Introduction. Recent technological advancements have led to the introduction of robotic-assisted total knee arthroplasty to improve the accuracy and precision of bony resections and implant position. However, the in vivo accuracy is not widely reported. The primary objective of this study is to determine the accuracy and precision of a cut block positioning robotic arm. Method. Seventy-seven patients underwent total knee arthroplasty with various workflows and alignment targets by three arthroplasty-trained surgeons with previous experience using the ROSA® Knee System. Accuracy and precision were determined by measuring the difference between various workflow time points, including the final pre-operative plan, validated resection angle, and post-operative radiographs. The mean difference between the measurements determined accuracy, and the standard deviation represented precision. Results. The accuracy and precision for all angles comparing the final planned resection and validated resection angles was 0.90° ± 0.76°. The proportion within 3° ranged from 97.9% to 100%. The accuracy and precision for all angles comparing the final intra- operative plan and post-operative radiographs was 1.95 ± 1.48°. The proportion of patients within 3° was 93.2%, 95.3%, 96.6%, and 71.4% for the distal femur, proximal tibia, femoral flexion, and tibial slope angles when the final intra-operative plan was compared to post-operative radiographs. No patients had a postoperative complication requiring revision at the final follow-up. Conclusions. This study demonstrates that the ROSA Knee System has accurate and precise coronal plane resections with few outliers. However, the tibial slope demonstrated decreased accuracy and precision were measured on post-operative short-leg lateral radiographs with this platform

Taylor Spatial Frame (TSF) is a six axis deformity correction frame and accuracy of correction depend on the accuracy of parameters input in to the web based software. There are various methods of obtaining frame and deformity parameters (13 in total) including the use of dedicated software known as SpatialCAD™. We tested the accuracy of SpatialCAD™ using a saw bone two ring frame construct of known parameters. We mounted a two-ring (155mm) frame on a saw bone tibia and fibula unit and worked out the accurate mounting and deformity parameters. Then we obtained orthogonal and nonorthogonal antero-posterior and lateral images of frame using a metallic sphere of known dimensions placed at the level of the bone, to aid calibration of x-ray images. We also obtained orthogonal and non-orthogonal images without a calibrating sphere. We then uploaded the images in to SpatialCAD™ software and obtained the mounting and deformity parameters and compared with the real parameters. SpatialCAD™ is capable of yielding measurements within 1–2mm of actual measurements when Calibrated orthogonal images were used. The software was inaccurate when frame hardware of known dimensions was used for calibration because the hardware was not in the same plane as the bone

The diagnosis of infection following shoulder arthroplasty is notoriously difficult. The prevalence of prosthetic shoulder infection after arthroplasty ranges from 3.9 – 15.4% and the most common infective organism is Cutibacterium acnes. Current preoperative diagnostic tests fail to provide a reliable means of diagnosis including WBC, ESR, CRP and joint aspiration. Fluoroscopic-guided percutaneous synovial biopsy (PSB) has previously been reported in the context of a pilot study and demonstrated promising results. The purpose of this study was to determine the diagnostic accuracy of percutaneous synovial biopsy compared with open culture results (gold standard). This was a multicenter prospective cohort study involving four sites and 98 patients who underwent revision shoulder arthroplasty. The cohort was 60% female with a mean age was 65 years (range 36-83 years). Enrollment occurred between June 2014 and November 2021. Pre-operative fluoroscopy-guided synovial biopsies were carried out by musculoskeletal radiologists prior to revision surgery. A minimum of five synovial capsular tissue biopsies were obtained from five separate regions in the shoulder. Revision shoulder arthroplasty was performed by fellowship-trained shoulder surgeons. Intraoperative tissue samples were taken from five regions of the joint capsule during revision surgery. Of 98 patients who underwent revision surgery, 71 patients underwent both the synovial biopsy and open biopsy at time of revision surgery. Nineteen percent had positive infection based on PSB, and 22% had confirmed culture positive infections based on intra-operative tissue sampling. The diagnostic accuracy of PSB compared with open biopsy results were as follows: sensitivity 0.37 (95%CI 0.13-0.61), specificity 0.81 (95%CI 0.7-0.91), positive predictive value 0.37 (95%CI 0.13 – 0.61), negative predictive value 0.81 (95%CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77. A patient with a positive pre-operative PSB undergoing revision surgery had an 37% probability of having true positive infection. A patient with a negative pre-operative PSB has an 81% chance of being infection-free. PSB appears to be of value mainly in ruling out the presence of peri-prosthetic infection. However, poor likelihood ratios suggest that other ancillary tests are required in the pre-operative workup of the potentially infected patient

