Background. Knee osteoarthritis (OA) is a major cause of ambulatory disabilities. Although total knee arthroplasty (TKA) has been reported as the most effective treatment for severe knee OA, quantitative evaluation of ambulatory function have not been well investigated. We hypothesized that better functional recovery would result in better patient satisfaction. The purpose of this study was to quantitatively evaluate ambulatory functional recovery and assess the influence on patient satisfaction after TKA. Material and Methods. 90 patients (80 females and 10 males) were involved in this study. The mean age at TKA was 75.2 ± 5.8 years. Patients were subjected to 3 meters timed up and go test (TUG) to evaluate ambulatory function. TUG was performed at 6 time periods; before surgery, 2 weeks, 1, 3, 6 months, and 1 year after surgery. We also asked the patients to fill out the questionnaire of patient satisfaction category in the New Knee Society Score at 1 year after TKA. The sequential changes in TUG were analyzed using repeated measures ANOVA (p<0.05). The influences of each parameter (age, TUGs) on the patient satisfaction score were analyzed with simple regression analysis (p<0.05). Results. The mean TUGs were 12.2, 16.7, 13.3, 11.1, 10.7, 10.4 seconds at before surgery, 2 weeks, 1, 3, 6 months, and 1 year after surgery respectively. TUG time significantly increased at 2 weeks after TKA and decreased afterward until 3 months. We found TUG significantly decreased at 3 months comparing to preoperative measurement. No significant changes in TUG were found from 3 months to 1 year after TKA. The mean patient satisfaction score was 29.2 ± 6.3 (12–40) points. There was a significant negative correlation between age and satisfaction. Patient satisfaction was negatively correlated to preoperative TUG and TUG at 1 year. Discussion. In this study, we evaluated sequential changes of ambulatory function in detail using TUG test during 1 year after TKA. Ambulatory function significantly deteriorated at 2 weeks, followed by gradual improvement and reached to significantly better level at 3 months after TKA comparing to preoperative level. We also found that the patient satisfaction was affected equally by both preoperative and 1 year postoperative TUG time. Although our patients' age was relatively elder than in the major literature, significant improvement in ambulatory function was observed as short as 3 months. This is shorter than previous reports. We provided a rehabilitation program in hospital for 3 weeks after TKA. This would be beneficial for early ambulatory functional recovery even with elder patients. The ambulatory function generally deteriorates as patients get old. Therefore TKA should be considered before patients get too old. Conclusion. Ambulatory function significantly improved at 3 months after TKA, and no more improvement was found afterward. The younger age and better preoperative ambulatory function would be beneficial for the patient satisfaction after TKA in elderly population

