Despite the vast quantities of published artificial intelligence (AI) algorithms that target trauma and orthopaedic applications, very few progress to inform clinical practice. One key reason for this is the lack of a clear pathway from development to deployment. In order to assist with this process, we have developed the Clinical Practice Integration of Artificial Intelligence (CPI-AI) framework – a five-stage approach to the clinical practice adoption of AI in the setting of trauma and orthopaedics, based on the IDEAL principles (https://www.ideal-collaboration.net/). Adherence to the framework would provide a robust evidence-based mechanism for developing trust in AI applications, where the underlying algorithms are unlikely to be fully understood by clinical teams.

Cite this article: Bone Joint Res 2024;13(9):507–512.

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

Introduction. LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children with Lower limb differences (LLDs). The objective is to conduct an international field test study. Materials & Methods. A mixed method multiphase approach was used to develop LIMB-Q Kids. In phase one, a systematic review was conducted to identify concepts from existing PROMs used in research with children with LLDs. A preliminary conceptual framework derived from the systematic review informed an international qualitative study. The data from qualitative interviews were used to form the LIMB-Q Kids, which was further refined through multiple rounds of cognitive debriefing interviews with children. Input was obtained from parents and healthcare professionals from Australia, Canada, Ethiopia, India, UK, and the USA. LIMB-Q Kids was translated and culturally adapted into multiple languages. Results. The final field-test version consists of 11 scales (159 items) that measure appearance, physical function, symptoms (hip, knee, ankle, foot, and leg), leg-related distress, and school, social and psychological function. This version was rigorously translated into Danish and German. Translations that are in progress include Arabic, Finnish, Hindi, Swahili, Portuguese, Spanish, and Luganda. An international field-test study is underway in nine countries (15 sites with a target recruitment of 150 participants per country). At the time of abstract submission, 190 patients from seven sites have completed LIMB-Q Kids. The UK collaborative has worked on language adaption for the UK and is currently validating the score across five paediatric limb reconstruction units. Conclusions. No internationally applicable PROM exists for children with LLDs. We present the current progress in developing and validating such a score. Data from the international field-test study will be used to reduce items and perform psychometric testing of LIMB-Q Kids. The rigorous translation and cultural adaption process will provide versions of LIMB-Q Kids in different languages. Once completed, the LIMB-Q Kids will provide a common metric for outcome assessment for children with lower limb differences internationally

Increased collection of patient-reported outcome measures (PROM) in registries enables international comparison of patient-centered outcomes after knee and hip replacement. We aimed to investigate 1) variations in PROM improvement, 2) the possible confounding factor of BMI, and 3) differences in comorbidity distributions between registries. Registries affiliated with the International Society of Arthroplasty Registries (ISAR) or OECD membership countries were invited to report aggregate EQ-5D, OKS, OHS, HOOS-PS and KOOS-PS values. Eligible patients underwent primary total, unilateral knee or hip replacement for osteoarthritis within three years and had completed PROMs preoperatively and either 6 or 12 months postoperatively, excluding patients with subsequent revisions. For each PROM cohort, Chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (male/female, age 20-64/65-74/>75, high or low preoperative PROM scores). Comorbidity distributions were reported for available comorbidity indexes. Thirteen registries from 9 countries contributed data, n~130000 knee (range 140 to 79848) and n~113000 hip (range 137 to 85281). Mean EQ-5D index values (10 registries) ranged from 0.53 to 0.71 (knee) and 0.50 to 0.70 (hips) preoperatively and 0.78 to 0.85 (knee) and 0.83 to 0.87 (hip) postoperatively. Mean OKS (6 registries) ranged from 19.3 to 23.6 preoperatively and 36.2 to 41.2 postoperatively. Mean OHS (7 registries) ranged from 18.0 to 23.2 preoperatively and 39.8 to 44.2 postoperatively. Four registries reported KOOS-PS and three reported HOOS-PS. Proportions of patients with BMI >30 ranged from 35 to 62% (10 knee registries) and 16 to 43% (11 hip registries). For both knee and hip registries, distributions of patients across six BMI categories differed significantly among registries (p30 were for patients in the youngest age groups (20 to 64 and 65 to 74 years) with the lowest baseline scores. Additionally, females with lowest preoperative PROM scores had highest BMI. These findings were echoed for the OHS and OKS cohorts. Proportions of patients with ASA scores ≥3 ranged from 7 to 42% (9 knee registries) and 6 to 35% (8 hip registries). PROM-score improvement varies between international registries, which may be partially explained by differences in age, sex and preoperative scores. BMI and comorbidity may be relevant to adjust for