Abstract. Introduction. A spotlight has been placed upon virtual assessment of patients during the coronavirus pandemic. This has been particularly prevalent in the assessment of acute knee injuries. In this study we aim to assess the accuracy of telephone triage, confirmed by Magnetic Resonance Imaging (MRI) in the diagnosis of acute knee injuries. Methods. Case records of patients triaged by telephone in the acute knee clinic at Leeds General Infirmary were analysed. Provisional diagnoses made following telephone triage were compared to radiological diagnoses made on subsequent MRI scans. Diagnostic accuracy was compared between those patients assessed virtually and those assessed in face-to-face clinics. Results. 1160 patients were referred to the acute knee injury clinic during the study period. 587 of these were triaged telephonically. MRI scans were requested for 107 (18%) virtually reviewed patients. Of these patients, 92 (79%) had an MRI scan requested after making a provisional diagnosis over the phone. Of the MRI requests made after virtual consultation, there was a 75% diagnostic accuracy of the pre-imaging diagnosis. Of the patients seen in face-to-face appointments, a diagnostic accuracy of 73% was observed. Conclusion. Virtual assessment can provide an efficient and cost-effective establishment of diagnosis of acute knee injuries whilst reducing hospital attendance. A combination of virtual and in-person clinics may allow quicker access to specialist opinion and therefore reduce patient waiting times

Introduction. A key outcome measured by national joint registries are revision events. This informs best practice and identifies poor-performing surgical devices. Although registry data often record reasons for revision arthroplasty, interpretation is limited by lack of standardised definitions of revision reasons and objective assessment of radiologic and laboratory parameters. Our study aim was to compare reasons for unicompartmental knee arthroplasty (UKA) revision reported to the New Zealand Joint Registry (NZJR) with reasons identified by independent clinical review. Methods. A total of 2,272 patients undergoing primary medial and lateral UKA at four large tertiary hospitals between 2000 and 2017 were included. A total of 158 patients underwent subsequent revision with mean follow-up of 8 years. A systematic review of clinical findings, radiographs and operative data was performed to identify revision cases and to determine the reasons for revision using a standardised protocol. These were compared to reasons reported to the NZJR using Chi-squared and Fisher exact tests. Results. Osteoarthritis progression was the most common reason for revision on systematic clinical review (30%), however this was underreported to the registry (4%, p<0.001). A larger proportion of revisions reported to the registry were for ‘unexplained pain’ (30% of cases vs. 4% on clinical review, p<0.001). A reason for revision was not reported to the registry for 24 (15%) of cases. Discussion and Conclusion. We found significant inaccuracies in registry-reported reasons for revision following UKA. These included over-reporting of ‘unexplained pain’, under-reporting of osteoarthritis progression, and failure to identify a reason for revision. Efforts to improve registry capture of revision reasons for UKA should focus on increasing accuracy in these three areas. This could be addressed through standardised recording methods and tailored revision reason options for UKA for surgeons to select when recording the reasons

Introduction. Derotation osteotomies are commonly performed in paediatric orthopaedic and limb reconstruction practice. The purpose of this study was to determine whether the use of a digital inclinometer significantly improves the accuracy in attaining the desired correction. Materials & Methods. We designed an electronic survey regarding derotation femoral osteotomy (DFO) including methods of intra-operative angular correction assessment and acceptable margins of error for correction. This was distributed to 28 paediatric orthopaedic surgeons in our region. A DFO model was created, using an anatomic sawbone with foam covering. 8 orthopaedic surgeons each performed two 30-degree DFOs, one using K-wires and visual estimation (VE), and the other using a Digital Inclinometer (DI). Two radiologists reported pre and post procedure rotational profile CT scans to assess the achieved rotational correction. Results. There was a 68% response rate to the survey. The most popular methods of estimating intra-operative correction were reported to be K-wires and rotation marks on bone. The majority of respondents reported that a 6–10 degree margin of error was acceptable for a 30-degree derotation. This was therefore set as the upper limit for acceptable error margin in the simulation study. The mean error in rotation in the VE group of simulated DFO was 19.7 degrees, with error>5 degrees and error>10 degrees in 7 (88%) and 6 (75%) cases respectively. Mean error in DI group was 3.1 degrees, with error>5 degrees in 1 case (13%). Conclusions. Our results show that the compared to conventional techniques, the use of an inclinometer significantly improves the accuracy of femoral de-rotation and significantly reduces the incidence of unacceptable errors in correction. We would suggest that digital inclinometers be used to assess intra-operative correction during derotation osteotomies

Introduction. The accuracy of hexapod circular external fixator deformity correction is contingent on the precision of radiographic analysis during the planning stage. The aim of this study was to compare the SMART TSF (Smith and Nephew, Memphis, Tennessee) in-suite radiographic analysis methods with the traditional manual deformity analysis methods in terms of accuracy of correction. Materials and Methods. Sawbones models were used to simulate two commonly encountered clinical scenarios. Traditional manual radiographic analysis and digital SMART TSF analysis methods were used to correct the simulated deformities. Results. The final outcomes of all six analysis methods across both simulated scenarios were satisfactory. Any differences in residual deformity between the analysis methods are unlikely to be clinically relevant. All three SMART TSF digital analyses were faster to complete than manual radiographic analyses. Conclusions. With experience and a good understanding of the software, manual radiographic analysis can be extremely accurate and remains the gold standard for deformity analysis. In-suite SMART TSF radiographic analysis is fast and accurate to within clinically relevant parameters. Surgeons can with confidence trust the SMART TSF software to provide analysis and corrections that are clinically acceptable