Introduction. As the aging society progresses rapidly, the number of patients underwent total knee arthroplasty (TKA) is increasing especially for the elderly population. In Japan, the average age for TKA is around 75 years old. Japanese Orthopaedic Association indicated a new clinical entity of musculoskeletal ambulation disability symptom complex (MADS) to define the higher risk of fall and ambulatory disability in the elderly population in 2006. The diagnosing criteria for MADS consists of 2 simple performance tests. 3m timed up and go test (TUG) evaluates ambulatory function, and one leg standing time (ST) assesses balancing ability. Objective. In this study, we analyzed the effect of TKA on the ambulatory function by quantitative measurement using 2 simple performances test: TUG and ST. Materials & Methods. Forty four patients (6 males and 38 females) with varus type osteoarthritic knees underwent TKA were involved. The mean age of surgery was 72.7 years old. TUG and ST were performed at 4 time periods; pre-operatively, 2 weeks after surgery, at hospital discharge (average 24.1 days) and 1year after surgery. Ambulatory disability (MADS) was diagnosed if TUG was not less than 11 seconds and/or ST was less than 15 seconds. 36 patients (82%) were diagnosed to MADS preoperatively. We divided these 36 patients into two groups depending on the performance tests one year after TKA. 24 patients (67%) still suffered from MADS (Group1), and remaining 12 patients (33%) recovered from MADS (Group2). We compared preoperative factors (age, femoro-tibial angle, ROM, etc.) and the results of ST and TUG between Group 1 and Group 2 using the Mann-Whitney test (p<0.05). Results. The complication rates of MADS in all 44 patients were 82.0, 88.9, 83.3, and 55.6% at 4 time periods respectively. Significant functional recoveries were observed with decrease of TUG and increase of ST at 1 year after surgery (Fig. 1). Average age at surgery was significantly higher in Group 1 (74.7yo) comparing to Group 2 (69.3yo). The sequential change of mean TUG and ST at 4 time periods were shown for each group in Fig. 2 and Fig. 3. We found no significant difference in TUG but significant difference in ST between two groups. Patient in Group 2 could stand on one leg longer than Group 1 preoperatively even with no significant difference in TUG. Discussions. We evaluated the ambulatory function using 2 simple performance tests, and found significant improvements in both balancing ability (ST) and ambulatory function (TUG) one year after TKA. However, more than 50% of our patient population still suffered from ambulatory disability (MADS) at 1 year after surgery. As much as 70% of preoperatively MADS complicated patients were found to meet MADS criteria even one year after TKA. Only 30% of preoperatively MADS complicated patient could recover from MADS. This group was relatively younger and showed better balancing ability preoperatively. Our results suggested that standing time measurement would be simple and useful predictor for the functional recovery after TKA

To assess long and short term kinematic gait outcomes after rectus femoris transfers (RFT) in ambulatory children with cerebral palsy (CP). A retrospective review was conducted of ambulatory children with spastic diplegic CP, who had RFT plus motion analysis preoperatively and 1 year post-operatively. Those with 5 and 10 year post-operative motion analysis were also included. The primary variables were: peak knee flexion range of motion in swing (PKFSW), timing of peak knee flexion in swing as a percent of the gait cycle (PKF%GC), and knee range of motion from peak to terminal swing (KROM). Responders and non-responders were identified. Descriptive, kinematic and kinetic variables were evaluated as predictors of response. 119 ambulatory children (237 limbs) with spastic diplegic CP who had RFT were included. Mean age at surgery was 10.2 years (range 5.5 to 17.5). Sixty-seven participants were classified at GMFCS Level II and 52 at GMFCS Level III. All participants (237 limbs) had a preoperative and 1 year postoperative motion analysis. Motion analysis at 5 and 10 years post-operatively included 82 limbs and 28 limbs, respectively. Ninety-three (39%) limbs improved in both PKFSW and PKF%GC. PKFSW improved in 59% of limbs. Responders started 1.2 SD below the mean PKFSW preoperatively, and improved by an average of 1.9 SD to reach a normal range at 1 year post-operatively (p < 0.05). Improvement was maintained at 5 and 10 years postoperatively. Those at GMFCS level II were more likely [OR 1.71, CI 1.02, 2.89] to have improved PKFSW at 1 year postoperatively than those at GMFCS level III. PKF%GC improved in 70% of limbs. Responders had delayed PKF%GC, starting 10 SD above the mean (later in the gait cycle) preoperatively. Their timing improved towards normal values: 5 SD, 5.9 SD, 3.5 SD from the mean, (earlier in the gait cycle) at 1, 5 and 10 years postoperatively, respectively (p<0.05). KROM improved in only 24% of limbs. For all variables, there was a significant difference in mean preoperative values between responders and non-responders (p<0.05). RFT improves short and long-term kinematic gait outcomes. The majority of children responded to RFT with improvements in PKFSW or PKF%GC at 1, 5, and 10 years post RFT. GMFCS level is a predictor of improved PKFSW, with children at GMFCS Level II having an increased likelihood of improvement at 1 year post surgery. Children who have worse preoperative values of PKFSW, PKF%GC, and KROM have a greater potential for benefit from RFT. Characteristics associated with responders who maintain long term positive outcomes need to be identified

