Aims

Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.

Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis. We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and cost savings by minimising time spent bending plates during surgery. This study analysed 4 patients who underwent shoulder arthrodesis by a single consultant orthopaedic surgeon at GCUH between 2017-2021. A CT-based life-size model of each patient's shoulder girdle was 3D printed using freely available computer software programs: 3D Slicer, Blender, Mesh Mixer & Cura. Once the patient's 3D model was created, plate benders were used to contour the plate pre-op, which was then sterilised prior to surgery. Arthrodesis was performed according to AO principles of fixation. The time spent pre-bending the plate using the 3D model was calculated to analyse the intra-op time and cost-saving benefits. For the 4 cases, the plate pre-bending times were 45, 40, 45 & 20 minutes (average 38.8 mins). The intra-op correction time to make small adjustments to the plate was 2 min/ case. 3 plates needed minor (3 degree) adjustment to fine-tune scapula spine contouring. 1 plate needed a 5 degree correction to fine-tune hand position. On average, the pre-bending of the plate saved approximately 38.8 mins intra-op/ case. These shorter anaesthetic and operating times equate to approximately $2586 saving/ case, given an estimate of $4000/hour of theatre costs. We conclude that pre-bending plates around 3D-printed life-size models of an individual's shoulder girdle prior to surgery results in approximately 38.8 mins time saving intra-op when used in shoulder arthrodesis. This is a viable and effective technique that will ultimately result in significant operative time and financial savings

To determine the effect of Dexamethasone on post-operative pain management in patients undergoing Total Knee Arthroplasty in terms of numerical pain rating scale and total opoid consumption. This Randomized Controlled Trail (RCT) was conducted for 02 years (7th September 2015 to 6th September 2017). All patients undergoing primary Unilateral Total Knee Replacement (TKR) for Osteoarthritis knee were included in the study. Patients with poor glycemic control (HbA1c > 7.6), Hepatic/Renal failure, corticosteroids/ Immunosuppression drug usage in the last 06 months, known psychiatric illnesses were excluded from the study. All patients were operated by consultant Orthopaedic surgeon under Spinal Anaesthesia and tourniquet control using medial para-patellar approach. Patients were randomly divided into 02 groups, A and B. 79 patients were placed in each group. Group A given 0.1mg/kg body weight Dexamethasone Intravenously 15 minutes prior to surgery and another dose 24 hours post-operatively while in group B (control group) no Dexamethasone given. Post-operative pain using the numerical pain rating scale (NRS) and total narcotics consumed converted to morphine dose equivalent noted immediately post-op, 12-, 24- and 48-hours post-operatively. Data analysis done using SPSS version 23. A total of 158 patients were included in the study. Of the total, 98 (62.02%) were females and 60 (37.98%) males. Average BMI of patients 26.94 ±3.14 kg/m2. Patients in group A required less post-operative analgesics (p < 0 .01) and had a better numerical pain rating scale score (p < 0 .01) as compared to group B. Pain scores at 24- and 48-hours post-op were significantly less for Dexamethasone group (p < 0 .01). Use of Dexamethasone per- and post-operatively reduces the pain and amount of analgesics used in patients undergoing TKA. For any reader queries, please contact . drjunaidrmc@gmail.com

We undertook 37 reverse total shoulder replacements within a 2 yr period for chronic complex shoulder conditions. All cases were undertook by one of two upper limb consultant orthopaedic surgeons. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Retrospective data was collected on the need for analgesia at final follow up and range of movement. Of the 37 patients, 12 underwent BIO-RSA procedures. Indications for surgery was predominantly rotator cuff arthropathy (n=9) but two patients had severe OA and one had a complex proximal humeral fracture. The average age of the patient was 76.6 yrs (69–87 yrs) with a mean follow-up of 6.8 months (6 weeks to 1 yr). The remaining 25 patients were similar in terms of indication, with 18 patients with cuff tear arthropathies and 7 with severe OA. Average age was slightly lower at 74.9 years (50–85). In terms of range of movement, outcomes between the two groups were broadly similar; those receiving BIO-RSA having an active forward flexion of 90.5° (50–130°) and abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely painfree (33.3% BIO-RSA and 44% RSA) or requiring only occasional analgesia. The vast majority of patients were either very satisfied or satisfied with the outcome of the surgery, with one patient in the BIO-RSA group being slightly dissatisfied and three in RSA group. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA

Trauma ward rounds (TWR) are usually preceded by trauma meetings where previous day admissions are discussed and management decisions made. Therefore, one would expect TWR to be relatively quick and efficient. We measured the distance walked during TWR over a one week period and examined effects of number of patients and their location on distance walked. We used a pedometer (after calibration) to measure the distance walked by a single consultant orthopaedic surgeon during his trauma week. The consultant conducted a daily TWR after the trauma meeting where previous day admissions and postoperative patients were reviewed. We initially measured the distance required to visit five wards where trauma patients could be found (trial distance) and used that for comparison. We recorded number of patients reviewed and wards visited daily. The distance walked daily during TWR was 1.37–2.4 times longer than trial distance. There was no correlation between number of patients reviewed or number of wards visited and distance walked. Despite the larger number of patients towards the end of the week (33 patients on 3 wards on last TWR), the distance walked remained shorter than on the first TWR (11 patients on 3 wards). The distance walked during the whole week was 30.8 miles!. We found no correlation between number of patients reviewed or their location and distance walked during TWR. The relatively shorter distances walked towards the end of the week could be explained by more familiarity and therefore, better organisation by the team as the week progressed

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability. The majority of proximal humerus fractures can be managed non-operatively with surgery reserved for approximately 10–20% of patients. The choice of surgical treatment is usually between a humeral head head-conserving fracture reduction and internal fixation and humeral head sacrifice hemiarthroplasty. Current indications for primary hemiarthroplasty include a displaced four-part fracture (with or without associated dislocation of the humeral head) and a head-splitting fracture (with involvement of >40% of the articular surface), due to the high associated risk of avascular necrosis. However, the indications for internal fixation of proximal humerus fractures have expanded over the last decade, and many fractures which have previously been considered unsalvageable and treated either non-operatively or with hemiarthroplasty are now deemed reconstructable. This is partially as a result of improved appreciation of sub-groups of fractures which have a better prognosis from head-salvage, the possibility that subsequent development of osteonecrosis may be relatively asymptomatic and the realisation that functional results after hemiarthroplasty are often sub-optimal. The purpose of this talk is to discuss the current concepts in fracture classification and the indications for operative treatment for these fractures. The novel surgical approaches, techniques and implants which have renewed interest in their treatment are also highlighted. None of the authors have received any payment or consideration from any source for the conduct of this study

Introduction. Menisci performs multiple functions in the knee.'These depend largely on the structural integrity of the meniscus. Arthroscopic partial menisectomy is the treatment of choice for meniscal tears in adults. There is conflicting evidence about the progression of degenerative changes in the medial or lateral compartment of the knee following menisectomy. Aim. The aim of our study was to demonstrate the subjective, objective and radiographic outcome of arthroscopic partial lateral menisectomy in the intermediate term and to identify any association between age, sex, activity level, the type of meniscal tear, pre operative articular surface damage and the amount of meniscus resected on the outcome. Materials and Methods. Between 1999 and 2003,152 patients in the18 to 40 year age group underwent arthroscopic partial lateral menisectomy. A senior consultant orthopaedic surgeon performed all procedures. 72 patients were available for final clinical and radiological review. Patient's subjective & objective assessments were undertaken using validated scoring systems. Musculoskeletal physiotherapist & radiologists performed clinical & radiological assessments independently. Progression of degenerative changes was recorded. Results. All patients demonstrated initial improvement of symptoms lasting upto 2 ½ years followed by gradual deterioration of subjective symptoms. There was statistically significant deterioration in the IKDC & Lysolm scores. Radiological changes developed or progressed in 36.6% of the patients (P value < 0.005). These changes were most marked in the 35 to 40 year age group. There was no statistical correlation between clinical symptoms and radiological changes. No other statistically significant associations were demonstrated. Conclusions. Arthroscopic partial lateral menisectomy leads to progressive deterioration in clinical and radiological outcome in the Intermediate term. However there is no correlation between clinical & radiological outcomes

