Since the advent of the COVID-19 pandemic, there has been a technologically based progression to almost every sector of society. This has led to an influx of e-hailing motorcycle drivers (online based consumable transportation platforms) and thus an increase in road traffic accidents. This group experiences an abundance of Orthopaedic related trauma with a considerable economic burden. Therefore, the study aimed to determine the incidence of this study group as well as quantify the severity and cost implications thereof for the sake of public health and epidemiology. This was an observational study whereby a prospective cohort analysis was respectively conducted at a single centre to determine the incidence, of the study group, over a seven-month period. The study included any e-hailing motorcycle driver who sustained Orthopaedic related trauma, whilst on duty, within the catchment area whereas all other patients were excluded and used as a comparator. A descriptive statistical analysis was done to further delineate the severity of injury by comparing the type of injury, anatomical location injured, and management plan incurred. A total of 5096 individuals experienced Orthopaedic related trauma with 60 individuals (1.18%) being e-hailing motorcyclists who sustained injury whilst on duty. The incidence being 118 per 10000 patients. Further analysis revealed that 78.33% of the population experienced fractures or dislocations with 52.31% of these injuries requiring surgical intervention. The Upper limb (53.85%) and Lower limb (43.08%) were the most affected anatomical locations. The Orthopaedic care for this population group places a meaningful burden on the South African Health sector. These drivers work in unsafe environments and sustain high energy impacts, yet very little oversight exists. Therefore, continued research with new regulations needs to be drafted, looking into vehicle safety, working conditions, operative hours, and the need for public awareness

Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up. At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit. Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%. We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit

Integrated Regional Orthopaedic (MSK) Assessment clinics (ROAC) are now mandated in many provinces for the assessment and triage of patients referred for total joint arthroplasty (TJA). Their introduction underscores the lack of means for Primary Care Physicians (PCP) to appropriately refer patients for surgical consideration. Thus, problems arise when patients who are clear candidates for surgery are subject to a significant extra step in the care pathway by attending a ROAC while those who have insufficient problems are also seen, contributing to costs and crowding the access portal. We postulated that a patient reported outcome measure, decision aid combined with a validated grading of a weight bearing knee X-ray would provide an inexpensive yet effective tool to significantly improve the referral process for Knee OA (compared with the current mechanism). To date we have enrolled two hundred and forty-five consenting patients to the study, all referred by their PCP to the ROAC with a diagnosis of symptomatic Knee Osteoarthritis. All patients were evaluated as per the current ROAC protocol which included a medical history, physical examination and an X-ray (standing AP, lateral and patella-femoral skyline). Prior to the visit, subjects were sent a copy of a patient decision aid, Oxford Knee Score (OKS) and requested to answer whether their current clinical status described as Patient Acceptable Symptom State (PASS2) was acceptable. All radiographs were analyzed and scored for OA severity using the validated grading from 0 – 13. Of the 245 cases, 200 completed OKS and PASS2 uestionnaires and had standing X-rays for evaluation (only 120 completed the decision aid and these were left out of this report). Of the 200 included cases, 104 were referred from the ROAC to see a surgeon. In analysis, we found that a self-reported PASS 2 answer NO and an AP X-ray graded at 6 or above predicted over 75% of those patients that were referred. This represents a 3.4 greater likelihood of referral using this simple analysis. The OKS did not modify this prediction. Thus, use of a validated grading of a standing AP X-ray along with a response, ‘readiness for surgery’ indicated 75% of patients appropriate for surgical consideration. Patients with less severe gradings are likely being unnecessarily referred to ROAC leading to overuse of scarce resources, crowding the access and adding to costs, others, who score higher, are being needlessly delayed. The ability to discreetly screen for the best possible candidates should be a continued focus of ROAC and will lead to improved use of expensive resources, overall patient care and satisfaction and the provision of tools to the PCP for appropriate referral