Introduction. Model-based radiostereometric analysis (MBRSA) allows the in vivo measurement of implant loosening (i.e. migration) from a host bone by acquiring a pair of biplanar radiographs of the patient's implant over time. Focusing on total knee replacement patients, the accuracy of MBRSA in calculating tibial baseplate migration depends on the accuracy in registering a 3D model onto the biplanar radiographs; thus, the shape of the baseplate and its orientation relative to the imaging planes is pertinent. Conventionally, the baseplate coordinate system is aligned with the laboratory coordinate system, however, this reference orientation is unnecessary and may hide unique baseplate features resulting in less accurate registration (Figure 1). Therefore, the primary objective of this study was to determine the optimal baseplate orientation for improving accuracy during MBRSA, and an acceptable range of orientations for clinical use. A second objective was to demonstrate that a custom knee positioning guide repeatably oriented the baseplate within the acceptable range of orientations. Materials and Methods. A tibia phantom consisting of a baseplate rigidly fixed to a sawbone was placed in 24 orientations (combination of six rotations about X (i.e. knee flexion) and four rotations about Z (i.e. hip abduction)) with three pairs of radiographs acquired at each orientation. The radiographs were processed in MBRSA software, and the mean maximum total point motion (MTPM), an indicator of bias error during model registration, was plotted as a function of the two rotations to determine the optimal orientation and a range of acceptable orientations (Figure 2). A custom knee positioning guide was manufactured with the goal of orienting the baseplate close to the optimal orientation and within the acceptable range of orientations (Figure 3). Ten independent pairs of biplanar radiographs were acquired by repeatedly placing a knee model in the knee positioning guide, and the images were processed in MBRSA software to determine the baseplate orientation. Results and Discussion. Results showed an 85% decrease in bias error between the reference orientation (i.e. no rotation) and the optimal orientation (10° rotation about X and 5° rotation about Z). An acceptable range of orientations from 5° − 20° rotation about an axis perpendicular to the sagittal imaging plane and from 5° − 15° rotation about an axis perpendicular to the coronal imaging plane was defined as these orientations decreased the bias error by more than 50%. Additionally, the custom knee positioning guide controlled the mean orientation ± one standard deviation within the acceptable range of orientations. Conclusions. The accuracy of MBRSA is significantly improved if the tibial baseplate is placed in the range of acceptable orientations as opposed to the conventional reference orientation. A custom knee positioning guide can be used during a clinical study to repeatably position the patient's knee within the range of acceptable orientations. For any figures or tables, please contact the authors directly

Introduction. Deformity influences the weight bearing stresses on the knee joint. Correction of mechanical alignment is performed to offload the knee and slow the rate of degenerative change. Fixator assisted deformity correction facilitates accurate correction prior to internal fixation. We present our results with standard Ilizarov and UNYCO system assisted deformity correction of the lower limb. Materials and Methods. Retrospective analysis of adult surgical cases of mechanical re-alignment performed between 2010 and 2019 in a tertiary referral centre. We recorded standard demographics and operative time from the electronic patient record. We analysed digitalised radiographs to record pre- and post-operative measurements of: Mechanical axis deviation (MAD), femoral tibial angle (FTA), Medial Proximal tibial angle (MPTA) and Mechanical lateral distal femoral angle (mLDFA). The accuracy of the correction was analysed. Time to healing, secondary interventions and complications were also recorded. Results. 7 patients underwent fixator assisted deformity correction with the UNYCO system and 11 with a standard Ilizarov frame. Mean pre-op MAD was 45.8mm in the UNYCO group and 43.4mm in Ilazrov; Mean post-op MAD was 9.5mm in the UNYCO group (5–15) and 12.3 in the Ilizarov group (1–25) p=0.07. The average surgical time in the UNYCO group was 200 minutes (128–325) and 252 minutes (203–301) in the Ilizarov group p=0.07. The mean post op MPTA was 90.2 (87–96) in the UNYCO group and 87.4 (81–94) in the Ilizarov group. The mean mLDFA was 90.0(81–93.5) in the UNYCO group and 87.3(82.2–93.9) in the Ilizarov group. All the corrections involved a plate or nail fixation and mean time to union was 76.3 days in the UNYCO and 117.3 in the Ilizarov group. Conclusions. Both systems allowed accurate correction of deformity and limb alignment. In this small series we were unable to show a difference in theatre time. The application of the principles of deformity correction are as important as the surgical methods

