Up to 20 percent of patients remain dissatisfied after primary total knee arthroplasty (TKA) surgery. Understanding the reasons for dissatisfaction post TKA may allow for better patient selection and optimized treatment for those who remain dissatisfied. The association between function, mobility and satisfaction are not well understood. The purpose of this study was to investigate the association between post-TKA satisfaction and i) pre-operative, ii) post-operative, and iii) change in knee joint function during gait. Thirty-one patients scheduled to receive primary TKA for knee osteoarthritis (OA) diagnosis were recruited and visited the Dynamics of Human Motion laboratory for instrumented walking gait analysis (using a synchronized NDI Optotrak motion capture system and AMTI force platforms in the walkway) at two time points, first within the week prior to their surgery, and second at approximately one year after surgery. At their post-operative visit, patients were asked to indicate their satisfaction with their knee prosthesis on a scale from zero to 100, with zero being totally unsatisfied and 100 being completely satisfied. Knee joint mechanics during gait at both time points were characterized by discriminant scores, the projection of their three-dimensional knee angles and moments during gait onto an existing discriminant model that was created to optimize separation of severe knee OA and healthy asymptomatic gait patterns. This discriminant model was created using data from 73 healthy participants and 73 with severe knee OA, and includes the magnitude and pattern features (captured with principal component analysis) of the knee adduction and flexion moment, and the magnitude of the knee flexion angle during gait. Larger discriminant scores indicate improved function toward healthy patterns, and smaller scores indicate more severe function. Associations between post-operative satisfaction and pre, post and change in discriminant scores were examined using Pearson correlation analyses. We also examined associations between satisfaction and pre-operative BMI, EQ5D and Oxford 12 scores, as well as changes in these scores from pre to post-TKA. Discriminant scores representing knee joint function during gait significantly improved on average after surgery (P =0.05). While overall knee joint function improved after primary TKA surgery, the amount of improvement in function was not reflected in post-operative patient satisfaction. However, the pre-operative function of the patient was negatively associated with satisfaction, indicating that patients with higher pre-operative function are overall less satisfied with their TKA surgery, regardless of any functional improvement due to the surgery. Interestingly, the only significant association with post-operative satisfaction was knee joint function, and the relationship between function and patient satisfaction following TKA appears to relate only to the baseline functional state of the patient, and not with functional improvement. This suggests that dissatisfaction post-surgery is more likely reflecting the unmet expectations of a higher functioning patient, and has implications for the need for improved understanding of pre-operative patient functional variability in TKA triage and expectation management

Abstract. Introduction. The extent to which hip arthroscopy (HA) treatments influence sexual function is not well described and limited to small cohorts. This study aims to describe trends in self-reported reported sexual function before and after HA. Methods. Adult (≥18 years) patients who underwent HA between 1/01/2012 and 31/10/2020 were extracted from the UK Non-Arthroplasty Hip Registry. International Hip Outcome Tool 12 (iHOT-12) questionnaires were collected pre-operatively and at 6 and 12 months. The iHOT-12 then asks asking patients to quantify ‘how much trouble they experience with sexual activity because of their hip?’ with responses converted to a continuous scale (0–100) to measure function. Results. Of 7639 procedures (59% female, mean age 36.5 years (SD 11)), 91% (5616 of 6151 respondents) indicated pre-operatively that questions about sexual activity were relevant to them (male 93%, female 90%, p < 0.001). Overall, mean pre-operative sexual function increased from 42.0 (95%CI 41.2 to 42.8, n=5267) to 61.8 (60.6 to 63.1, n=2393) at 6 months, and 62.1 (60.8 to 63.5, n=2246) at 12 months post-operatively. At 12 months, both sexes saw significant improvement in their pre-operative sexual function scores (p<0.0001). Males started from significantly higher baseline sexual function (53.3 vs 34.2) and achieved higher scores by 12 months (68.8 vs 58.0) compared to female patients. There was no significant difference in pre- or post-operative scores when comparing younger (<40 years) and older (>40 years). Conclusions. Most patients can expect to experience improvement in their sexual function following hip arthroscopy, regardless of sex or age group