Septic Arthritis (SA) is considered a surgical urgency/ emergency by physicians around the world. As our understanding grows, and improved diagnostic algorithms are developed, it has become apparent that competing interests in terms of accurately diagnosing concurrent osteomyelitis may supercede rapid surgical intervention when the imaging is timely. Nevertheless, even in cases of isolated SA, many patients will require repeat surgery. We aimed to assess factors which could predict this. A multicenter retrospective redcap database was created involving 20 pediatric centers from the CORTICES study group with the goal of better understanding pediatric musculoskeletal infection (PMSKI). All patients who met inclusion for the database were considered, surgeons for each site determined through imaging and chart review which patients met the diagnosis of isolated SA. Patients with concomitant abscesses or osteomyelitis were expressly excluded. Appropriate non parametric statistics were used to assess univariate significance. Multivariable logistic regression was used to assess clinical factors associated with an increased likelihood of more than one surgery. Receiver characteristics operating curve (ROC) analysis was used to determine optimal cutoffs to discriminate between children who required more than one surgery compared to those who required only one surgery. A probability algorithm was developed for the number of clinical factors present and the likelihood requiring more than one surgery following SA diagnosis. “Four hundred and fifty-four patients with isolated SA were analyzed from 20 US hospitals. Patients were 5.4 +/− 4.8 years old at admission, and the cohort was 56% male. Of the 454 patients, 47 (10.4%) needed more than one surgery. Bivariate comparisons across surgery groups found significant differences in minimum platelet count (pplatelet, a patient has a 0.3% reduction in the odds of needing more than one surgery (OR=.997; p=0.04). For each additional ten units of CRP, a patient has a 0.1% increase in the odds of needing more than one surgery (OR=1.001; p<0.001). Our predictive algorithm found that children with both risk factors had a 64% chance of requiring multiple surgeries. Higher CRP values and lower platelet values indicate more severe disease in isolated SA with a greater likelihood of repeat surgery. Higher CRP and lower platelet counts may portend multiple surgeries and caregivers of children with isolated SA should be advised as such

Introduction. Provision of prehabilitation prior to total knee arthroplasty (TKA) through a digital mobile application is a novel concept. The primary aim of our research is to determine whether provision of prehabilitation through a mobile digital application impacts length of stay (LOS), requirement for inpatient rehabilitation and hospital-associated costs after TKA. Our study hypothesis is that a mobile digital application provides a low resource, cost effective method of delivering prehabilitation prior to TKA. Methods. An observational, retrospective analysis was performed on a consecutive case series of 64 patients who underwent TKA by a single surgeon over a 21-month period. Pre operative Knee Osteoarthritis Outcome Score (KOOS) Patient Reported Outcome Measures (PROMs) were collected on all patients. The first group of patients (control) did not undergo prehabilitation, the subsequent group of patients (experimental) were offered prehabilitation through a mobile application called PhysiTrack. The experimental group were provided with progressive quadriceps and hamstring strengthening exercises, and calf and hamstring stretches. Exercises were automatically progressed after 2 weeks unless the patient requested otherwise or a physiotherapist clinically intervened. The non-compliance rate was 33% (n=11), after removing these patients from the analysis, 22 patients remained and these were age matched to 22 patients from the control group. Aside from the access to prehabilitation, all patients underwent TKA using identical surgical technique and peri-operative care regime. Length of stay data for inpatient care and rehabilitation were captured for all patients. Cost was calculated using the inpatient and rehabilitation costs provided by the hospital. Results. 44 patients were included in our final analysis. Pre operative KOOS were collected for all of the experimental group and 18 (81%) of control group. These subscores were not statistically different (p>0.05) reflecting pre operative equivalence. The average inpatient length of stay was statistically different, being 5.04 days for the control group and 4.31 days for the experimental group (p=0.01). The decision for ongoing inpatient rehabilitation (after the immediate post-operative inpatient period) was not statistically different between the groups (chi-quared p=0.07). Rehabilitation length of stay was 9.12 days in the experimental and 10.85 days in the control group (p = 0.25). The remaining outcomes were statistically significant with total length of stay 11.95 days in the control and 7.63 days in the experimental group (p=0.01) and the total cost of the hospital stay $6362.55AUD for the control and $4145.17AUD for the experimental group (p=0.01). This represents an average saving $2217.38 per patient who participated in prehabiliation prior to surgery. Conclusions. Our research shows a significant cost saving with this intervention, as measured by reduction in total length of stay in patients undergoing prehabilitation using PhysiTrack. To our knowledge, this is the first study that analyses the impact of a mobile application providing prehabilitation prior to TKA. Further work is required to determine the effect in a larger, randomised cohort of patients. Future studies should also be directed towards assessing the utility of digital prehabilitation on a per patient basis prior to total knee arthroplasty