Introduction. In total hip arthroplasty, correct sizing is critical for fixation and longevity of cementless components. Previously, three-dimensional CT templating has been shown to be more accurate than using 2D radiographs. The accuracy of the Optimized Positioning System (OPS. TM. ) planning software has not been reported. The aim of this study was to measure the accuracy of the OPS planning software in predicting the implanted acetabular cup and femoral stem size when used with the direct anterior approach. Method. Between October 2018 and March 2019, 95 patients received a bone preserving cementless MiniHip stem (Corin, UK). Sixty-three of these patients also received a cementless Trinity cup (Corin, UK). All patients were sent for OPS. TM. pre-operative planning, a patient-specific dynamic modelling software used to determine the optimal acetabular and femoral component size and positions. Average age was 57 (28 to 78) and 44% were female. All cases were performed using the direct anterior approach. The sizes of implants used were retrospectively compared to the planned OPS. TM. sizes. Results. Of the 95 cases, 98% (n=93) of MiniHip stems were within one size of that predicted, and 66% (n=63) matched exactly the predicted size. Of the 63 Trinity cups, 98% (n=62) were within one size of that predicted and 48% (n=30) matched exactly the predicted size. All stems and cups were within 2 sizes of plan [Fig. 1]. Conclusion. The OPS. TM. planning software successfully predicted more than 95% of implanted cup and stems within one size, with 100% implants being within 2 sizes. There is significant value in accurately predicting implant sizes preoperatively, both as an indicator to the surgeon as to the size expected, and for reducing the inventory supplied to the hospitals. For any figures or tables, please contact the authors directly

Aims. Accurate and precise acetabular reaming is a requirement for the press-fit stability of cementless acetabular hip replacement components. The accuracy of reaming depends on the reamer, the reaming technique and the bone quality. Conventional reamers wear with use resulting in inaccurate reaming diameters, whilst the theoretical beneficial effect of ‘whirlwind’ reaming over straight reaming has not previously been documented. Our aim was to compare the accuracy and precision of single use additively-manufactured reamers with new conventional reamers and to compare the effect of different acetabular reaming techniques. Materials and Methods. Forty composite bone models, half high-density and half low-density, were reamed with a new 61 mm conventional acetabular reamer using either straight or ‘whirlwind’ reaming techniques. This was repeated with a 61 mm single use additively-manufactured reamer. Reamed cavities were scanned using a 3D laser scanner with mean diameters of reamed cavities compared using the Mann-Whitney U test to determine any statistically significant differences between groups (p<0.05) [Fig. 1). Results. Reaming errors were significantly higher in low-density bone compared to high-density bone for both reamer types and reaming techniques tested (61.9 mm (SD 0.7) vs 61.4 mm (SD 0.4), respectively; p=0.0045). Whirlwind reaming was significantly more accurate and precise than straight reaming using both conventional (61.3 mm (SD 0.1) vs 62.3 mm (SD 0.4), respectively; p<0.0001) and single use reamers (61.1 mm (SD 0.3) vs 61.7 mm (SD 0.7), respectively; p=0.0058) [Fig. 2]. The novel single use reamer was significantly more accurate than the unused conventional reamer, using both the straight (61.7 mm (SD 0.7) vs 62.4 mm (SD 0.4), respectively; p=0.0011) and whirlwind techniques (61.2 mm (SD 0.3) vs 61.3 mm (SD 0.1), respectively; p=0.0002) [Fig. 3]. Conclusion. This is the first study to our knowledge that has assessed acetabular reaming technique in both low and high density saw bones. Improved reaming accuracy and precision was seen in both devices tested when using the ‘whirlwind’ technique in both high-density and low-density bone models when compared to a straight reaming technique. The single use device assessed reamed a cavity size closer to its stated size (61mm) compared to conventional reamers. Based on this study we suggest using a careful “whirlwind” technique when performing acetabular reaming, and for the surgeon to pay particular attention when performing joint replacement in patients with reduced bone quality as there is likely to be more variability in acetabular reaming accuracy in these patients

Introduction. Leg length discrepancy (LLD) is a common sequalae of limb reconstruction procedures. The subsequent biomechanical compensation can be directly linked to degenerative arthritis, lower back pain, scoliosis and functional impairment. It becomes particularly problematic when >2cm, established as a clinical standard. This two-arm experimental study assesses how reliable an iPhone application is in the measurement of LLD at different distances in control and LLD patients. Materials and Methods. 42 participants were included in the study, divided evenly into 21 control and 21 LLD patients. A standardised measurement technique was used to obtain TMM and iPhone application measurements, taken at a distance of 0.25m, 0.50m and 0.75m. Results. The mean discrepancy of iPhone-based measurements in the control group was 1.57cm, 1.59cm and 2.19cm at 0.25m, 0.50m and 0.75m respectively. This compares to measurements in the LLD cohort with a mean discrepancy of 1.71cm, 1.85cm and 2.19cm. The overall mean discrepancy of iPhone data was 1.78cm in the control cohort compared to 1.92cm in the LLD cohort. Conclusions. Results suggest that the iPhone application can be used to identify clinically significant leg length discrepancies. At 0.75 metres anomalous results become more prevalent and the accuracy of the application appears to decline. The results also suggest the application is slightly more accurate in the control group, nevertheless, in distances up to 0.50 metres the mean discrepancy sits within the 2cm standard of clinically significant LLD