Background. In recent literatures, medial instability after TKA was reported to deteriorate early postoperative pain relief and have negative effects on functional outcome. Furthermore, lateral laxity of the knee is physiological, necessary for medial pivot knee kinematics, and important for postoperative knee flexion angle after cruciate-retaining total knee arthroplasty (CR-TKA). However, the influences of knee stability and laxity on postoperative patient satisfaction after CR-TKA are not clearly described. We hypothesized that postoperative knee stability and ligament balance affected patient satisfaction after CR-TKA. In this study, we investigated the effect of early postoperative ligament balance at extension on one-year postoperative patient satisfaction and ambulatory function in CR-TKAs. Materials & Methods. Sixty patients with varus osteoarthritis (OA) of the knee underwent CR-TKAs were included in this study. The mean age was 73.6 years old. Preoperative average varus deformity (HKA angle) was 12.5 degrees with long leg standing radiographs. The knee stability and laxity at extension were assessed by stress radiographies; varus-valgus stress X-ray at one-month after operation. We measured joint separation distance (mm) at medial compartment with valgus stress as medial joint opening (MJO), and distance at lateral compartment with varus stress as lateral joint opening (LJO) at knee extension position. To analyze ligament balance; relative lateral laxity comparing to the medial, varus angle was calculated. New Knee Society Score (NKSS) was used to evaluate the patient satisfaction at one-year after TKA. We measured basic ambulatory functions using 3m timed up and go test (TUG) at one-year after surgery. The influences of stability and laxity parameters (MJO, LJO and varus angle at extension) on one-year patient satisfaction and ambulatory function (TUG) was analyzed using single linear regression analysis (p<0.01). Results. MJOs at knee extension one-month after TKA negatively correlated to patient satisfaction (r=−0.37, p<0.01) and positively correlated to TUG time (r=0.38, p<0.01). LJOs at knee extension had no statistically significant correlations to patient satisfaction and TUG. The extension varus angle had significant positive correlation with patient satisfaction (r=0.40, p<0.01). Discussions. In our study, we have found significant correlations of the early postoperative MJOs at extension to postoperative patient satisfaction and TUG one-year after CR-TKA. Our results suggested that early postoperative medial knee stabilities at extension were important for one-year postoperative patient satisfaction and ambulatory function in CR-TKA. Other interest finding was that postoperative patient satisfaction was positively correlated with extension varus angle. This finding suggested that varus ligament balance; relative lateral laxity to medial stability, was beneficial for postoperative patient satisfaction after CR-TKA. Intra-operative soft tissue balance had been reported to significantly affect postoperative knee stabilities. Therefore, with our findings, surgeons might be better to manage intra-operative soft tissue balance to preserve medial stability at extension with permitting lateral laxity, which would enhance patient satisfaction and ambulatory function after CR-TKA for varus type OA knee. Conclusion. Early postoperative medial knee stability and relative lateral laxity would be beneficial for patient satisfaction and function after CR-TKA