The WHO surgical safety checklist was introduced at Derriford Hospital in 2009. Evidence of the effect on efficiency has been slow to appear in the literature. Using a standardised, locally modified WHO surgical safety checklist theatre list capacity, start and finish times as well as time between cases was measured in 4 elective orthopaedic theatres. Data from 3 successive years was analysed retrospectively: prior to checklist introduction, during checklist introduction and routine checklist use. Data was analysed using the One-Way ANOVA with post-hoc Tukey test. The number of cases per list showed a statistical difference from Year 1–2 and this increase was sustained in Year 3. The number of delayed starts showed no difference between Year 1&2, followed by a statistically significant decrease in Year 3. The number of late finishes showed a statistical difference from Year 1–2 and this decrease was sustained in Year 3. However, the number of lost minutes between cases showed no difference between Year 1&2, followed by an increase in Year 3. This study demonstrates that pre-list briefings combined with the WHO surgical checklist can improve theatre list capacity and prompt starts, reduce the number of overruns, however fails to improve turnaround time between cases

INTRODUCTION. The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient THA/TKA program are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and patients' satisfaction. METHODS. We conducted an ambidirectional single subject cohort study on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). We compared complications according to Clavien-Dindo scale and Comprehensive Complications Index (CCI), and unplanned episodes of care. Postoperative pain assessed with a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient-reported outcome measures (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated. RESULTS. Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs 4.4, p<0.001), CCI was significantly lower (12.3 vs 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced with ERAS-outpatient care (9.3 vs 26.5 MME, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner after ERAS-outpatient surgery (p<0.001), but PROMs were similar between groups at the last follow-up (p> 0.188). Patients were more satisfied with hospital stay, pain management, functional recovery, wound management, and overall experience of the ERAS-outpatient pathway and recommended it significantly more (p <0.002). DISCUSSION. Most studies comparing outpatient to inpatient programs conclude that outpatient surgeries did not increase complication or readmission rates, and, overall, were not inferior. We found that compared to std-inpatient practice, ERAS-outpatient program reduced complications by half while not resulting in more unplanned episodes of care. Moreover, it resulted in similar pain relief with fewer opioids, faster early functional recovery and higher satisfaction. Patients were significantly more inclined to recommend the ERAS-outpatient pathway after having personally experienced both outpatient and inpatient protocols. These finding are likely multifactorial and linked to the specific ERAS interventions. CONCLUSION. Results of this study highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program

Introduction:. Obesity is one of the biggest issues to harm health so as increase medical costs worldwide. Unfortunately, Japan is no exception. Under a big governmental campaign, obese rate in Japanese elderly begins to decrease very recently. However, we cannot help to have impression that our patients who undergo hip/knee replacement surgery have been getting heavier and heavier. The purpose of this study is to examine the change of body mass in our patients and find related factors. Patients and methods:. We reviewed hospital record of patients who underwent knee or hip replacement from January 1 to December 31 in 2004 or 2012. Patient who underwent either unicompartmental or total knee arthroplasty was included, however, those who went through femoral head replacement (hemiarthroplasty) was excluded from this study population. Body mass index (BMI) was calculated from body height and weight measured within a week before surgery. Unlike in United States, BMI greater than 25 is categorized as obese, and below 18.5 is considered underweight in Japan. Additionally, gender, age at surgery, operated site (hip or knee), primary surgery or revision, blood loss in operation, surgery time, anesthesia time were evaluated as co-factors. Results:. Overall, 48 patients from 2004 and 107 patients from 2012 were included to the study population. We included patients with osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN), high energy trauma, low energy trauma, and psoriatic arthritis (PSO). Mean age of patients was 66 years old in 2004, and 68 years old in 2012. Table 1 summarizes characteristics of subjects. Mean BMI of all patients in 2004 was significantly lower than the one in 2012 (23.7 vs. 25.8, p = 0.0019). Especially, BMI of patients underwent knee replacement because of OA in 2012 was significantly higher than those who went through the surgery in 2004 (p = 0.083: Table 2). Whereas, BMI of THA patient with hip OA in 2012 was not significantly higher than in 2004 (p = 0.15). Focus to OA, obese patient was 19% with hip OA and 36% with knee OA in 2004. In 2012, more than 50% of knee OA patients were obese while obese hip OA patients were a little less than half of THA participants (47%: Figure 1). Perioperative blood loss, surgery time and anesthesia time showed significant decrease from 2004 to 2012. Discussion:. Thanks to the great progress of biological treatment on RA, we perform less knee/hip replacement surgery among RA patients, and then majority of operated patients is now affected by osteoarthritis. According to a Japanese official report, obese rate of women age 40 to 69 was decreased to 23% in 2011 comparing to 24.6% in 2004. Regarding to Japanese age 70 and above, obesity rate is around 26% in both men and women, far lower than our study population of OA patients. In conclusion, BMI of our patients who underwent knee/hip replacement surgery became significantly higher during eight years and nearly half of operated knee/hip OA patients were obese last year