Introduction. Diagnosis of chronic osteomyelitis (COM) is based mainly on the correlation between history, clinical picture, lab analysis, bacteriological, pathological, and imaging studies. Bone biopsy for culture and sensitivity is the gold standard for the correct identification of the causative organism. The present prospective study aims to evaluate the accuracy of FDG PET-CT in the diagnosis of COM in comparison to the bacteriological, pathological findings. Materials and Methods. 18 patients (16 males/two females) underwent FDG-PET/CT scanning for clinically or radiologically suspected COM of the lower extremity. Fourteen patients had septic non-union, three patients with aseptic non-union, and one with chronic diffuse sclerosing OM of Garre. Seven patients had implants at site of examination at the time of the scan. Diagnosis of COM was confirmed by deep surgical cultures and pathological analysis (index debridement done by s single surgeon in one centre) following PET/CT scanning. FDG-PET uptake was measured by SUV max (the highest uptake of the radioisotope in the infection area). These findings were correlated to the microbiological and histopathological results. Results. Infection was clinically evident at a mean of 15 weeks (range, 2 to 60 weeks) after the date of injury. Patients had a mean of 2.3 (range 0 – 7) operations, before index debridement. The mean SUV max on the affected side was (9.55 ± 5.22), While mean SUV max on the contralateral healthy side was (1.82 ± 0.98). The pattern of FDG-uptake was diffuse in nine (50%), localised in seven (38.9%), and intramedullary in two (11.1%) patients respectively. The sensitivity, specificity, accuracy, PPV and NPV of PET SUV max were 100%, 66.7%, 94.44%, 93.75% and 100% respectively in the diagnosis of COM at a cut-off value of (4.46). The present study included 15 true positive, two true negative and one false-positive PET/CT results. Conclusions. 18F-FDG PET/CT is a highly sensitive and specific method for the evaluation of chronic osteomyelitis in patients with or without trauma. PET/CT provides anatomical localisation and characterisation of the infected area and has a crucial role in preoperative planning

Recent innovations in total ankle replacement (TAR) have led to improvements in implant survivorship, accuracy of component positioning and sizing, and patient outcomes. CT-generated pre-operative plans and cutting guides show promising results in terms of placement enhancement and reproducibility in clinical studies. The purpose of this study was to determine the accuracy of 1) implant sizes used and 2) alignment corrections obtained intraoperatively using the cutting guides provided, compared to what was predicted in the CT generated pre-operative plans. This is a retrospective study looking at 36 patients who underwent total ankle arthroplasty using a CT generated pre-operative planning system between July 2015 and December 2017. Personalized pre-operative planning data was obtained from the implant company. Two evaluators took measurements of the angle corrected using pre- and post-operative weight bearing ankle AP X-rays. All patients had a minimum three-month follow-up with weightbearing postoperative radiographs. The actual correction calculated from the radiographic assessment was compared with the predicted angles obtained from pre-operative plans. The predicted and predicted alternative component sizes and actual sizes used were also compared. If either a predicted or predicted alternative size was implanted, we considered it to be accurate. Average age for all patients was 64 years (range 40–83), with a body mass index of 28.2 ± 5.6. All surgeries were performed by two foot and ankle surgeons. The average total surgical time was 110 ± 23 minutes. Pre-operative alignment ranged from 36.7 degrees valgus to 20 degrees varus. Average predicted coronal alignment correction was 0.8 degrees varus ± 9.3 degrees (range, 18.2 degrees valgus to 29 degrees varus) and average correction obtained was 2.1 degrees valgus ± 11.1 degrees. Average post-op alignment was consistently within 5 degrees of neutral. There were no significant differences between the predicted alignments and the postoperative weightbearing alignments. The predicted tibia implant size was accurate in all cases. The predicted sizes were less accurate for talar implants and predicted the actual talar implant size used in 66% of cases. In all cases of predicted talar size mismatch, surgical plans predicted 1 implant size larger than used. Preliminary analyses of our data is comparable to previous studies looking at similar outcomes. However, our study had higher pre-operative deformities. Despite that, post-op alignments were consistently within 5 degress of neutral with no significant difference between the predicted and actual corrections. Tibial implant sizes are highly accurate while talar implant sizes had a trend of being one size smaller than predicted. Moreover, this effect seems to be more pronounced in the earlier cases likely reflective of increasing surgeon comfort with the implant with each subsequent case. These results confirm that pre-operative cutting guides are indeed helpful in intra-operative implant selection and positioning, however, there is still some room for innovation