Risk factors for poor outcomes after total knee replacement (TKR) have been identified, but the underlying causes are not fully understood. The aim of this research was to establish the relationship between measurable gait parameters and patients' subjective function, pre and post total knee replacement. 25 subjects underwent gait analysis, before and one year following total knee replacement. Patient reported function was investigated using the Activities of Daily Living Scale of the Knee Outcome Survey (KOS). Gait analysis was performed using infrared cameras and reflective marker clusters. Correlation between motion analysis data and patient reported function was investigate. Whilst multiple gait parameters correlated with KOS score preoperatively, there was no correlation after TKR. Three preoperative measurements correlated with the improvement in score a subject achieved following surgery: These were preoperative rate of extension in swing, total range of flexion from heel strike and time point of maximum stance extension. Our results suggest that whilst preoperatively there is a close relationship between knee biomechanical function and patient reported function, after TKR factors other than biomechanical function determine patient outcomes

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

Smartphone-based apps that measure step-count and patient reported outcomes (PROMs) are being increasingly used to quantify recovery in total hip arthroplasty (THA). However, optimum patient-specific activity level before and during THA early-recovery is not well characterised. This study investigated 1) correlations between step-count and PROMs and 2) how patient demographics impact step-count preoperatively and during early postoperative recovery. Smartphone step-count and PROM data from 554 THA patients was retrospectively reviewed. Mean age was 64±10yr, BMI was 29±13kg/m2, 56% were female. Mean daily step count was calculated over three time-windows: 60 days prior to surgery (preop), 5–6 weeks postop (6wk), and 11–12 weeks postop (12wk). Linear correlations between step-count and HOOS12 Function and UCLA activity scores were performed. Patients were separated into three step-count levels: low (<2500steps/day), medium (2500-5500steps/day), and high (>5500steps/day). Age >65years, BMI >30, and sex were used for demographic comparisons. Student's t-tests determined significant differences in mean step-counts between demographic groups and in mean PROMs between step-count groups. UCLA correlated with step-count at all time-windows (p<0.01). HOOS12 Function correlated with step-count preoperatively and at 6wk (p<0.01). High vs low step count individuals had improved UCLA scores preoperatively (∆1.8,p<0.001), at 6wk (∆1.1,p<0.05), and 12wk (∆1.6,p<0.01), and improved HOOS12 Function scores preoperatively (∆8.4,p<0.05) and at 6wk (∆8.8,p<0.001). Younger patients had greater step-count preoperatively (4.1±3.0k vs 3.0±2.5k, p<0.01) and at 12wk (5.1±3.3k vs 3.6±2.9k, p<0.01). Males had greater step-count preoperatively (4.1±3.0k vs. 3.0±2.7k, p<0.001), at 6wk (4.5±3.2k vs 2.6±2.5k, p<0.001), and at 12wk (5.2±3.6k vs. 3.4±2.5k, p<0.001). Low BMI patients had greater step-count at 6wk (4.3±3.3k vs. 2.6±2.7k, p<0.01) and 12wk (5.0±3.6k vs. 3.6±2.6k, p<0.05). Daily step-count is significantly impacted by patient demographics and correlates with PROMs, where patients with high step count exhibit improved PROMs. Generic recovery profiles may therefore not be appropriate for benchmarking across diverse populations