Introduction. There is a paucity of studies analyzing the rates of revision total knee arthroplasty in diabetic patients stratified by glycated hemoglobin levels. The purpose of this study was to: 1) determine the incidence of revision TKA; 2) correlate the percent of glycated hemoglobin with incidence of revision; and 3) determine the cause of revision in diabetic patients stratified by glycated hemoglobin level. Methods. We utilized a national private payer dataset within the PearlDiver database from 2007 to 2015 quarter 1 to determine who had diabetes and underwent TKA. There were 424,107 patients who were included in the analysis. We determined the incidence of revision TKA in the overall cohort, in addition to stratifying the incidence by glycated hemoglobin levels. To determine the effect of glycated hemoglobin levels on revision TKA rate, we performed a correlation analysis between the level of glycated hemoglobin and the incidence of revision TKA. We performed descriptive statistics of the underlying cause of revision TKA in both the overall and stratified cohorts. Results. There was a 3.2% incidence of revision in the overall cohort. When stratified by glycated hemoglobin levels, the cohort in the 6.6 to 7.0% category had the lowest incidence of revision (2.9%). The cohorts in the 8.6 to 9%, 5.1 to 5.5%, and 4.6 to 5%, glycated hemoglobin categories had the highest revision rates of 3.7, 3.7 and 4.7%, respectively. There was a significantly positive correlation between rate of revision and ascending glycated hemoglobin levels, and significantly negative correlation between descending glycated hemoglobin levels and revision incidence. The most common cause of revision was infection in the overall and stratified groups. Conclusion. Sub-optimal glycated hemoglobin levels in diabetic patients correlated with increase revision rates in those who underwent TKA. This may imply that management of blood glucose levels should be optimized before undergoing total knee arthroplasty to minimize revision surgery risk