Introduction. The application of digital radiography in clinical settings has provided the opportunity to obtain high quality images while reducing the overall cost of imaging, thus this technology is gaining more popularity in clinical settings specifically in orthopaedic clinics . 1. In addition, advanced computer software helps with quick and easy approach to perform preoperative measurements with high accuracy . 2. Preoperative templating has become one of the standard of care procedures that prepares the surgical team to lower surgical time and more efficiently face intraoperative complications . 3. Commonly, the acetabular cup size and femoral stem size are templated and used for estimation process . 4. However, the goal of this study was to investigate whether patients' demographics would play a role in increasing the accuracy of templating. We hypothesized that preoperative implant templating (acetabular and femoral components), gender, weight, height, and body mass index (BMI) would contribute to higher accuracy of templating in total hip arthroplasty (THA). Method. Digital radiographs of 468 patients treated with THA from August 2012 to December 2013 at a single institution were reviewed. They aged 59.96 ±12.50 years and 436 of them were diagnosed with osteoarthritis, 53 with avascular necrosis, 13 with failed THA, 2 with infection, 4 post trauma, and 13 with failed hemi arthroplasty. THA templating was conducted by assessing the anteroposterior view of the pelvis that was centered over the pubic symphysis, with the hips in 10° to 15° of internal rotation and we utilized a lateral frog-leg view of the affected hip. A backward stepwise multiple regression model was used to exclude the parameters that had no significant contribution to the accuracy of the measurement. Results. The outcome of the backward stepwise analysis indicated that in estimation of actual acetabular size, gender and body weight did not have a significant role however preoperative femoral and acetabular component size, BMI, and height were significant factors to predict the model. This model had an adjusted R2=0.795. The femoral component size was significantly predicted from preoperative femoral size and other parameters did not add significant accuracy to the model. The model reached an adjusted R2 = 0.723. Discussion. We explored the possibility of using other factors to improve the accuracy of preoperative templating. We were successful to predict the acetabular size with accuracy of 98.5% within two sizes and 100% femoral size in the same range. The additional accuracy may be translated in lower treatment costs by reducing expensive inventory fees

Introduction. Machine learning is a relatively novel method to orthopaedics which can be used to evaluate complex associations and patterns in outcomes and healthcare data. The purpose of this study is to utilize 3 different supervised machine learning algorithms to evaluate outcomes from a multi-center international database of a single shoulder prosthesis to evaluate the accuracy of each model to predict post-operative outcomes of both aTSA and rTSA. Methods. Data from a multi-center international database consisting of 6485 patients who received primary total shoulder arthroplasty using a single shoulder prosthesis (Equinoxe, Exactech, Inc) were analyzed from 19,796 patient visits in this study. Specifically, demographic, comorbidity, implant type and implant size, surgical technique, pre-operative PROMs and ROM measures, post-operative PROMs and ROM measures, pre-operative and post-operative radiographic data, and also adverse event and complication data were obtained for 2367 primary aTSA patients from 8042 visits at an average follow-up of 22 months and 4118 primary rTSA from 11,754 visits at an average follow-up of 16 months were analyzed to create a predictive model using 3 different supervised machine learning techniques: 1) linear regression, 2) random forest, and 3) XGBoost. Each of these 3 different machine learning techniques evaluated the pre-operative parameters and created a predictive model which targeted the post-operative composite score, which was a 100 point score consisting of 50% post-operative composite outcome score (calculated from 33.3% ASES + 33.3% UCLA + 33.3% Constant) and 50% post-operative composite ROM score (calculated from S curves weighted by 70% active forward flexion + 15% internal rotation score + 15% active external rotation). 3 additional predictive models were created to control for the time required for patient improvement after surgery, to do this, each primary aTSA and primary rTSA cohort was subdivided to only include patient data follow-up visits >20 months after surgery, this yielded 1317 primary aTSA patients from 2962 visits at an average follow-up of 50 months and 1593 primary rTSA from 3144 visits at an average follow-up of 42 months. Each of these 6 predictive models were trained using a random selection of 80% of each cohort, then each model predicted the outcomes of the remaining 20% of the data based upon the demographic, comorbidity, implant type and implant size, surgical technique, pre-operative PROMs and ROM measures inputs of each 20% cohort. The error of all 6 predictive models was calculated from the root mean square error (RMSE) between the actual and predicted post-op composite score. The accuracy of each model was determined by subtracting the percent difference of each RMSE value from the average composite score associated with each cohort. Results. For all patient visits, the XGBoost decision tree algorithm was the most accurate model for both aTSA & rTSA patients, with an accuracy of ∼89.5% for both aTSA and rTSA. However for patients with 20+ month visits only, the random forest decision tree algorithm was the most accurate model for both aTSA & rTSA patients, with an accuracy of ∼89.5% for both aTSA and rTSA. The linear regression model was the least accurate predictive model for each of the cohorts analyzed. However, it should be noted that all 3 machine learning models provided accuracy of ∼85% or better and a RMSE <12. (Table 1) Figures 1 and 2 depict the typical spread and RMSE of the actual vs. predicted total composite score associated with the 3 models for aTSA (Figure 1) and rTSA (Figure 2). Discussion. The results of this study demonstrate that multiple different machine learning algorithms can be utilized to create models that predict outcomes with higher accuracy for both aTSA and rTSA, for numerous timepoints after surgery. Future research should test this model on different datasets and using different machine learning methods in order to reduce over- and under-fitting model errors. For any figures or tables, please contact the authors directly