An ACL reconstruction is designed to restore the normal knee function and prevent the onset and progression of degenerative changes such as osteoarthritis. However, contemporary literature provides limited consensus on whether knee degeneration can be attenuated by the reconstruction procedure. The aim of this pilot study was to identify the presence of early osteoarthritis after ACL reconstruction using MRI analysis. 19 patients who had undergone an ACL reconstruction (9 isolated ACL rupture, 8 ACL rupture and meniscectomy, 2 ACL rupture and meniscal repair) volunteered for this study. MRI's were collected preoperatively and postoperatively for analysis with a mean follow up of 23 months. The Boston-Leeds Osteoarthritis Knee Score (BLOKS) was used for the analysis of the articular cartilage by a consultant orthopaedic surgeon. Scores ranged from 0–3, with 0 being total coverage and thickness of the cartilage and 3 being no coverage. Qualitative analysis was then conducted on each patient to determine if the articular cartilage improved, degenerated, or did not change between preoperative and follow-up scans. All patients with isolated ACL rupture were found to either have no change or improved articular cartilage scores in their follow up scans compared preoperatively. In contrast, patients with a meniscal repair displayed worse cartilage scores postoperatively. Lastly, of the patients who had an associated meniscectomy, 6 had worse follow-up results, with the remaining patients showing no change or improved cartilage scores. The present results indicate that patients with an isolated ACL rupture have a reduced risk of developing OA compared to those with associated meniscal injuries. This has implications for analysing the outcome of current ACL reconstruction techniques and in predicting the likelihood of patients developing OA after ACL reconstruction. Future work will involve confirming this pattern in a larger patient sample, as well as exploring additional factors such as time to surgery delay and rehabilitation strategy

Patients with skeletal dysplasia are prone to developing advanced degenerative knee disease requiring total knee replacement (TKR) at a younger age than the general population. TKR in this unique group of patients is a technically demanding procedure due to the bone deformity, flexion contracture, generalised hypotonia and ligamentous laxity. We set out to retrospectively review the outcome of 11 TKR's performed in eight patients with skeletal dysplasia at our institution using the SMILES custom-made rotating-hinge total knee system. There were 3 males and 5 females with mean age 57 years (range, 41–79 years), mean height 138 cm (range, 122–155 cm) and mean weight 56 kg (range, 40–102 kg). Preoperative diagnoses included achondroplasia, spondyloepiphyseal dysplasia, pseudoachondroplasia, multiple epiphyseal dysplasia, morquio syndrome, diastrophic dysplasia and Larson's Syndrome. Patients were followed clinically and radiographically for a mean of 7 years (range, 3–11.5 years). Knee pain and function improved in all 11 joints. Mean Knee Society clinical and function scores improved from 24 (range, 14–36) and 20 points (range, 5–40) preoperatively to 68 (range, 28–80) and 50 points (range, 22–74) respectively at final follow-up. Four complications were recorded (36%), including a patellar fracture following a fall, a tibial periprosthetic fracture, persistent anterior knee pain and a femoral component revision for aseptic loosening. Our results suggest that custom rotating-hinge TKR in patients with skeletal dysplasia is effective at relieving pain, optimising movement and improving function. It compensates for bony deformity and ligament deficiency and reduces the need for corrective osteotomy. Patellofemoral joint complications are frequent and functional outcome is worse than primary TKR in the general population. Submission endorsed by Mr Peter Calder, Consultant Orthopaedic Surgeon and Society member

Introduction. There have been concerns regarding the quality of training received by Orthopaedic trainees. There has been a reduction in working hours according to the European working times directive. National targets to reduce surgical waiting lists has increased the workload of consultants, further reducing the trainees' surgical experience. Navigation assisted procedures are successfully used in orthopaedics and provides useful feedback to the surgeon regarding precision of implant placement. We investigated the use of navigation aids as an alternative source of training surgical trainees. Methods. We choose a navigation assisted knee replacement (TKR) model for this study. A first year Orthopaedic registrar level trainee was taught the TKR procedure by a scrubbed consultant in 5 cases. He was then trained in use of non-CT based navigation surgery. The Trainee then performed navigation assisted non-complex primary TKR surgery. A consultant Orthopaedic surgeon was available throughout for advice and support. Data collected included pre and post procedure valgus and varus alignment of the knee, total operative time and WOMAC scores pre and post operatively. Results. A total of 42 TKRs were performed. Intra-operative review by the consultant surgeon was necessary on 3 occasions in the first 10 cases and two occasions in the remaining cases. The average operative time reduced from 184.25 minutes in the first 10 cases to 163.11 minutes in the next 20 cases and 150.33 minutes in the next 12 cases. The varus/valgus alignment was corrected to within 8 degrees in all cases. A significant improvement in WOMAC scores was recorded for all patients (p< 0.05). Conclusion. We believe that this model can be used as a training aid in various orthopaedic surgical procedures