[Introduction]. Rapid increase of aged population has been one of major issue affecting national health care plan in Japan. In 2006, Japanese Orthopaedic Association indicated a new clinical entity of musculoskeletal ambulation disorder symptom complex (MADS) to define the higher risk of fall and ambulatory disability in the elderly population caused by musculoskeletal disorders. Osteoarthritis of the knee is one of major cause of MADS. The number of patients with MADS underwent total knee arthroplasty (TKA) had been increased in Japan, and also expected to increase worldwide in the near future. The effectiveness of TKA for the patient with MADS would be a key issue for the patient satisfaction in TKA. In the present study, we analyzed the influence of pre-operative factors on the ambulatory functions in the patients of primary TKA. [Material & Method]. 132 patients with osteoarthritic knees implanted with posterior-stabilized (PS) TKAs were subjected to this study. There were 113 female and 19 male patients. The mean age of the patients was 73.6 years (range, 59 to 87 years). Patients were pre-operatively subjected to 2 functional performance tests which were essential tests for MADS diagnosis. Firstly, 3 meter timed up and go test (TUG) was used to evaluate ambulation ability. Secondary one leg standing time (ST) with open eyes was measured with both operated and non-operated leg to assess balancing ability. MADS was diagnosed if TUG and ST were not less than 11 seconds and/or less than 15 seconds respectively. The influence of each pre-operative factor was evaluated simple linear regression analysis (p < 0.05). Pre-operative factors consisted of age, sex, weight, height, BMI, standing femoro-tibial angle (FTA) and active knee range of motion. [Results]. Pre-operatively, 74% of the patients was diagnosed as MADS, with the results of 64, 74 and 64% of the patient matched to the MADS criteria with the evaluation of TUG and ST with operated and non-operated leg respectively (Fig 1). Firstly, pre-operative TUG was found to be negatively correlated to the weight (R = −0.25), ST with non-operated leg (R = −0.24) and active knee flexion angle (R = −0.28, Fig 2). Secondary, ST with operated leg was significantly affected by age (R = −0.32), standing FTA (R = −0.38) and ST with non-operated leg (R = 0.66, Fig 3). [Discussion & Conclusion]. As much as 74% of our patients was suffered from MADS before primary TKA. Majority of patient had both ambulatory and balancing disability with higher risk of fall and ambulatory dysfunction. We found ST with non-operated leg significantly affected both TUG representing ambulatory function and ST representing balancing function. This means the contra-lateral lower extremity function would play an important role on the pre-operative functional ability in the patient of TKA. Furthermore, we found pre-operatively that active knee flexion influenced ambulatory function, and coronal knee deformity deteriorated balancing ability. Then we should evaluate these pre-operative factors in analyzing the effectiveness of TKA on the functional recovery in the elderly patient underwent primary TKA

Objective. As the aging society progresses rapidly in Japan, the number of elderly patients underwent TKA is increasing. These elderly patients do not expect to do sports, but regain independency in the activity of daily living. Therefore, we measured basic ambulatory function quantitatively using 3m timed up and go (TUG) test. We clinically experienced patient with medially unstable knee after TKA was more likely to result in the unsatisfactory outcome. We hypothesized that post-operative knee stability influenced ambulatory function recovery after TKA. In this study, we evaluated ambulatory function and knee stability quantitatively, and analyzed the effect of knee stability on the ambulatory function recovery after TKA. Materials & Methods. Seventy nine patients with varus type osteoarthritic knees underwent TKA were subjected to this study. The mean age of surgery was 72.4 years old. Preoperative standing coronal deformity was 9.6 degrees in varus. TUG test results in less duration with faster ambulatory function. TUG (seconds) was measured at 3 time periods; pre-operatively, at hospital discharge and 1year after surgery. To standardize TUG recovery time during 1 year after TKA, we defined TUG recovery rate as the percentage of recovery time to the pre-operative TUG as shown in the following equation. TUG recovery rate (%) = (TUG pre-op –TUG 1y po) / TUG pre-op ×100. We also evaluated the knee stability at hospital discharge and 1year after surgery. The knee stability at extension and flexion were assessed by varus and valgus stress radiography using Telos (10kg) and stress epicondylar view with 1.5kg weight at the ankle respectively. Image analyzing software was used to measure joint separation distance (mm) at medial as medial joint opening (MJO) and at lateral as lateral joint opening (LJO) at both knee extension and flexion. (Fig.1). The sequential change of TUG was analyzed using repeated measures ANOVA (p<0.05). The influence of joint opening distances (MJO and LJO at extension and flexion) on TUG 1y po and TUG recovery rate were analyzed using simple linear regression analysis (p<0.05). Results. The mean TUGs were 13.4, 13.7 and 10.8 seconds pre-operatively, at hospital discharge and 1 year after TKA respectively. Significant decrease was found at 1 year after surgery. TUG pre-op did not show significant correlation to any joint openings. TUG 1y po was positively correlated with both flexion and extension MJO at hospital discharge. (Fig.2) TUG recovery rate negatively correlated to flexion-MJO at hospital discharge. (Fig.3). Discussions. The most interesting findings in the present study were that both flexion and extension MJO at hospital discharge were positively correlated with TUG 1y po and negatively correlated with TUG recovery rate. This indicated that early post-operative medial stability played an important role in the recovery of ambulatory function. The early post-operative medial instability would cause pain and deteriorate functional recovery after surgery. There is some disagreement regarding the importance of pursuing the perfect ligament balance, which would be more likely to result in medial instability. Consequently, surgeons should prioritize medial stability for better ambulatory functional recovery after TKA