Introduction. Surgical outcome analysis has shifted from surgeon- to patient-reported outcome measures (PROM). High rates of dissatisfaction (13–20%) in PROM after TKA have persisted despite significant advances in pain-management, implant design and introduction of newer surgical techniques. The NAVIO robotic-assisted TKA (RA-TKA) was introduced in May 2017 as an integrative approach to planning, execution and evaluation in TKA surgery. The goal of this study was to assess differences PROM scores between conventional instrumented TKA (CI-TKA) and RA-TKA. Methods. Starting in December 2016, prospective data collection of PROM's was initiated in a single-surgeon total joint arthroplasty registry. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected for all patients pre-operatively, at three months and at one year post-operatively. In Group A, from December 2016 through May 2017, patients were treated with CI-TKA instrumentation. In Group B, from June 2017 through December 2018, surgery was performed with the NAVIO RA-TKA technique. The Journey II total knee prosthesis was used for all cases. Peri-operative management was consistent for all patients in both groups. Results. A total of 625 patients were available for analysis. 270 RA-TKA and 355 CI-TKA. The results showed a trend toward higher scores for RA-TKA for KOOS overall (p-value = 0.20) and subspecialty scores at 1-year postop, especially for pain and quality of life (p-value = 0.13) and pain (p-value = 0.12). Discussion/Conclusion. In this preliminary study, patients undergoing RA-TKA demonstrated a trend toward higher PROM scores, especially in the categories of Quality of Life and Pain, when compared to CI-TKA. Due to the limited sample size, weighted 1.3:1 for CI-TKA, statistical significance was not shown. Because of the short timeframe available since the introduction of RA-TKA, further data collection and analysis will be necessary to re-assess statistically power in this comparison

Background. Oxford joint scores are increasingly being used in evaluating outcomes following orthopaedic surgery. These patient-reported outcome measures (PROM) have been well validated, but only before and after surgical intervention. We postulated that the scores would deteriorate in the normal population with age. Methods. Members of the public accompanying patients to out-patients and the emergency department in our hospitals were asked to complete an Oxford score questionnaire having ascertained that they had no previous problem with that joint. Exclusions included other multiple joint pathologies and known connective tissue disorders. Power analysis advocated 40 subjects per decade per joint for significance at the 80% mark. 993 subjects between 20 and 80 years of age completed the forms. There were more females than males. The scores were analysed using STATA 8 software. Non-parametric tests of variance, regression analysis, and ANOVA were used. The data were analysed by decades. Results. In all joints (hip, knee, shoulder, and elbow) the mean Oxford score in the 20-30 year olds (third decade) was at least one point below the maximum. The scores then deteriorated with age at the rate of one point per decade. This was statistically significant in all groups (p = 0.002 or less) Sex had no statistical influence on the scores. Conclusion. In our mainly (98%) Caucasian population the Oxford Scores deteriorate with age. We suggest that this should be taken into account when cohort studies are being compared between surgeons and units, especially in units dealing with many younger patients. Oxford scores should be age adjusted, starting at the 3. rd. decade by adding 1 point for the 3. rd. decade, 2 for the fourth, etc. up to 6 points for the eighth decade. Other ethnic groups should also be studied

Distal radius fractures are common, yet the long-term functional outcome of these patients is unknown. This study investigated the long-term functional outcomes after distal radius fracture (DRF) in adult patients 16–23 years following injury. Secondary aims were to establish morbidity, mortality and function related to pattern of injury and patient demographics. Methods. 622 consented adult patients with a DRF were enrolled in the study. Prospective data was recorded; patient age, mechanism of injury and fracture pattern. Patients were assessed 16–23 years post-injury. 275 patients were deceased. 194 patients were able to complete a Quick Dash (QD) validated upper limb pain and function Patient-Reported Outcome Measure (PROM). Five patients declined follow-up. Socioeconomic status was assessed using the Scottish Index of Multiple Deprivation (SIMD) 2009. Results. The mean age at injury was 41 years for men and 64 for women in the initial cohort. 146 women and 48 men completed final follow-up. The mean age at QD assessment was 57 years for men and 76 for women; mean and median SIMD deciles were 6.7 and 7, respectively, for both genders. The mean QD score was 10.35 for all patients, with no significant gender difference (p=0.63). 85.6% (n=166) reported no or at most, mild limitation. High socioeconomic status, absence of other injuries at DRF and age under 85 years old at follow-up was associated with better long-term function. Early function and pain predicted long-term function; comminution pattern, treatment modality as chosen by surgeon, and early complications did not. Mortality data was analysed for the deceased (n=275). The mean patient survival from DRF to death was 11 years 5 months, with no significant gender difference (p=0.43); survival was predicted by age at injury, post-treatment dorsal angulation and early function. Respiratory, cardiovascular causes and malignancy were the three most common primary causes of death

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.