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability. The traditional view that the vast majority clavicle fractures heal with non- operative treatment with consistently good functional outcomes is no longer valid. Recent studies have identified a higher rate of nonunion and specific defects of shoulder function in sub-groups of patients with these injuries. These fractures should therefore be viewed as a spectrum of injuries with diverse functional outcomes, each requiring careful assessment and individualised treatment. This talk provides an overview of the current knowledge regarding their epidemiology, classification, clinical assessment and treatment in adults. The following key points will be highlighted:. Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union and good functional outcomes after non-operative treatment. Non-operative treatment of displaced shaft fractures may be associated with a higher rate of non-union and functional deficit than previously reported. However, it remains difficult to predict which patients will develop these complications. Since satisfactory functional outcome may be regained from operative treatment for clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment for these injuries. Displaced lateral-end fractures have a higher risk of nonunion after non-operative treatment than shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in the elderly. The results of operative treatment are more unpredictable than for shaft fractures. None of the authors have received any payment or consideration from any source for the conduct of this study

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. Standard RSA technique involves medialising the centre of rotation (COR) maximising the deltoid lever arm and compensating for rotator cuff deficiency. However reported complications include scapular notching, prosthetic loosening and loss of shoulder contour. As a result the use of Bony Increased Offset Reverse Shoulder Arthroplasty (BIO-RSA) has been gaining in popularity. The BIO-RSA is reported to avoid these complications by lateralising the COR using a modified base plate, longer central post and augmentation with cancellous bone graft harvested from the patients humeral head. Objectives. This study aims to compare the outcome in terms of analgesic effect, function and satisfaction, in patients treated with standard RSA and BIO-RSA. Methods. All cases were performed in a single centre by one of two upper limb consultant orthopaedic surgeons over a consecutive 2-year period. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Standard deltopectoral approach was performed. Standard and Bony increased offset Tournier reverse was the implant of choice (BIO-RSA). All patients underwent a standardised rehabilitation programme. Standard follow up was clinical review with radiographs at 2 weeks, 6weeks and 3months. Retrospective data was collected using case notes on patient reported stausfaction and oxford shoulder score, analgesia requirement at final follow up, and final range of movement. Results. A total of 60 patients (65 shoulders) were treated with reverse total shoulder replacements (RSA) within a 2-year period in a single centre for chronic complex shoulder conditions. Mean age at time of intervention was 74.1years (49.3 – 88.7). Mean follow up was 7.1 months (3.4 – 24). Average time to discharge 16.1 months (3.4 – 37.4). 43 patients currently under review. Of the 65 shoulders, 40 underwent BIO-RSA procedures. Indications for surgery were predominantly rotator cuff arthropathy (N=36). Other indications included severe osteoarthritis (N=1) and complex proximal humeral fracture (N=3). The remaining 25 patients treated with standard RSA were similar in terms of indication and basic demographics. In terms of range of movement, outcomes between the two groups were broadly similar. Patients receiving BIO-RSA demonstrated mean active forward flexion of 92.2° (70–120°) and abduction 93.3° (80–120°). The RSA group had mean forward flexion 90.5° (50–130°) and mean abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely pain free or requiring only occasional analgesia. The majority of patients were either very satisfied or satisfied with the outcome of the surgery. Mean Oxford shoulder score for the BIO-RSA group was 4.9 (0–13) preoperatively and 43.7 (36–48) postoperatively. The mean RSA pre-operative score was 7.9 (0–19) and postoperatively 40.2(32–48). In total three patients experienced complications; 1 haematoma (BIO-RSA), 1 brachial plexus contusion (BIO-RSA) and 1 deep infection (RSA). Conclusion. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA. Early results also suggest the Bio-RSA allows earlier improvement and conserves a larger bone stock. These early result are encouraging however a further study with longer follow-up is required