INTRODUCTION. Clinical trials have generally failed to demonstrate superior clinical effectiveness of minimally invasive surgical approaches for total knee arthroplasty (TKA). The hypothesis of the current study was that avoiding incision of the quadriceps tendon would result in a significantly faster recovery of ambulatory function after total knee arthroplasty, compared to a technique that incised the quadriceps tendon. METHODOLOGY. The MIKRO (Minimally Invasive Knee Replacement Outcomes) Study is a prospective, level 1 RCT that enrolled 128 patients with knee osteoarthritis who had failed non-operative treatment, and had decided to proceed with TKA. After skin incision, 64 patients each were randomized to either a subvastus (SV) or medial parapatellar arthrotomy (MPPA) approach. All surgeries were done with the same TKA implant, with anesthesia, post-operative analgesia, and physical therapy standardized for both groups. A Patient Diary methodology was used as the primary outcome measure for ambulatory function. During the first 8 weeks after TKA, a research assistant blinded to treatment assignment telephoned each patient and completed study forms that documented indoor and outdoor walking relative to use of ambulatory devices, as well as Knee Society Score (KSS) and the UCLA activity scale. The UCLA score and change in KSS from baseline at 4- and 12-week follow-up were used to begin the validation process for an Ambulatory Function Score (AFS) derived from diary indoor and outdoor scores. RESULTS. There was a trend for the SV group to report more independent ambulation than the MPPA group at week 1 after surgery, as indicated by self-reported AFS (p < .052). Both treatment groups demonstrated significant week to week AFS gains through 5 weeks, after which weekly changes were minimal. As expected, outdoor AFSs were initially slower to improve than indoor AFSs, but by 6 weeks the initial 20-pt difference was less than 10-pts. AFS scores were significantly correlated with UCLA scores across all 8 weeks. Knee Society Scores (KSS) at baseline were rarely correlated with AFS scores across the 8 weeks. However, 1-month and 3-month KSS scores were significantly correlated with AFS scores at p < .05 beginning with weeks 2 or 3 and through week 8. CONCLUSION. Avoiding incision of the quadriceps tendon during primary TKA resulted in a short-lived trend of quicker improvement in the AFS score in the SV TKA group versus the MPPA group. However, there appeared to be a similar rate of subsequent AFS improvement across the subsequent 8 weeks between the two groups. Preliminary results suggest a pattern of results – general improvement across 5–6 weeks that was maintained through the 8 weeks of evaluation, and significant correlations with UCLA and KSS scores after 2–3 weeks – that are consistent with the notion that the AFS is sensitive to change, and is variable depending on context (indoor vs. outdoor ambulation). Although related to UCLA and KSS scores, observed correlation magnitudes were not so high as to suggest that UCLA or KSS scores might be reasonable proxies for AFS