Despite total knee arthroplasty demonstrating high levels of success, 20% of patients report dissatisfaction with their result. Wellness Stasis Socks are embedded with a proprietary pattern of neuro-receptor activation points that have been proven to activate a precise neuro-response, as according to the pattern theory of haptic perception, which stimulates improvements in pain and function. Technologies that manipulate this sensory environment, such as textured insoles, have proven to be effective in improving gait patterns in patients with knee osteoarthritis. In regard to patients undergoing TKA using this new technology may prove beneficial as an adjunct to recovery as many patients suffer from further deficits to their proprioceptive system caused by ligamentous damage and alterations to mechanoreceptors during procedure. We hypothesized that the Wellness Stasis Socks are a safe, cost-effective and easily scalable strategy to support TKA patients through their recovery. Double-blinded, placebo-controlled randomized trial. Randomization using a computer-generated program . All study coordinators, healthcare personel and patients were blinded to patient groups. All surgical procedures were conducted by the same technique and orthopaedic surgeon. Intervention group: Wellness Stasis socks containing receptor point-activation technology. Control group: indentical appearing Wellness Stasis socks without receptor point-activation technology. Sock use during the waking hours . All additional post-operative protocols remained consistent between groups including same facility physiotherapy . Additional modalities (ice machines, soft-tissue massages, acupuncture) were prohibited. WOMAC questionnaire completed at baseline, 2 weeks, and 6 weeks to assess pain, stiffness and physical function. G. *. Power software to determine minimum sample of 50 in each group. No patients were lost to follow up and all followed study protocol. Data analysis using SPSS software. P-values, effect sizes, and confidence intervals are reported to assess clinical relevance of the finding. Physical status classifications were compared using t-test. Within-subject and between-subject differences in the mean WOMAC were analyzed by ANOVA. Cramer's V statistical analysis noted that other variables of Sex, BMI, ASA classification and Age were not statistically different between the control and intervention groups. No statistical difference between groups in Preop Womac scores. The data showed a consistent improvement in Womac scores for pain and stiffness at 2 weeks post op in the interventional group over the control group. The womac scores assessing physical function showed a consistent improvement at both 2 and 6 weeks post op in the intervention group compared to the control group. There were no complications in either group associated the sock use. The intervention proved to be a low cost and safe additional intervention post operatively from TKA to help patients improve with regard to pain, stiffness and physical function. This study suggests this modality can be added to the list of other commonly used post op interventions such as cryocuffs, physiotherapy, and relaxation techniques as safe post op interventions to help patients improve post op TKA and can act as an adjunct in providing non narcotic pain control

Introduction. Despite the rising popularity of 1st carpometacarpal joint (CMCJ) arthrodesis as one of the surgical options for basilar thumb arthritis, the available literature on this is poor. This study aims to investigate post-operative pinch and grip strength following 1st CMCJ arthrodesis, at a minimum of 1 year follow-up. Complication rates, range of motion and patient reported scores were also evaluated. Methods. A retrospective cohort (2012–2020) was used, which included patients who had arthrodesis performed by the Hands surgeons at Counties Manukau DHB. In a 15 minute visit, we took the measurements using our standard dynamometer and pinch gauge, and collected three questionnaires [QuickDASH, PRWHE, PEM]. For analysis, we compared our results to the preoperative measures, contralateral hand, and to a previous study on a similar cohort looking at thumb strength following trapeziectomy. Results. 42 arthrodesis were performed, and 24 were available for follow-up. The average follow-up time was 77 months and the average age was 51 years old. Overall, we found a statistically significant improvement in thumb strength following surgery. Mean preoperative grip strength was 21.4kg and 32.5kg postoperatively (= +11kg). Preoperative pinch strength was 5.5kg and 7kg postoperatively (= +1.5kg). These results were significantly higher compared to the trapeziectomy cohort. We also found an improvement in 1st CMCJ ROM post-operatively. 7 complications were reported (29.1%). 4 were metalware-related and 3 were non-union. QuickDASH score significantly improved from a median of 42.95 to 12.5 while PRWHE from 67.5 to 14.5. Overall patient satisfaction was 87.4%. Conclusion. 1st CMCJ arthrodesis leads to an improvement in thumb function, pain and range of movement and results in high patient satisfaction, and therefore should be recommended for younger patients who need a pain-free and strong thumb