Knee osteoarthritis results in pain and functional limitations. In cases where the arthritis is limited to one compartment of the knee joint then a unicondylar knee arthroplasty (UKA) is successful, bone preserving option. UKA have been shown to result in superior clinical and functional outcomes compared to TKA patients. However, utilisation of this procedure has been limited due primarily to the high revision rates reported in joint registers. Robotic assisted devices have recently been introduced to the market for use in UKA. They have limited follow up periods but have reported good implant accuracy when compared to the pre-operative planned implant placement. UKA was completed on 25 cadaver specimens (hip to toe) using an image-free approach with infrared optical navigation system with a hand held robotically assisted cutting tool. Therefore, no CT scan or MRI was required. The surface of the condylar was mapped intra operatively using a probe to record the 3 dimensional surface of the area of the knee joint to be resurfaced. Based on this data the size and orientation of the implant was planned. The user was able to rotate and translate the implant in all three planes. The system also displays the predicted gap balance graph through flexion as well as the predicted contact points on the femoral and tibial component through flexion. The required bone was removed using a bur. The depth of the cut was controlled by the robotically controlled freehand sculpting tool. Four users (3 consultant orthopaedic surgeon and a post-doctoral research associate) who had been trained on the system prior to the cadaveric study carried out the procedures. The aim of this study was to quantify the differences between the ‘planned’ and ‘achieved’ cuts. A 3D image of the ‘actual’ implant position was overlaid on the ‘planned’ implant image. The errors between the ‘actual’ and the ‘planned’ implant placement were calculated in three planes and the three rotations. The maximum femoral RMS angular error was 2.34°. The maximum femoral RMS translational error across all directions was up to 1.61mm. The maximum tibial RMS angular error was 2.60°. The maximum tibial RMS translational error across all directions was up to 1.67mm. In conclusion, the results of this cadaver study reported low RMS errors in implant position placement compared to the plan. The results were comparable with those published from clinical studies investigating other robotic orthopaedic devices. Therefore, the freehand sculpting tool was shown to be a reliable tool for cutting bone in UKA and the system allows the surgeon to plan the placement of the implant intra operatively and then execute the plan successfully

Background. Many Accident and Emergency units employ a “one size fits all” policy with regard to referring patients with musculoskeletal injury for further review in fracture clinic. This may result in inappropriate timings of review in the clinic wasting patient time, clinic time and hospital resources. Aim. Our firm employs a rapid review of all radiographs and A&E notes of all musculoskeletal injury patients referred to our fracture clinic on a weekly basis. We aimed to investigate the impact this review has on the running of our clinic and what benefits were gained. Patients and Methods. Over a three month period all the rapid trauma review meetings were audited with respect to time taken; number of referrals; outcome of referral and staff members present. During this time an audit of the number of patients reviewed in fracture clinic by the Consultant orthopaedic surgeon was also undertaken to allow the average time taken for review of a patient in the clinic to be established. Results and Discussion. Over the three month period 117 patients were reviewed with 44(38%) being given a later appointment; 6(5%) being given an earlier appointment; 8(7%) being discharged to general practice or physiotherapy and 4(3%) being referred to a different clinic. Man time taken to review was 2.4minutes per patient. Mean time for review in fracture clinic was 12.6minutes. Taking the changes to later appointment, discharges and changes to different clinic to be inappropriate referrals, 4.7 occurred per review meeting. This equated to a mean time saved per fracture clinic of 60.6 minutes. Conclusion. This data supports the use of a rapid trauma review meeting to ensure appropriate timing of review of musculoskeletal injury patients. It saves time wasted on inappropriate reviews, saves patient dissatisfaction with being seen unnecessarily and allows patients who should be reviewed more promptly to be identified and reviewed appropriately

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability. Primary traumatic anterior dislocations of the glenohumeral joint in young adults are common injuries, which are associated with persistent deficits of shoulder function and a high risk of recurrent instability. Although several risk factors have been implicated, a younger age at the time of the primary dislocation, and male gender, are the factors that have been most consistently associated with a higher risk of recurrence. Recent studies have suggested that primary arthroscopic repair of the anteroinferior detachment of the glenoid labrum (Bankart repair) may reduce the risk of subsequent recurrent instability and improve function, when compared with non-operative treatment. However, the unblinded or single-blind design of these studies fails to eliminate the potential for error due to observer or subject bias, and the therapeutic effects of the Bankart repair cannot be distinguished from those of the arthroscopic examination and washout alone. The latter may reduce the rate of subsequent instability, by promoting healing of the labral detachment, or by altering the patient's subsequent level of physical activity and compliance with rehabilitation protocols. A clinical trial conducted recently in our Institution assessed the efficacy of a primary arthroscopic stabilisation after a first-time dislcoation, whilst controlling for the therapeutic effects of the arthroscopic examination and washout alone. We aimed to specifically test the null hypothesis, that an arthroscopic Bankart repair (ABR) would not produce an improvement in the rate of recurrent instability, functional outcome, range of movement, levels of patient satisfaction or total cost of treatment, when compared with an arthroscopic examination and washout (AWO) alone. The results of this study will be presented, together with an overview of the advantages and disadvantages of primary arthroscopic stabilisation. None of the authors have received any payment or consideration from any source for the conduct of this study