Introduction. Female gender, old age (men >60y and women > 55y), severe acetabular dysplasia, poor proximal femoral bone geometry, large (>1cm) femoral head cysts, limb-length discrepancy (> 2cm) and small prosthetic head size (less than 50mm for men and less than 46mm for women) are risk factors for hip resurfacing arthroplasty (HRA). Purpose. To present clinical and radiographic results of HRA in patients having risk factors. Patients and methods: A total of 39 HRA was inserted in 33 patients (11 men and 22 women). Birmingham hip resurfacing (Smith & Nephew, UK) was used in 9 hips and Adept (Finsbury, UK) was used in 30 hips. Among the 30 hips inserted Adept, 11 cups were fixed with rim screws. The mean age of the patients at the time of operation was 52 years. The mean weight and height of the male and female patients were 70.4kg and 167cm, 58.5kg and 154.4cm, respectively. The median head size of the male and female patients was 50mm and 42mm, respectively. Preoperative diagnosis was primary osteoarthritis in 6 hips and secondary osteoarthritis due to aceatbular dysplasia (DDH) in 33 hips. Risk factors of HRA were listed for each patient. The Harris hip score and visual analogue pain scale (VAS) were measures of clinical outcome. Radiographic review was performed retrospectively. MRI and CT images were acquired in 29 hips and 2 hips, respectively, at a mean of 4.8 years after HRA to find periprosthetic soft tissue abnormality such as a psedotumor. Kaplan-Meier method was used to calculate implant survivorship. Results. Two hips had no risk factor, whereas 37 hips had at least one risk factor. Risk factors were listed as follows: female gender in 27, old age in nine, severe acetabular dysplasia in 25, poor proximal femoral bone geometry in 11, head cysts in 13, limb-length discrepancy in three and small head size in 21. There were two revisions in two men. One hip was revised because of acute infection. The patient had a risk factor (old age). Another hip was revised because of cup loosening. The patient had two risk factors (severe acetabular dysplasia and small head size). The mean follow-up period for unrevised hips was 5 years (range, 2 to 8 years). The Harris hip score improved from 47.3 points preoperatively to 96.5 points at the latest follow-up (p<0.001). VAS improved from 65 preoperatively to 5 at the latest follow-up (p<0.001). Using revision for any reason as the endpoint, the Kaplan-Meier survivorship was 94.9% at 5years. No implant was loose at the latest radiographic examination. MRI and CT of the hip revealed no pseudotumor. Discussion. In this series, only two patients had no risk factor for HRA. Although majority of our patients were women with acetabular dysplasia and small head size, clinical and radiographic results of HRA were good up to five years (Figs 1 and 2: pre- and post-operative X-ray of 49y women having five risk factors). Conclusion. Clinical and radiographic results of HRA were good in patients who have risk factors

Introduction

In total knee arthroplasty (TKA), component realignment with bone-based surgical correction (BBSC) can provide soft tissue balance and avoid the unpredictability of soft tissue releases (STR) and potential for more post-operative pain. Robotic-assisted TKA enhances the ability to accurately control bone resection and implant position. The purpose of this study was to identify preoperative and intraoperative predictors for soft tissue release where maximum use of component realignment was desired.

[Objective]. The objectives of this study are to measure the morphometric parameters of pre-operative distal femur in Japanese patients who received TKA, to investigate the differences in distal femoral anatomy between the genders, and to compare the measurements with the dimensions of femoral implants current used in Japan. [Methods]. One-hundred seventy-nine Japanese patients who underwent TKA in Osaka Koseinenkin Hospital from April, 2009 to December, 2011 were included in this study. The genders and diagnoses were 25/ 154 patients (male/ female) and 143/ 36 patients [osteoarthritis (OA)/ rheumatoid arthritis (RA)], respectively. The mean age, height and body weight were 73.2 years, 152.2 cm and 56.7 kg, respectively. We measured the AP length, ML width, aspect ratio angle of distal femur. The measurement points on the medial condyle was 10 mm and on the lateral condyle was 8 mm from the lowest points of the medial and lateral posterior condyle to stimulate the optimal cutting thickness. We evaluated the relationship between AP length and ML width, or aspect ratio and ML width in diagnosis, alignment and gender. We also compared the measurements with the dimensions of femoral implants current used in Japan. Continuous variables were assessed using the Mann-Whitney's U test. Relationship between AP length and ML width, or aspect ratio and ML width were assessed using simple regression analysis. Regression lines were assessed using analysis of covariance. For all tests, probability values (p values) of < 0.05 were considered to indicate statistical significance. [Results]. The mean AP length, ML width, aspect ratio, SEA/PCA angle and Whiteside/SEA angle were 58.8 mm, 64.7 mm, 0.91, 3.5 degrees of external rotation and 1.6 degrees of external rotation, respectively. The both relationship between AP length and ML width, and aspect ratio and ML width were significant (p < 0.001). As the ML width was getting longer, AP length was getting shorter and aspect ratio was getting lower. Although analysis of covariance between OA and RA in the relationship between aspect ratio and ML width was not significant (p = 0.955), that of valgus alignment [femorotibial angle (FTA) < 170 degrees] and varus alignment (FTA > 176 degrees) were significant (p = 0.003). The AP length, ML width in male (63.6 mm, 72.7 mm) were longer than those in female (58.1 mm, 63.4 mm), and aspect ratio in male (0.88) were lower than that in female (0.92) significantly (all p < 0.001). Although analysis of covariance between male and female in the relationship between AP length and ML width, and aspect ratio and ML width were not significant (p = 0.985 and 0.555). [Conclusion]. The aspect ratio showed a higher ratio for smaller knees and a proportionally lower ratio for lager knees in Japanese. The tendency of aspect ratio change with ML width was different between valgus and varus alignment. As the tendency of aspect ratio change with ML width was not different between male and female, the gender difference of aspect ratio was related to the difference of skeleton size (ML width) between male and female