Introduction. Robotic-assisted total knee arthroplasty (TKA) has demonstrated significant benefits, including improved accuracy of component positioning compared to conventional jig-based TKA. However, previous studies have often failed to associate these findings with clinically significant improvements in patient-reported outcome measures (PROMs). Inertial measurement units (IMUs) provide a more nuanced assessment of a patient's functional recovery after TKA. This study aims to compare outcomes of patients undergoing robotic-assisted and conventional TKA in the early postoperative period using conventional PROMS and wearable sensors. Method. 100 patients with symptomatic end-stage knee osteoarthritis undergoing primary TKA were included in this study (44 robotic-assisted TKA and 56 conventional TKA). Functional outcomes were assessed using ankle-worn IMUs and PROMs. IMU- based outcomes included impact load, impact asymmetry, maximum knee flexion angle, and bone stimulus. PROMs, including Oxford Knee Score (OKS), EuroQol-Five Dimension (EQ-5D-5L), EuroQol Visual Analogue Scale (EQ-VAS), and Forgotten Joint Score (FJS-12) were evaluated at preoperative baseline, weeks 2 to 6 postoperatively, and at 3-month postoperative follow-up. Results. By postoperative week 6, when compared to conventional TKA, robotic-assisted TKA was associated with significant improvements in maximum knee flexion angle (118o ± 6.6 vs. 113o ± 5.4; p=0.04), symmetrical loading of limbs (82.3% vs.22.4%; p<0.01), cumulative impact load (146.6% vs 37%; p<0.01), and bone stimulus (25.1% vs 13.6%; p<0.01). Whilst there were no significant differences in PROMs (OKS, EQ-5D-5L, EQ-VAS, and FJS-12) at any time point between the two groups, when comparing OKS subscales, significantly more robotic-assisted TKA patients achieved an ‘excellent’ outcome at 6 weeks compared to conventional (47% vs 41%, p= 0.013). Conclusions. IMU-based metrics detected an earlier return to function among patients that underwent robotic-assisted TKA compared to conventional TKA that PROMs were unable to detect within the first six weeks of surgery

Combined Partial Knee Arthroplasty (CPKA) is a promising alternative to Total Knee Arthroplasty (TKA) for the treatment of multi-compartment arthrosis. Through the simultaneous or staged implantation of multiple Partial Knee Arthroplasties (PKAs), CPKA aims to restore near-normal function of the knee, through retention of the anterior cruciate ligament and native disease-free compartment. Whilst PKA is well established, CPKA is comparatively novel and associated biomechanics are less well understood. Clinically, PKA and CPKA have been shown to better restore knee function compared to TKA, particularly during fast walking. The biomechanical explanation for this superiority remains unclear but may be due to better preservation of the extensor mechanism. This study sought to assess and compare extensor function after PKA, CPKA, and TKA. An instrumented knee extension rig facilitated the measurement extension moment of twenty-four cadaveric knees, which were measured in the native state and then following a sequence of arthroplasty procedures. Eight knees underwent medial Unicompartmental Knee Arthroplasty (UKA-M), followed by patellofemoral arthroplasty (PFA) thereby converting to medial Bicompartmental Knee Arthroplasty (BCA-M). In the final round of testing the PKA implants were removed a posterior-cruciate retaining TKA was implanted. The second eight received lateral equivalents (UKA-L then BCA-L) then TKA. The final eight underwent simultaneous Bi-Unicondylar Arthroplasty (Bi-UKA) before TKA. Extensor efficiencies over extension ranges typical of daily tasks were also calculated and differences between arthroplasties were assessed using repeated measures analysis of variance. For both the medial and lateral groups, UKA demonstrated the same extensor function as the native knee. BCA resulted in a small reduction in extensor moment between 70–90° flexion but, in the context of daily activity, extensor efficiency was largely unaffected and no significant reductions were found. TKA, however, resulted in significantly reduced extensor moments, leading to efficiency deficits ranging from 8% to 43% in flexion ranges associated with downhill walking and the stance phase of gait, respectively. Comparing the arthroplasties: TKA was significantly less efficient than both UKA-M and BCA-M over ranges representing stair ascent and gait; TKA showed a significant 23% reduction compared to BCA-L in the same range. There were no differences in efficiency between the UKAs and BCAs over any flexion range and TKA efficiency was consistently lower than all other arthroplasties. Bi-UKA generated the same extensor moment as native knee at flexion angles typical of fast gait (0–30°). Again, TKA displayed significantly reduced extensor moments towards full extension but returned to the normal range in deep flexion. Overall, TKA was significantly less efficient following TKA than Bi-UKA. Recipients of PKA and CPKA have superior functional outcomes compared to TKA, particularly in relation to fast walking. This in vitro study found that both UKA and CPKA better preserve extensor function compared to TKA, especially when evaluated in the context of daily functional tasks. TKA reduced knee extensor efficiency by over 40% at flexion angles associated with gait, arguably the most important activity to maintain patient satisfaction. These findings go some way to explaining functional deficiencies of TKA compared to CPKA observed clinically

While controversy remains as to the relative benefit of operative (OM) versus non-operative management (NOM) of Achilles tendon ruptures (ATR), few studies have examined the effect on high impact maneuvers such as jumping and hopping. The purpose of this study is to compare functional performance and musculotendinous morphology in patients following OM or NOM for acute ATR.