During a retrospective case note analysis, a significant difference was found in prosthesis survival, between two cohorts of patients who underwent different total knee replacements. The first cohort included 70 patients who underwent Kinemax Plus total knee replacement, the second cohort included 58 patients who underwent PFC Total Knee replacement. All patients were under the care of one Consultant Orthopaedic Surgeon. Interestingly, the Kinemax Plus cohort was found to have a higher rate of revision compared to the PFC cohort. A detailed comparison was carried out between the two groups to identify any obvious cause for the disparity. The two cohorts were found to be well matched with respect to age, sex, ASA grade, underlying pathology and operative technique. Median follow up being 6 years and 5 years for the Kinemax Plus and PFC groups respectively. There were 11 failed prostheses in the Kinemax Plus cohort, 7 undergoing revision with the remaining 4 patients offered revision but unwilling to have surgery. Wear of the polyethylene tibial insert was the most obvious finding at revision, present in six of the seven revisions. 97% of the Kinemax Plus Prostheses were intact at 5 years but by 8 years only 87% were intact. There were no revisions performed in the PFC cohort. Post-operative x-ray analysis was undertaken to rule out prosthesis malalignment as a cause for the increased failure rate. The coronal alignment of the prostheses (CAK) was calculated and all post operative x-rays were within the normal limits of 4-10 degrees. Analysis of the explanted Kinemax Plus polyethylene liners was undertaken. In six cases, the polyethylene bearing surfaces displayed severe surface and subsurface delamination. This suggests massive fatigue and fatigue wear. Only one implant showed localised delamination. These findings suggest the hypothesis of weak polyethylene particle interface strength

Purpose. Pediatric orthopaedic surgeons encounter referrals from primary care practitioners and pediatricians that are benign in nature or within accepted limitations for physiological musculoskeletal variance. These referrals are believed to be secondary to insufficient pediatric musculoskeletal expertise and consume already limited pediatric orthopaedic resources. To date, our annual CME course dedicated to pediatric musculoskeletal medicine is the only one of its kind in Canada. It includes didactic teaching as well as a clinic of unnecessary referrals in which participants examine patients and receive feedback from consultants. The purpose of this study was to evaluate the impact of a pediatric musculoskeletal CME course on the quality of local outpatient referrals over a four year period. Method. Retrospective chart reviews were performed to evaluate outpatient referrals at a tertiary orthopaedic center over an eight month period prior to the commencement of an annual CME course (2006–2007) and three years following its initiation (2010). 1041 consecutive referrals from the first time period and 1124 consecutive referrals from the second time period were collected. Referrals for normal conditions within physiological tolerance were identified based on the final clinical diagnosis by the consultant orthopaedic surgeon and the scheduled follow up. Results. 872 referrals from the first time period and 1006 referrals from the second time period were provided by primary care practitioners and pediatricians. Prior to the CME course, 27.7% of referrals were for physiological conditions. These referrals were most often associated with specific benign diagnoses: torsional variation (88%) and flexible flatfoot (45%). Three years following the induction of the CME course, referrals for physiological conditions from family physicians decreased by 20.1%. Conclusion. Results from this study suggest that a pediatric musculoskeletal CME course designed for family physicians and pediatricans is an effective method for reducing unnecessary local pediatric orthopaedic referrals. We advocate that additional CME initiatives based on our annual course be implemented in communities across Canada in order to improve patient care and optimize the outpatient referral process