INTRODUCTION. Mobile-bearing knee prostheses have been designed in order to provide less constrained knee kinematics compared to fixed-bearing prosthesis. Currently, there is no evidence to confirm the superiority of either of the two implants with regard to walking performances. It has been shown that subjective outcome scores correlate poorly with real walking performance and it has been recommended to obtain an additional assessment of walking ability with objective gait analysis. OBJECTIVES. We assessed recovery after total knee arthroplasty (TKA) with mobile- and fixed-bearing between patients during the first postoperative year, and at 5 years follow-up, using a new objective method to measure gait parameters in real life conditions. METHODS. 56 patients with mobile- and fixed-bearing of the same design were included in this randomised controlled double-blinded study and evaluated pre- and post-operatively at 6 weeks, 3 months, 6 months 1 year and 5 years. At each visit a WOMAC and Knee Society Score were calculated and each participant completed an EQ-5D questionnaire. To assess the patients' gait five miniature angular rate sensors mounted respectively on the sacrum and each shank and thigh measured lower limb movement and rotation. The patients walked 30 metres on a flat surface and gait parameters were recorded with a small ambulatory device in order to carry out an objective gait analysis. RESULTS. Objective recovery was strongly correlated with patients' age. When the whole population was considered, there was no significant difference between groups at any time in objective gait parameters. After separating the population according to their age (less than 71 years old, compared to those of more than 71 years old) a secondary analysis showed that the bearing type can lead to opposite results in different age groups. At five years follow-up, most of the recorded gait parameters (stride length, knee max rotation speed, shank and thigh range of motion, and limp) showed better results for mobile bearing in younger patients, while better gait performances were found systematically with fixed-bearing TKA in older patients. CONCLUSION. To our knowledge, this is the first study where similarly designed posterior-stabilised knee replacements with fixed- and mobile-bearing have been compared with gait analysis in real-life conditions. We observed systematically differences between mobile and fixed bearing groups, which are confirmed by multivariate analysis. Our results suggest that older patients might not benefit from a mobile bearing TKA and that extended age controlled study should be performed to identify an age, above which fixed bearing should not be the recommended choice. Before choosing the bearing type, surgeons should take into account the age of the patient

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:. 1). the volume and variations of arthroscopic knee debridement across Canada. 2). The costs associated with potentially unnecessary arthroscopy. 3). The characteristics of surgeons performing knee arthroscopy in older adults. Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age. The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001). Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care

Aims. COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic. Methods. An orthopaedic research consortium at a multi-hospital tertiary care academic medical system developed a three-part survey examining provider perspectives on strategies to expand orthopaedic patient care and financial recovery. Section 1 asked for preferences regarding extending clinic hours, section 2 assessed surgeon opinions on expanding surgical opportunities, and section 3 questioned preferred strategies for departmental financial recovery. The survey was sent to the institution’s surgical and nonoperative orthopaedic providers. Results. In all, 73 of 75 operative (n = 55) and nonoperative (n = 18) providers responded to the survey. A total of 92% of orthopaedic providers (n = 67) were willing to extend clinic hours. Most providers preferred extending clinic schedule until 6pm on weekdays. When asked about extending surgical block hours, 96% of the surgeons (n = 53) were willing to extend operating room (OR) block times. Most surgeons preferred block times to be extended until 7pm (63.6%, n = 35). A majority of surgeons (53%, n = 29) believe that over 50% of their surgical cases could be performed at an ambulatory surgery centre (ASC). Of the strategies to address departmental financial deficits, 85% of providers (n = 72) were willing to work extra hours without a pay cut. Conclusion. Most orthopaedic providers are willing to help with patient care backlogs and revenue recovery by working extended hours instead of having their pay reduced. These findings provide insights that can be incorporated into COVID-19 recovery strategies. Level of Evidence: III. Cite this article: Bone Jt Open 2021;2(7):562–568