Purpose. Surgical complications are common and frequently preventable. The introduction of the WHO Surgical Safety Checklist has improved surgical outcomes. WHO guidelines reduce, but do not prevent errors. Successful arthroplasty surgery requires strict infection control measures. We observed a single surgical team to see if errors caused by operating room personnel were covered by the WHO Checklist. Method. Two independent observers studied compliance of WHO Checklists and operating room etiquette, for one surgical team. All operating room personnel were observed during thirteen arthroplasties (hips and knees) from induction to recovery. All Personnel were blinded to the purpose of this study. Data was categorised into errors with WHO checklists and operating room etiquette. Results. 120 errors were observed in thirteen cases, none of these errors affected patient outcome and they were all corrected promptly. 113 (94%) were operating room etiquette errors and 7 (6%) were WHO checklist errors. Types of operating room etiquette errors which occurred were 32% laminar flow errors, 27% sterility errors and 20% operating room attire errors. Eleven arthroplasties were signed off as WHO Checklist compliant and two arthroplasties were observed prior to the introduction of WHO checklists. Despite going through the checklist, in seven of the eleven cases subsequent errors were found which should have been identified during the initial surgical pause: two imaging errors, two implant error and three other patient safety errors. Conclusion. The majority of errors are breaches of operating room etiquette, all being infection control issues in arthroplasty procedures. Many of these errors are not covered by the WHO Checklists. Standardised teaching of operating room etiquette may reduce these. The development of a specific arthroplasty checklist may optimise patient safety

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p< 0.05) and 6 weeks follow-up 64.0° vs 97.3° (p< 0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p< 0.0025), those 3–12 months (42 patients) from 67° to 83.0° (p< 0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p< 0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA following primary TKA improves their range of motion if done within 12 months, however only 50% improvement is maintained. Patients with less than 75° flexion at discharge or those on warfarin therapy are likely to require a manipulation to improve their range of movement

Three important objectives in knee arthroplasty are improving outcome, providing stability and obtaining correct alignment. Alignment has always been described either by anatomically measured alignment (short films, Knee Society Radiologic Score) or by mechanically measured alignment (HKA angle on long leg films). The difficulty of obtaining correct alignment in knee arthroplasty, is that as surgeons we need to find and use anatomical axes and landmarks, in the arthritic and often deformed knee, to align the implant well mechanically. Conventional instruments do the job well for 2/3 of patients, but for 1/3 we need some additional help. Navigation and patient-specific instruments (PSI) should make us more accurate surgeons.

Introduction. Anterior cruciate ligament (ACL) rupture is a common sporting injury, often managed surgically with patella-tendon or hamstrings autograft. Surgeons are under increasing pressure for open transparent assessment of their performance. Scoring systems can be used to assess outcome. More than 50 different scoring systems have been identified to assess the ACL deficient knee. Aims. The survey is investigating the use of ACL scoring systems between knee surgeons in the United Kingdom as a method of assessing performance. Method. 134 knee surgeons in the United Kingdom, performing ACL reconstruction, were asked to complete a written questionnaire regarding their use of scoring systems & outcome measures. Written questionnaires were sent and responses were received by post. Results. 81 (60%) surgeons responded to the questionnaire by stating their preferred scoring system. 40 (49%) surgeons routinely use ACL scoring systems versus 41 (51%) surgeons who do not. The Lysholm (I and II) knee scoring scale (80%) and Tegner activity score (67.5%) were most commonly used (57.5% both of them) followed by the Knee injury and osteoarthritis outcome score (KOOS) (30%), International Knee Documentation Committee (IKDC) subjective knee score (22.5%), Medical Outcome Study 12 Item Short Form (SF12) (20%), the Medical Outcome Study 36 Item Short Form (SF 36) (12.5%), Cincinnati Knee Scoring System (10%), and ACL Quality of Life scoring system (7.5%). Recommendations. The routine use of ACL scoring systems by 49% of surgeons raises the question - should all surgeons be using scoring systems in their ACL practice? This would be relatively easy to do as most patients are followed up post operatively for 6 months. This will help to adopt a transparent assessment of the performance of every consultant to the procedure they perform