Clinical laxity tests are frequently used for assessing knee ligament injuries and for soft tissue balancing in total knee arthroplasty (TKA). Current routine methods are highly subjective with respect to examination technique, magnitude of clinician-applied load and assessment of joint displacement. Alignment measurements generated by computer-assisted technology have led to the development of quantitative TKA soft tissue balancing algorithms. However to make the algorithms applicable in practice requires the standardisation of several parameters: knee flexion angle should be maintained to minimise the potential positional variation in ligament restraining properties; hand positioning of the examining clinician should correspond to a measured lever arm, defined as the perpendicular distance of the applied force from the rotational knee centre; accurate measurement of force applied is required to calculate the moment applied to the knee joint; resultant displacement of the knee should be quantified. The primary aim of this study was to determine whether different clinicians could reliably assess coronal knee laxity with a standardised protocol that controlled these variables. Furthermore, a secondary question was to examine if the experience of the clinician makes a difference. We hypothesised that standardisation would result in a narrow range of laxity measurements obtained by different clinicians. Six consultant orthopaedic surgeons, six orthopaedic trainees and six physiotherapists were instructed to assess the coronal laxity of the right knee of a healthy volunteer. Points were marked over the femoral epicondyles and the malleoli to indicate hand positioning and give a constant moment arm. The non-invasive adaptation of a commercially available image-free navigation system enabled real-time measurement of coronal and sagittal mechanical femorotibial (MFT) angles. This has been previously validated to an accuracy of ±1°. Collateral knee laxity was defined as the amount of angular displacement during a stress manoeuvre. Participants were instructed to maintain the knee joint in 2° of flexion whilst performing a varus-valgus stress test using what they perceived as an acceptable load. They were blinded to the coronal MFT angle measurements. A hand-held force application device (FAD) was then employed to allow the clinicians to apply a moment of 18Nm. This level was based on previous work to determine a suitable subject tolerance limit. They were instructed to repeat the test using the device in the palm of their right hand and to apply the force until the visual display and an auditory alarm indicated that the target had been reached. The FAD was then removed and participants were asked to repeat the clinical varus-valgus stress test, but to try and apply the same amount of force as they had been doing with the device. Maximum MFT angular deviation was automatically recorded for each stress test and the maximum moment applied was recorded for each of the tests using the FAD. Means and standard deviations (SD) were used to compare different clinicians under the same conditions. Paired t-tests were used to measure the change in practice of groups of clinicians before, during and after use of the FAD for both varus and valgus stress tests. All three groups of clinicians initially produced measurements of valgus laxity with consistent mean values (1.5° for physiotherapists, 1.8° for consultants and 1.6° for trainees) and standard deviations (<1°). For varus, mean values were consistent (5.9° for physiotherapists, 5.0° for consultants and 5.4° for trainees) but standard deviations were larger (0.9° to 1.6°). When using the FAD, the standard deviations remained low for all groups for both varus and valgus laxity. Introducing the FAD overall produced a significantly greater angulation in valgus (2.4° compared to 1.6°, p<0.001) but not varus (p = 0.67) when compared to the initial examination. In attempting to reach the target moment of 18Nm, the mean ‘overshoot’ was 0.9Nm for both varus and valgus tests. Standard deviations for varus laxity were lower for all groups following use of the FAD. The consultants' performance remained consistent and valgus assessment remained consistent for all groups. The only statistically significant change in practice for a group before and after use of the FAD was for the trainees testing valgus, who may have been trained to push harder (p = 0.01). Standardising the applied moment indicated that usually a lower force is applied during valgus stress testing than varus. This was re-enforced by clinicians, one third of whom commented that they felt they had to push harder for valgus than varus, despite the FAD target being the same. We have successfully standardised the manual technique of coronal knee laxity assessment by controlling the subjective variables. The results support the hypothesis of producing a narrow range of laxity measurements but with valgus laxity appearing more consistent than varus. The incorporation of a FAD into assessment of coronal knee laxity did not affect the clinicians' ability to produce reliable and repeatable measurements, despite removing the manual perception of laxity. The FAD also provided additional information about the actual moment applied. This information may have a role in improving the balancing techniques of TKA and the management of collateral ligament injuries with regard initial diagnosis and grading as well as rehabilitation. Finally, the results suggest that following use of the FAD, more experienced clinicians returned to applying their usual manual force, while trainees appeared to use this augmented feedback to adapt their technique. Therefore this technique could be a way to harness the experience of senior clinicians and use it to enhance the perceptive skills of more junior trainees who do not have the benefit of this knowledge

Aims

The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to “frontline” specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education.