Eligible patients were aged 18-65 years old with an ATR who underwent OM or NOM within three weeks of injury and were at least one-year post injury. Gastrocnemius muscle thickness and Achilles tendon length and thickness were assessed with ultrasound. Functional performance was examined with single-leg hop tests and isokinetic plantar strength at 60o/s and 120o/s.

24 participants completed testing (12/ group). Medial (OM: 2.2 ± 0.4 cm vs 1.9 ± 0.3 cm, NOM 2.15 ± 0.5 cm vs 1.7 ± 0.5 cm; p = 0.002) and lateral (OM 1.8 ± 0.3 cm vs 1.5 ± 0.4 cm, NOM 1.6 ± 0.4 cm vs 1.3 ± 0.5 cm; p = 0.008) gastrocnemius thickness were reduced on the affected limb. The Achilles tendon was longer (OM: 19.9 ± 2.2 cm vs 21.9 ± 1.6 cm; NOM: 19.0 ± 3.7 cm vs 21.4 ± 2.9 cm; p = 0.009) and thicker (OM: 0.48 ± 0.16 cm vs 1.24 ± 0.20 cm; NOM: 0.54 ± 0.08 cm vs 1.13 ± 0.23 cm; p < 0.001) on the affected limb with no differences between groups. Affected limb plantar flexion torque at 20o plantar flexion was reduced at 60o/s (OM: 55.6 ± 20.2 nm vs 47.8 ± 18.3 nm; NOM: 59.5 ± 27.5 nm vs 44.7 ± 21.0 nm; p = 0.06) and 120o/s (OM: 44.6 ± 17.9 nm vs 36.6 ± 15.0 nm; NOM: 48.6 ± 16.9 nm vs 35.8 ± 10.7 nm; p = 0.028) with no group effect. There was no difference in single leg hop performance. Achilles tendon length explained 31.6% (p = 0.003) and 18.0% (p = 0.025) of the variance in plantar flexion peak torque limb symmetry index (LSI) at 60o/s and 120o/s respectively. Tendon length explained 28.6% (p=0.006) and 9.5% (p = 0.087) of LSI when torque was measured at 20o plantar flexion at 60o/s and 120o/s respectively. Conversely, tendon length did not predict affected limb plantar flexion peak torque (nm), angle-specific torque at 20o plantar flexion (nm) and affected limb single leg hop distance (cm) or LSI (%).

There was no difference in tendon length between treatment groups and deficits in gastrocnemius thickness and strength are persistent. Deficits in the plantar flexion strength LSI are partially explained by increased tendon length following Achilles tendon rupture, regardless of treatment strategy. Hop test performance is maintained and may be the result of compensatory movements at other joints despite persistent plantarflexion weakness.

Total joint arthroplasty (TJA) is often utilized to improve pain and dysfunction associated with end-stage osteoarthritis. Previous research has suggested that depression may negatively impact patient reported pain and function. The purpose of this study was to determine the effect of pre-operative depressive symptoms, using the Center for Epidemiologic Scale for Depression (CES-D) scale, on patient reported function and pain at one, three and six months following TJA, after controlling for the impact of age, sex, pain, joint replaced, and other comorbidities. This was a secondary analysis of a prospective cohort of 710 patients aged 40 years and older who underwent elective primary TJA in the Edmonton zone. Participants were recruited pre-operatively and reported socio-demographics, comorbid conditions and medications (including depression medications where appropriate), each participant also completed the Western Ontario McMaster (WOMAC) Osteoarthritis Index and the CES-D scale preoperatively. Participants then completed the WOMAC and CES-D scale again at one, three, and six months postoperatively. Risk-adjusted longitudinal data analysis using a linear mixed regression model was performed, controlling for age, sex, joint replaced, chronic pain, comorbidity, social support and employment status. THA participants had a mean age of 65.9±10.1 years and included 175 (57%) female while TKA participants had a mean age of 67.9±10.1 years and included 249 (61%) females. ‘Possible’ depressive symptoms (CES-D score 16–19) were identified in 58 (8.1%) participants while ‘probable’ depressive symptoms (CES-D score ≥20) were identified in 68 (9.6%) participants. The mean WOMAC pain and function scores, when analyzed using the linear mixed regression model, demonstrated improvement from baseline at one, three, and six months (p < 0 .001 for both pain and function models as well as over time). However, in the patients with possible and probable depressive symptoms, WOMAC pain scores were 7.6±1.5 and 11.7±1.3 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, chronic pain, comorbidities and social support. Similarly, WOMAC function scores in the patients with possible and probable depressive symptoms were 8.8±1.4 and 14.2±1.2 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, comorbidities and employment status. Depressive symptoms negatively affect postoperative pain and function measured using WOMAC scales even after risk adjustment up to six-months post TJA. Screening for depressive symptomology both pre- and postoperatively may provide an opportunity to identify and manage depressive symptoms to improve postoperative pain and function