Increased knee flexion is seen as a primary goal in achieving a better functional outcome following TKR. However, the relationship between passive knee flexion and biomechanical outcome remains unclear. The aim of this study was to compare kinematic outcomes in TKR patients and controls during high flexion activities. A three dimensional motion analysis system and two force platforms were used to collect kinematic and kinetic data from 40 patients who had undergone total knee replacement at least 12 months previously and 40 controls who were matched to the patients for age and gender. Participants completed the following activities six times: standing from a seated position, squatting, and lunging with each leg leading. Peak knee flexion angles and moments were compared between groups using t-tests and the correlations between passive knee flexion and functional knee flexion were calculated using ‘Pearson's r’. For both squatting and lunging, peak knee flexion in the TKR group was significantly less than in the control group. There was no difference between the two groups for the sit to stand activity as peak flexion for this activity was primarily determined by the chair height. Squat: control 124, TKR 91 (p<0.001) Lunge - op. forward: control 100, TKR 81 (p<0.001) Lunge - op. trail: control 106, TKR 84 (p<0.001) Sit to stand: control 87, TKR 85 (p=0.5). Although there were significant correlations between functional and passive knee flexion in the TKR group for the squatting and lunging activities, the patients used only approximately 70 to 75% of their available flexion during these activities. As anticipated, there was only a weak correlation between passive and functional flexion for the sit to stand activity. Percentage of passive flexion used: squat: 77%, lunge - op. forward: 68%, lunge - op. trail: 70% Sit to stand: 71%, Correlations: squat: 0.50, lunge - op. forward: 0.57, lunge - op. trail: 0.50, Sit to stand: 0.27. Normal sagittal knee kinematics during high flexion activities was not restored following TKR. Patients did not or were unable to use their available range of flexion to achieve a normal kinematic pattern. The cause of this important functional deficit remains to be established but may be amenable to targeted rehabilitation

Introduction. Renal homeostasis has been shown to influence mortality after hip fractures; this is true for patients with both chronic kidney disease, and those who develop acute renal dysfunction after surgery. We have examined the influence of impaired renal function upon mortality and length of stay. We investigated this relationship through accurate mathematical modelling of available biochemistry data on a cohort of hip fracture patients. Methods. Complete data were available for 566 patients treated over a 27-month period. All patients had urea and creatinine checked on admission, and at 24–48 hours after surgery. Post-operative analgesia, fluid therapy, transfusion protocols and orthogeriatric reviews were standardised. Generalised Linear Models and correlation matrices were used. Cox-proportional hazards analyses investigated the association between serum concentrations of urea and creatinine on admission and length of stay and mortality after surgery. Results. The cohort included 427 females and 139 males (mean age 80.6 years, mean post-operative length of stay 19 days). 1-year mortality was 19.1%. Urea and creatinine were significantly, positively correlated with age (more significant for urea). After adjusting for age and sex, risk of mortality was positively related to serum concentrations of creatinine and marginally so for urea. Increased age and a male gender were associated with a higher mortality risk. Risk of discharge from trauma ward, length of stay on trauma ward, and overall length of stay were not related to levels of creatinine and urea at admission. Conclusions. This study shows a quantifiable correlation between renal dysfunction and NOF mortality. The low risk of survival with both male sex and raised creatinine identified this subgroup as the ‘most at risk’. Both age and gender are non-modifiable factors, so this subgroup may require a more targeted approach to the management of their fluid and electrolyte homeostasis