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

The purpose of this study was to measure the effect of the implementation of a LEAN continuous process improvement initiative on the waitlist in an ambulatory pediatric orthopaedic clinic. LEAN is a set of principles that guide organizational thinking and form a comprehensive approach to continuous process improvement. In 2016, our health centre began its journey towards becoming a LEAN organization. The health centre's Strategy and Performance portfolio collaborated with the Orthopaedic Clinic Team to facilitate a Value Stream Analysis, which mapped the clinic process from referral to discharge from care. This informed the plan for targeted improvement events designed to identify and reduce non-value added activity, while partnering with patients and families to share their experiences with care in the clinic. Improvement events included: In-Clinic Patient Flow; Scheduling Process Review; Standardized Triage Process; Clinician Schedule; 5-S Large Cast and Sample Exam Rooms; Booking Orthopedics Clinic; and Travelling and Remote Care. During each event, solutions were identified to improve the patient experience, access, and clinic flow. These solutions have been standardized, documented, and continuously monitored to identify additional improvement opportunities. Comparison of wait-list and percentage of new patients seen within target window was performed from August 2017 to December 2018. The LEAN initiative resulted in a 48% decrease in wait-list for new patients, which translated to an improvement from 39% to 70% of new patients seen within their target window. There was a 19% decrease in the 3400+ patient wait-list for follow-up appointments, an 85% reduction in follow-up patients waiting past their target date for an appointment, and the number of patients waiting over a year beyond their target appointment improved from over 300 patients to 0 patients. There was a 15% improvement in average length of clinic visit. Without the addition of new resources, the implementation of a LEAN continuous process improvement initiative improved the waitlist for new patients in an ambulatory pediatric orthopaedic clinic by almost 50%. Solutions identified and implemented through the LEAN process have contributed to unprecedented improvements in access to care. In fulfilling one of the LEAN theory principles to “pursue perfection”, the paediatric orthopaedic clinic team has embraced a culture of continuous improvement and continues to use LEAN tools such as daily huddles and visual management to monitor solutions and identify gaps

Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows earlier weight bearing, at the cost of longer operation times

Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021. Methods. A retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard. Results. A total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week. Conclusion. SBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway

In Canada, hip and knee replacements are each among the top three surgeries performed annually. In 2020, surgeries across the country were cancelled in response to the COVID-19 pandemic. We examined the impact on these joint replacement surgeries throughout the year. Using the Discharge Abstract Database and National Ambulatory Care Reporting System, we developed a dataset of all 208,041 hip and knee replacements performed in Canada (except from Quebec) between January 1, 2019 to December 31, 2020. We compared patient and surgical characteristics (including sex, age, main diagnosis, and type of surgery (planned/urgent, primary/revision, inpatient/day surgery) in 2020 to 2019. In 2020, hip and knee replacements volumes decreased by 18.8% compared to 2019. In April and May 2020, hip and knee replacements fell by 69.4% and 93.8%, respectively, compared to the same period in 2019. During those months, 66.5% of hip replacements were performed to treat hip fracture versus 20.2% in April and May 2019, and 64.5% of knee replacements were primaries versus 93.0% in April and May 2019. Patterns by patient age group and sex were similar compared to 2019. These patterns were similar across all provinces. By the summer, planned surgeries resumed across the country and volumes mostly returned to pre-pandemic monthly levels by the end of the year. We also found that there was an increase in the proportion of hip and knee replacements done as day surgery, with 4% in 2020 versus 1% in 2019, and patients undergoing day surgery replacement for osteoarthritis were older, with a median age of 64 for hip patients and 65 for knee patients, versus 63 for both joints the previous year. As a result of the COVID-19 pandemic, there was a notable drop in 2020 of hip and knee replacements performed in Canada. With the demand for joint replacements continuing to grow, the resulting backlog will have an immediate, significant impact on wait lists and patient quality of life. The shift to a greater proportion of joint replacements performed as day surgeries may have an effect on patient outcomes as well shifts in access to care. It will be important to continue monitor patient outcomes following day surgery and the impact on patients for which day surgery was not an option