Total joint arthroplasty (TJA) is often utilized to improve pain and dysfunction associated with end-stage osteoarthritis. Previous research has suggested that depression may negatively impact patient reported pain and function. The purpose of this study was to determine the effect of preoperative depressive symptoms, using the Center for Epidemiologic Scale for Depression (CES-D) scale, on patient reported function and pain at one, three and six months following TJA, after controlling for the impact of age, sex, pain, joint replaced, and other comorbidities. This was a secondary analysis of a prospective cohort of 710 patients aged 40 years and older who underwent elective primary TJA in the Edmonton zone. Participants were recruited pre-operatively and reported socio-demographics, comorbid conditions and medications (including depression medications where appropriate), each participant also completed the Western Ontario McMaster (WOMAC) Osteoarthritis Index and the CES-D scale preoperatively. Participants then completed the WOMAC and CES-D scale again at one, three, and six months postoperatively. Risk-adjusted longitudinal data analysis using a linear mixed regression model was performed, controlling for age, sex, joint replaced, chronic pain, comorbidity, social support and employment status. THA participants had a mean age of 65.9±10.1 years and included 175 (57%) female while TKA participants had a mean age of 67.9±10.1 years and included 249 (61%) females. ‘Possible’ depressive symptoms (CES-D score 16–19) were identified in 58 (8.1%) participants while ‘probable’ depressive symptoms (CES-D score ≥20) were identified in 68 (9.6%) participants. The mean WOMAC pain and function scores, when analyzed using the linear mixed regression model, demonstrated improvement from baseline at one, three, and six months (p < 0 .001 for both pain and function models as well as over time). However, in the patients with possible and probable depressive symptoms, WOMAC pain scores were 7.6±1.5 and 11.7±1.3 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, chronic pain, comorbidities and social support. Similarly, WOMAC function scores in the patients with possible and probable depressive symptoms were 8.8±1.4 and 14.2±1.2 worse respectively than those without depressive symptoms after controlling for age, sex, joint replaced, comorbidities and employment status. Depressive symptoms negatively affect postoperative pain and function measured using WOMAC scales even after risk adjustment up to six-months post TJA. Screening for depressive symptomology both pre- and postoperatively may provide an opportunity to identify and manage depressive symptoms to improve postoperative pain and function

Aim. Chronic bone infections and infected fractures are often treated with excision of the dead bone and implantation of biomaterials which elute antibiotics. Gentamicin has been a preferred drug for local delivery, but this could induce renal dysfunction due to systemic toxicity. This is a particular concern in patients with pre-existing chronic renal disease treated with new antibiotic carriers which achieve very high peak levels of gentamicin in the first few days after surgery. Method. 163 patients (109 males; average age 51.6 years) with Cierny-Mader Type 3 or 4 chronic osteomyelitis had a single-stage operation with excision of the dead bone, filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier, containing gentamicin and immediate soft tissue closure. 2. No patient was given systemic gentamicin or other renal toxic antibiotics. Mean carrier volume was 10.9mls (range 1–30mls) and mean gentamicin dosing was 190.75mg (maximum 525mg). Seven patients had pre-existing renal disease (4 diabetic nephropathy, 1 nephrotic syndrome, 1 renal transplant and 1 previous acute kidney injury). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Glomerular filtration rate (GFR) was calculated using the CKD-epi creatinine equation. Renal function was defined using the Chronic Kidney Disease (CKD) Staging system. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. Pre-operative CKD staging demonstrated 118 Class I (normal renal function), 30 Class II, 3 Class IIIa, 3 Class IIIb, and 1 Class V disease. Mean pre-operative GFR (99.7ml/min/1.73m. 2. , SD 21.0) was no different to post-operative GFR (103.2ml/min/1.73m. 2. , SD 21.3), p= 0.0861. Four cases had a >10% decline in GFR below normal, with only one case dropping a CKD stage, from I (normal) to II (mildly decreased). Only 1/7 cases with pre-existing renal disease had a GFR drop of >10% (from 11ml/min/1.73m. 2. to 8ml/min/1.73m. 2. ). 70/155 (45.2%) had a temporary GFR drop post-operatively, with the biggest drop occurring a mean 3.06 days following surgery (SD 2.1). No patient had clinical signs of new acute renal impairment post-operatively. Conclusions. Renal function is not significantly affected by local implantation of gentamicin up to 525mg. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