Objective. The optimal positioning of the acetabular component is a relevant prognostic factor in total hip arthroplasty (THA). Because of substantial errors of manual technique in cup placement even with experienced surgeon, computer aided navigation system has been developed in recent years. However, existence of the hardware around acetabulum likely deteriorates the accuracy of the navigation system, namely in revision THA case and postoperative status of pelvic fracture. Here we report a case who we successfully performed THA using CT based navigation system although there were multiple hardware around acetabulum due to osteosynthesis for the previous pelvic fracture. Case presentation. A forty-one years old man presented with intolerable hip pain with severe radiographic osteoarthritic findings in left hip joint. He had sustained left pelvic fracture and posterior hip dislocation due to traffic accident and undergone osteosynthesis using multiple plates and screws when he was forty years old. However, progressive collapsing of femoral head and acetabulum occurred. Then, we indicated THA for his situation and planned to apply the CT based navigation system (Stryker CT based hip Ver.1.1 softwear and Cart II system). Preoperative workup revealed incomplete union of posterior and superior acetabular wall and we had to retain plates and screws for the stable fixation of acetabular cup. The existence of the hardware made it complicated to perform three dimensional planning and templating. Meticulous surface editing of pelvis to exclude the metal artifact and fibrocartilagenous tissue was needed to achieve accurate surface registration. In the operation room, we had to use unusual way of registration to complete two steps of registration. In the first step (roughly matching between patient's physical pelvic surface and edited pelvic surface in work station using corresponding 5 points), we utilized head of screw and hole of the plate which we could easily identify intraoperatively, in addition to ASIS and innominate groove. In the second step (strict matching using more than 30 points of pelvic surface), we had to identify the pelvic bony surface, as excluding the metal surface and fibrocartilagenous tissue such as fracture callus. These efforts enabled us to accomplish substantial accuracy of registration with RMS of 0.5 mm. Final cup orientation at the end of surgery was 41° of inclination and 25° of anteversion. Postoperative CT scan revealed that cup placement angle was 40° of inclination and 25° of anteversion, almost identical with intraoperative value. Conclusion. Our experience showed that CT based navigation system provided accurate placement of the acetabular component in a case having multiple hardware as well as in normal primary THA. Although we need additional efforts such as meticulous preoperative planning, extra operation time, CT based navigation system has great advantages to minimize the mal-placement of the cup in complicated case

Background. Isolated fractures of the distal fourth or fifth metacarpal bones, known as boxer's fractures (BF), are the most common type of metacarpal fracture. Boxer's fractures received their name from one of their most common causes — punching an object with a closed fist. This injury has been described as “a tolerable fracture in an intolerable patient” (1) It occurs commonly during fistfights or from punching a hard object such as a wall. Greer and William demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self-defeating personality disorders, self harm and impulsive behaviour, compared with control groups (3). It has been suggested that all patients presenting with such an injury should have psychiatric assessment. The majority of studies in the literature have concentrated on adults and little has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients discharged with metacarpal fractures due to punching using a validated questionnaire and this abstract presents the interim analysis. Methodology. Following ethical permissions patients between 11 and 18 years of age, discharged with a metacarpal fracture caused by punching diagnosis codes S622, S623 or S624 and willing to complete an anonymous quetionnairre were included. All patients recieved an information sheet and for young people under 16 parental permission was sought. The Bus and Warren validated questionnaire was completed by post, in person or over the telephone. The questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring and patients were asked to complete all sections. Results. Twenty one patients who had metacarpal fractures due to punching have. completed the study to date. All were males aged between the age of 11 and 18. The physical aggression scores ranged from 13-39 with a mean of 27.5, median 31 and mode 33. Fifteen patients demonstrated high aggression scores. Six patients demonstrated average scores. Anger scores ranged from 7-31. Median 18.5, mode 13, median 20. Thirteen patients had high anger scores compared with their peers. Eight patients were within the average range. Overall aggression scores ranged from 66-133 with a mean of 100 and median of 100. Eleven patients demonstrated high scores and 5 were in the high average range. Discussion/Conclusions. The initial interim results of this study show that over half the patients had higher overall aggression levels than the normal population. The physical aggression subscale focussed on the use of physical force and 71% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders or abusive situations and in this study 62% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues which in turn may reduce recurrence of the injuries