Aim. Prompt recognition and identification of the causative microorganism in acute septic arthritis of native and prosthetic joints is vital to increase the chances of successful treatment. The aim of this study was to independently assess the diagnostic accuracy of the multiplex BIOFIRE® Joint Infection (JI) Panel (investigational use only) in synovial fluid for rapid diagnosis. Method. Synovial fluid samples were prospectively collected at the University Medical Center Groningen from patients who had a clinical suspicion of a native septic arthritis, early acute (post-operative, within 3 months after arthroplasty) periprosthetic joint infection (PJI) or late acute (hematogenous) PJI. JI Panel results were compared to culture-based methods as reference standard. Results. A total of 45 samples were analyzed. The BIOFIRE JI Panel showed a high specificity (100%, 95% CI 73 – 100) and positive predictive value (100%, 95% CI 79 – 100) in all patient categories. Sensitivity and negative predictive value were 83% (95% CI 36 – 99) and 88% (95% CI 47 – 99) respectively for patients with a clinical suspicion of native septic arthritis (n=12), 77% (95% CI: 46 – 94) and 63% (95% CI: 26 – 90) for patients with a clinical suspicion of a late acute PJI (n=14), and 27% (95% CI 7 – 61) and 27% (95% CI: 7 – 61) for patients with a clinical suspicion of an early acute PJI (n=19). Conclusions. The results of this pilot study indicate a clear clinical benefit of the BIOFIRE JI Panel in patients with a suspected native septic arthritis and late acute (hematogenous) PJI, but a low clinical benefit in patients with an early acute (post-operative) PJI due to the absence of low-grade microorganisms in the panel

Background. Accurate acetabular cup positioning is considered to be essential to prevent postoperative dislocation and improve the long-term outcome of total hip arthroplasty (THA). Recently various devices such as navigation systems and patient-specific guides have been used to ensure the accuracy of acetabular cup positioning. Objectives. The present study evaluated the usefulness of CT-based three-dimensional THA preoperative planning for acetabular cup positioning. Methods. This study included 120 hips aged mean 68.3 years, who underwent primary THA using CT-based THA preoperative planning software ZedHip® (LEXI, Tokyo Japan) and postoperative CT imaging (Fig.1). The surgical approach adopted the modified Watson-Jones approach in the lateral decubitus position and Trident HA acetabular cups were used for all cases. Preoperatively the optimum cup size and position in the acetabular were decided using the ZedHip® software, taking into consideration femoral anteversion and to achieve the maximum range of motion in dynamic motion simulation. Radiographic inclination (RI) was selected in the range between 40°∼45° and radiographic anteversion (RA) in the range between 5°∼25°. Three-dimensional planning images of the cup positioning were obtained from the ZedHip® software, and the distances between the edge of the implant and anatomical landmarks such as the edge of the anterior or superior acetabular wall were measured on the three-dimensional images and recorded (Fig.2). Intraoperatively, the RI and RA were confirmed by reference to these distances and the acetabular cup was inserted. Relative positional information of the implant was extracted from postoperative CT imaging using the ZedHip® software and used to reproduce the position of the implant on preoperative CT imaging with the software image matching function. The difference between the preoperative planning and the actual implant position was measured to assess the accuracy of acetabular cup positioning using the ZedHip® software. Results. Actual cup size corresponded with that of preoperative planning in 95% of cases (114 hips). Postoperative mean RI was 42.3° ± 4.2° (95% confidence interval (CI), 41.5° ∼ 43.0°) and mean RA was 16.1° ± 5.9° (95%CI, 15.0° ∼ 17.1°). Deviation from the target RI was 4.2° ± 3.7° (95%CI, 3.5° ∼ 4.9°) and deviation from the target RA was 4.0° ± 3.6° (95%CI, 3.4° ∼ 4.7°). Overall 116 hips (96.7%) were within the RI safe zone (30° ∼ 50°) and 108 hips (90.0%) were within the RA safe zone (5° ∼ 25°), and 105 hips (87.5%) were within both the RI and RA safe zones (Fig.3). Mean cup shift from preoperative planning was 0.0mm ± 3.0mm to the cranial side in the cranio-caudal direction, 2.1mm ± 3.0mm to the anterior side in the antero-posterior direction, and 1.7mm ± 2.1mm to the lateral side in the medio-lateral direction. Conclusion. The accuracy of acetabular cup positioning using our method of CT-based three-dimensional THA preoperative planning was slightly inferior to reported values for CT-based navigation, but obviously superior to those without navigation and similar to those with portable navigation. CT-based three-dimensional THA preoperative planning is effective for acetabular cup positioning, and has better cost performance than expensive CT-based navigation. For any figures or tables, please contact the authors directly