Background. The hip joint capsular ligaments passively restrain extreme range of motion (ROM), protecting the native hip against impingement, subluxation, edge loading and dislocation. This passive protection against instability would be beneficial following total hip arthroplasty (THA), however the reduced femoral head diameter postoperatively may prevent a wrapping mechanism that is essential to capsular ligament function in the native hip. Therefore we hypothesized that, post-THA, the reduced femoral head size would prevent the capsular ligaments protective biomechanical function. Methods. In vitro, THA was performed through the acetabular medial wall preserving the entire capsule, avoiding targeting a particular surgical approach. Eight fresh-frozen cadaveric hips were examined and capsular function was measured by internally/externally rotating the hip in five positions ranging from full extension with abduction, to full flexion with adduction. Three head sizes (28, 32, 36 mm) with three neck lengths (restored native 0, +5, +10 mm) were compared. Results. Internal and external rotation ROM increased following THA, indicating late engagement of the capsule and reduced biomechanical function (p<0.05). Internal rotation was affected more than external. Increasing neck length restored ROM more towards the native condition, but too much lengthening over-constrained external rotation. Increasing head size only had a small effect, restoring ROM towards the native condition. Conclusions. Following THA, the capsular ligaments were unable to wrap around the reduced diameter femoral head to restrain excessive hip movement. The posterior capsule was the most affected, indicating native posterior capsule preservation is not advantageous at least in the short-term. Decreased neck length could cause capsular dysfunction, whilst increased could over-tighten the anterior capsule. Relevance. Increased understanding of soft tissue balancing following THA could help prevent instability, a frequent and long-standing THA complication. This study illustrates how the capsule will function according to its preservation or repair following THA

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

The function of the shoulder joint has traditionally been evaluated based on range of motion (ROM) in predefined anatomical planes and also by using functional scores, which assessed shoulder function based on the ability to conduct certain activities of daily living (ADLs). However, measuring ROM only in terms of flexion-extension, abduction-adduction and internal-external rotation may under-account for the 3-dimensional mobility of the shoulder joint. Furthermore, functional scores, such as the Oxford shoulder score or American shoulder and elbow surgeons (ASES) score, are subjective measures and are not an accurate assessment of shoulder joint function. In this study, we proposed the use of the globe model of the shoulder joint which can be used to provide an objective measure of the global ROM and also function of the shoulder joint – termed the Global and Functional arc of motion (GAM and FAM). Thirty-three young, healthy male patients (23.7 ± 1.5 years) were recruited and tasked to perform eight ADLs and a full humeral circumduction movement which represented their active global ROM. Reflective markers were placed in accordance to the International Society of Biomechanics (ISB) and optical-based motion capture cameras were used to track relative motion of the dominant humerus with respect to the thorax (i.e. thoracohumeral motion). The GAM and FAM were generated by plotting the thoracohumeral on a spherical coordinate system during global ROM and the eight ADLs respectively. Shoulder joint global ROM and function were quantified by calculating the area enclosed by the closed loop of GAM and FAM respectively. The spherical coordinate system, or more commonly referred to as the globe model, describes thoracohumeral movement using plane of elevation (POE), angle of elevation (AOE) and rotation. In our model, POE and AOE represents longitude and latitude of the globe respectively, and rotation is depicted using a red-green-blue (RGB) colour scale. Overall, subject's GAM of the shoulder joint covered an area of 4.64 ± 0.48 units2 compared to only 1.12 ± 0.26 units2 for the FAM. Subjects only required 24.4 ± 5.7 % of their global shoulder ROM for basic daily functioning. Studies that reduced shoulder joint movement into planar movements (i.e. sagittal, coronal and rotation) do not account for the 3-dimensional nature of the joint and doing so may overestimate the requirement of the shoulder joint for ADLs relative to its ROM in each plane. While others have attempted to use the globe model, such studies tend to reduce the globe into its descriptive angles (i.e. POE, AOE and rotation), reducing its intuitiveness. In contrast, by keeping an intact globe, the proposed globe model was more intuitive and yet capable of quantifying both shoulder joint global ROM and function. Doing so, we found that young healthy subjects only required approximately a quarter of their global ROM of the shoulder joint to complete the most common daily tasks, which was significantly less than what was previously reported