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

The coronavirus pandemic has reduced the capability of Canadian hospitals to offer elective orthopaedic surgery requiring admission, despite ongoing and increasing demands for elective total hip and total knee arthroplasty surgery (THA and TKA). We sought to determine if the coronavirus pandemic resulted in more outpatient THA and TKA in Nova Scotia, and if so, what effect increased outpatient surgery had on 90 day post-operative readmission or Emergency Department/Family Doctor (FD) visits. The study cohort was constructed from hospital Discharge Abstract Data (DAD), inpatient admissions, and National Ambulatory Care Reporting System (NACRS) data, day surgery observations, using Canadian Classification of Health Intervention codes to select all primary hip and knee procedures from 2005-2020 in Nova Scotia. Emergency Department and General Practitioner visits were identified from the Physician Billings data and re-admissions from the DAD and NACRS. Rates were calculated by dividing the number of cases with any visit within 90 days after discharge. Chi-squared statistics at 95% confidence level used to test for statistical significance. Knee and hip procedures were modelled separately. There was a reduction in THA and TKA surgery in Nova Scotia during the coronavirus pandemic in 2020. Outpatient arthroplasty surgery in Nova Scotia in the years prior to 2020 were relatively stable. However, in 2020 there was a significant increase in the proportion and absolute number of outpatient THA and TKA. The proportion of THA increased from 1% in 2019 to 14% in 2020, while the proportion of TKA increased from 1% in 2019 to 11% in 2020. The absolute number of outpatient THA increased from 16 cases in 2019, to 163 cases in 2020. Outpatient TKA cases increased from 21 in 2019, to 173 in 2020. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED following TKA but not THA which was not statistically significant. For outpatient THA and TKA, there was a decrease in 90 day readmissions, and a statistically significant decrease in FD presentations. Outpatient THA and TKA increased significantly in 2020, likely due to the restrictions imposed during the coronavirus pandemic on elective Orthopaedic surgery requiring admission to hospital. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED for TKA, and a decrease in 90 day readmissions and FD presentations for THA and TKA. Reducing the inpatient surgical burden may result in a post-operative burden on ED, but does not appear to have caused an increase in hospital readmission rates

Aim. The aim of this paper is to analyse the cause of neuropathic diabetic foot ulcers and discuss their preventive measures. Methods. Review of patients with foot ulcers managed in our diabetic MDT clinics since Feb 2018 were analysed. Based on this observation and review of pertinent literature, following observations were made. Results. Forefoot. Progressive hindfoot equinus from contraction of gastroc-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus muscles and, progressive plantar flexed metatarsal heads secondary to claw toe deformity results in increased forefoot plantar pressures. In patients with insensate feet, this result in ulcer formation under the metatarsal heads from shear stress when walking. Callosity under the metatarsal heads is the earliest clinical sign. Most patients by this time have fixed tightness of the muscle groups as assessed by negative Silfverskiold test. Percutaneous tendo-Achilles lengthening (TAL) has shown to reduce the mid-forefoot plantar pressures by 32% and ulcer healing in 96% of patients within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. Proximal metatarsal osteotomies further reduce the forefoot pressures to near normality. Midfoot. Midfoot ulcers are secondary to rocker-bottom deformity a consequence of Charcot neuroarthropathy (CN). Hindfoot equinus as described and relative osteopenia from neurally mediated increased blood flow (neurovascular theory) and repeated micro-trauma (neurotraumatic theory) result in failure of medial column osseo-ligamentous structures. As the disease progress to the lateral column, the cuboid height drops resulting in a progressive rocker bottom deformity. The skin under this deformity gradually breaks down to ulceration. In the pre-ulcerative stages of midfoot CN, TAL has shown to stabilise the disease progression and in some patents’ regression of the disease process was noted. The lump can excised electively and the foot accommodated in surgical shoes. Hindfoot. These develop commonly at the pressure areas and bony exostosis in non-ambulatory patients. In ambulatory patients, the most common cause are factors that result in over lengthening of tendo-Achilles such as after TAL, spontaneous tears, or tongue-type fractures. Conclusions. Early identification of factors that result in plantar skin callosity and treating the deforming forces prevent progression to ulceration. Total contact cast without treatment of these deforming forces results in progression of these callosities to ulceration while in the cast or soon after completion of cast treatment

Aims. Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care. Methods. This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance. Results. Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits. Conclusion. These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity. Cite this article: Bone Jt Open 2021;2(7):493–502

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control