Aim. Diagnosing Fracture-Related Infections (FRI) is challenging. White blood cell (WBC) scintigraphy is considered the best nuclear imaging technique to diagnose FRI; a recent study by our group found a diagnostic accuracy of 92%. However, many centers use . 18. F-fluorodeoxyglucose positron emission tomography/computed tomography (. 18. F-FDG-PET/CT) which has several logistic advantages. Whether . 18. F-FDG-PET/CT has better diagnostic performance than white blood cell (WBC) scintigraphy is uncertain. Therefore, we aimed: 1) to determine the diagnostic performance of . 18. F-FDG-PET/CT for diagnosing FRI (defined as infection following an open fracture or fracture surgery) and 2) to determine cut-off values of standardized uptake values (SUV) that result in optimal diagnostic performance. Method. This retrospective cohort study included all consecutive patients who received . 18. F-FDG-PET/CT to diagnose FRI in two level 1 trauma centers. Baseline demographic- and surgical characteristics were retrospectively reviewed. The reference standard consisted of at least 2 representative microbiological culture results or the presence or absence of clinical confirmatory FRI signs in at least 6 months of clinical follow-up. A nuclear medicine specialist, blinded to the reference standard, re-reviewed all scans. Additionally, SUVs were measured using the “European Association of Nuclear Medicine Research Ltd. (EARL)” reconstructed . 18. F-FDG-PET/CT scans. Volume of interests were drawn around the suspected- and corresponding contralateral area to obtain the absolute values (SUVmax) and the ratio between suspected and contralateral area (SUVratio). Diagnostic accuracy of the re-reviewed scans was calculated (sensitivity and specificity). Additionally, diagnostic characteristics of the SUV measurements were plotted in the area under the receiver operating characteristics curve (AUROC). The sensitivity and specificity at the optimal threshold was deducted from the AUROC with the Q-point method. Results. 158 . 18. F-FDG-PET/CTs were included. Mean age was 46.2 years, 71.5% was male. Most cases (56.3%) were tibial shaft- or ankle fractures. Sixty patients (38.0%) had FRI. The sensitivity and specificity of the FDG-PET/CT scan was 70.0% (95% CI 56.8–81.2) and 79.6% (95% CI 70.3–87.1) respectively. Diagnostic accuracy was 76.0% (95% CI 68.5–82.4). AUROCs of SUVmax and SUVratio were 0.80 (95% CI 0.73–0.87) and 0.73 (95% CI 0.64–0.81), respectively. The optimal SUVmax threshold of 4.2 resulted in 80.0% sensitivity and 71.3% specificity, while an SUVratio of 2.9 resulted in 58.3% sensitivity and 80.9% specificity. Conclusions. The . 18. F-FDG-PET/CT has a sensitivity of 70.0%, specificity of 79.6% and a diagnostic accuracy of 76.0%. This makes . 18. F-FDG-PET/CT less accurate than WBC scintigraphy in diagnosing FRI, although adding SUV measurements may possibly increase its diagnostic accuracy

Bone age is a radiographical assessment used in pediatric medicine due to its relative objectivity in determining biological maturity compared to chronological age and size.1 Currently, Greulich and Pyle (GP) is one of the most common methods used to determine bone age from hand radiographs.2–4 In recent years, new methods were developed to increase the efficiency in bone age analysis like the shorthand bone age (SBA) and the automated artificial intelligence algorithms. The purpose of this study is to evaluate the accuracy and reliability of these two methods and examine if the reduction in analysis time compromises their accuracy. Two hundred thirteen males and 213 females were selected. Each participant had their bone age determined by two separate raters using the GP (M1) and SBA methods (M2). Three weeks later, the two raters repeated the analysis of the radiographs. The raters timed themselves using an online stopwatch while analyzing the radiograph on a computer screen. De-identified radiographs were securely uploaded to an automated algorithm developed by a group of radiologists in Toronto. The gold standard was determined to be the radiology report attached to each radiograph, written by experienced radiologists using GP (M1). For intra-rater variability, intraclass correlation analysis between trial 1 (T1) and trial 2 (T2) for each rater and method was performed. For inter-rater variability, intraclass correlation was performed between rater 1 (R1) and rater 2 (R2) for each method and trial. Intraclass correlation between each method and the gold standard fell within the 0.8–0.9 range, highlighting significant agreement. Most of the comparisons showed a statistically significant difference between the two new methods and the gold standard; however it may not be clinically significant as it ranges between 0.25–0.5 years. A bone age is considered clinically abnormal if it falls outside 2 standard deviations of the chronological age; standard deviations are calculated and provided in GP atlas.6–8 For a 10-year old female, 2 standard deviations constitute 21.6 months which far outweighs the difference reported here between SBA, automated algorithm and the gold standard. The median time for completion using the GP method was 21.83 seconds for rater 1 and 9.30 seconds for rater 2. In comparison, SBA required a median time of 7 seconds for rater 1 and 5 seconds for rater 2. The automated method had no time restraint as bone age was determined immediately upon radiograph upload. The correlation between the two trials in each method and rater (i.e. R1M1T1 vs R1M1T2) was excellent (κ= 0.9–1) confirming the reliability of the two new methods. Similarly, the correlation between the two raters in each method and trial (i.e. R1M1T1 vs R2M1T1) fell within the 0.9–1 range. This indicates a limited variability between raters who may use these two methods. The shorthand bone age method and an artificial intelligence automated algorithm produced values that are in agreement with the gold standard Greulich and Pyle, while reducing analysis time and maintaining a high inter-rater and intra-rater reliability