Perthes disease and the resultant restricted physical activities in early childhood does not affect the emotional and mental well being of patients in a long term

Introduction and Aims: Suture anchors allow consistent reattachment of tendons and ligaments to bone. Many options are available. The purpose of this study was to compare the initial strength of two rotator cuff repair techniques. The hypothesis was that rotator cuff repair strength with anchors would be inferior to transosseous sutures. Method: Eight paired shoulders with a standardised supraspinatus defect were randomised to bioabsorbable nonsuture-based anchor or transosseous suture repair. Each specimen was then subjected to a stepwise cyclic loading protocol, utilising a custom-designed loading apparatus. Repair site migration was measured using an optical measurement system, consisting of a digital camera and custom software. Mode of failure, number of cycles and load to failure were measured for 50% (5 mm) and 100% (10 mm) loss of repair. These results were correlated with bone mineral density, age and gender. Statistical analysis utilised paired t-tests and Pearson correlations. Results: The anchors failed at the anchor-tendon interface, whereas the sutures failed through the sutures. Mean values for 50 percent loss of repair were 206 ± 88 cycles and 44 ± 15 N for the sutures, and 1193 ± 252 cycles and 156 ± 20 N for the anchors (p< 0.05). The corresponding values for 100 percent loss of repair were 2458 ± 379 cycles and 294 ± 27 N for the sutures, and 2292 ± 333 cycles and 263 ± 28 N for the anchors (p> 0.05). These results may be due to the relative less deformability of the anchors. This may be relevant clinically, as in the early post-operative period, while tendon healing to bone is occurring, anchors may offer improved strength, allowing improved initial healing. Strength was unaffected by bone quality. This may be attributed to each repair failing primarily through the repair construct or at the anchor-tendon interface, and not through bone. Strengths of this study include the use of paired specimens, the stepwise cyclic loading protocol, as well as increased accuracy of our measurement system. Limitations include the use of an in vitro model, as well as a simulated, standardised rotator cuff tear. Conclusion: Repair strength with anchors was superior to sutures. Strength was unaffected by bone quality. Anchors facilitate an arthroscopic procedure, decrease operative time, and may allow a faster post-operative recovery. This study has described a new high-resolution method of measuring tendon repair failure and may be useful in future studies

Aims

The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery.

Aims

The extended wait that most patients are now experiencing for hip and knee arthroplasty has raised questions about whether reliance on waiting time as the primary driver for prioritization is ethical, and if other additional factors should be included in determining surgical priority. Our Prioritization of THose aWaiting hip and knee ArthroplastY (PATHWAY) project will explore which perioperative factors are important to consider when prioritizing those on the waiting list for hip and knee arthroplasty, and how these factors should be weighted. The final product will include a weighted benefit score that can be used to aid in surgical prioritization for those awaiting elective primary hip and knee arthroplasty.

Aims

The aim of this study was to evaluate the survival of a collarless, straight, hydroxyapatite-coated femoral stem in total hip arthroplasty (THA) at a minimum follow-up of 20 years.

Despite the vast quantities of published artificial intelligence (AI) algorithms that target trauma and orthopaedic applications, very few progress to inform clinical practice. One key reason for this is the lack of a clear pathway from development to deployment. In order to assist with this process, we have developed the Clinical Practice Integration of Artificial Intelligence (CPI-AI) framework – a five-stage approach to the clinical practice adoption of AI in the setting of trauma and orthopaedics, based on the IDEAL principles (https://www.ideal-collaboration.net/). Adherence to the framework would provide a robust evidence-based mechanism for developing trust in AI applications, where the underlying algorithms are unlikely to be fully understood by clinical teams.

Cite this article: Bone Joint Res 2024;13(9):507–512.

Aims

Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery’s outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis.

Aims

Achilles tendon re-rupture (ATRR) poses a significant risk of postoperative complication, even after a successful initial surgical repair. This study aimed to identify risk factors associated with Achilles tendon re-rupture following operative fixation.

Aims

To investigate the correlations among cytokines and regulatory T cells (T-regs) in ankylosing spondylitis (AS) patients, and their changes after anti-tumour necrosis factor-α (TNF-α) treatment.

Aims

Periprosthetic fracture and implant loosening are two of the major reasons for revision surgery of cementless implants. Optimal implant fixation with minimal bone damage is challenging in this procedure. This pilot study investigates whether vibratory implant insertion is gentler compared to consecutive single blows for acetabular component implantation in a surrogate polyurethane (PU) model.

Aims

The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support.