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

The Coronal Plane Alignment of the Knee (CPAK) is a recent method for classifying knees using the hip-knee-ankle angle and joint line obliquity to assist surgeons in selection of an optimal alignment philosophy in total knee arthroplasty (TKA)1. It is unclear, however, how CPAK classification impacts pre-operative joint balance. Our objective was to characterise joint balance differences between CPAK categories.

A retrospective review of TKA's using the OMNIBotics platform and BalanceBot (Corin, UK) using a tibia first workflow was performed. Lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were landmarked intra-operatively and corrected for wear. Joint gaps were measured under a load of 70–90N after the tibial resection. Resection thicknesses were validated to recreate the pre-tibial resection joint balance.

Knees were subdivided into 9 categories as described by MacDessi et al.1 Differences in balance at 10°, 40° and 90° were determined using a one-way 2-tailed ANOVA test with a critical p-value of 0.05.

1124 knees satisfied inclusion criteria. The highest proportion of knees (60.7%) are CPAK I with a varus aHKA and Distal Apex JLO, 79.8% report a Distal Apex JLO and 69.3% report a varus aHKA. Greater medial gaps are observed in varus (I, IV, VII) compared to neutral (II, V, VIII) and valgus knees (III, VI, IX) (p<0.05 in all cases) as well as in the Distal Apex (I, II, III) compared to Neutral groups (IV, V, VI) (p<0.05 in all cases). Comparisons could not be made with the Proximal Apex groups due to low frequency (≤2.5%).

Significant differences in joint balance were observed between and within CPAK groups. Although both hip-knee-ankle angle and joint line orientation are associated with joint balance, boney anatomy alone is not sufficient to fully characterize the knee.

Introduction. The treatment of chronic bone infection often involves excision of dead bone and implantation of biomaterials which elute antibiotics. Gentamicin is a preferred drug for local delivery, but its systemic use carries a well-established risk of nephrotoxicity. We aim to establish the risk of renal injury with local delivery in a ceramic carrier. Materials and Methods. 163 consecutive patients with Cierny-Mader Type 3 or 4 chronic osteomyelitis were treated with a single-stage operation which included filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier containing gentamicin. The mean carrier volume used was 10.9mls, leading to a mean implanted gentamicin dose of 191.3mg (maximum 525mg). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Renal impairment was graded using the Chronic Kidney Disease (CKD) Staging system, and AKI was assessed using the RIFLE criteria. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. 7 patients had pre-existing renal disease. 70 patients (45.2%) had a temporary eGFR drop post-operatively, with the greatest decrease occurring a mean 3.06 days following surgery. Twenty cases had a >10% decline in eGFR, but 12 resolved within 7 days. 7 patients transiently fell into the “Risk” category according to RIFLE criteria, but no patient had a change consistent with “Injury”, “Failure” or “Loss” of renal function and none had clinical signs of new acute renal impairment post-operatively. Conclusions. The implantation of up to 525mg of gentamicin contained within Cerament G, as part of the surgical treatment of osteomyelitis, is safe and carries minimal risk of significant acute kidney injury. A small, transient increase in serum creatinine may be observed in the early post-operative period, and attention should be paid to limit patients exposure to other nephrotoxic agents. The majority of patients will return to their baseline renal function within 7 days following the operation. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy