The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to free hand orthopaedic operation notes. A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to free hand operation notes. 97 cases were identified, of which 74 were free hand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes vs 0 (0%) in the free hand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the free hand op-note group (templated median 14, range 12-14, vs. free hand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by Registrars or Consultants identified Registrars as more likely to document the antibiotic prophylaxis given (p = 0.025). Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations

Glutamate regulates the expression of apoptosis-related genes and triggers the apoptosis of fibroblasts in rotator cuff tendons. Subacromial bursitis is always accompanied by symptomatic rotator cuff tear (RCT). However, no study has been reported on the presence of glutamate in subacromial bursa and on its involvement of shoulder pain in patients who had RCT. The purposes of this study were to determine whether the glutamate expression in subacromial bursa is associated with the presence of RCT and with the severity of shoulder pain accompanying RCT. Subacromial bursal tissues were harvested from patients who underwent arthroscopic rotator cuff tendon repair or glenoid labral repair with intact rotator cuff tendon. Glutamate tissue concentrations were measured, using a glutamate assay kit. Expressions of glutamate and its receptors in subacromial bursae were histologically determined. The sizes of RCT were determined by arthroscopic findings, using the DeOrio and Cofield classification. The severity of shoulder pain was determined, using visual analog scale (VAS). Any associations between glutamate concentrations and the size of RCT were evaluated, using logistic regression analysis. The correlation between glutamate concentrations and the severity of pain was determined, using the Pearson correlation coefficient. Differences with a probability <0.05 were considered statistically significant. Glutamate concentrations showed significant differences between the torn tendon group and the intact tendon group (P = 0.009). Concentrations of glutamate significantly increased according to increases in tear size (P < 0.001). In histological studies, the expressions of glutamate and of its ionotropic and metabotropic receptors have been confirmed in subacromial bursa. Glutamate concentrations were significantly correlated with pain on VAS (Rho=0.56 and P =0.01). The expression of glutamate in subacromial bursa is significantly associated with the presence of RCT and significantly correlated with its accompanying shoulder pain. Acknowledgements: This research was supported by the Basic Science Research Program, through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A3A01018955 and 2017R1D1A1B03035232)

Introduction. The identification of biological markers associated to implant failure in THA (total hip arthroplasty) patients remains a challenge in orthopedic surgery. In this search, previous studies have been mainly focused on typical mediators associated to bone metabolism and inflammation. Our group has evaluated changes in serum levels of insulin-like growth factor binding protein-1 (IGFBP-1), a protein which is not directly related to bone homeostasis, in patients undergoing THA. Method. We assessed IGFBP-1 levels in serum obtained from 131 patients (58% female, 42 % male; age: 68 ± 13 years) who underwent THA in the Orthopedic Surgery and Traumatology Department of our institution. In this cohort, 57% of patients had metal on polyethylene (MoP) as hip-bearing surface combination, 17 % had ceramic on ceramic (CoC) and 26% of them did not have any prosthesis. A test based on an enzyme-linked immunosorbent assay (ELISA) was used to determine IGFBP-1 levels in serum obtained from these patients. Result. Our results showed a significant increase in IGFBP- 1 levels in MoP group as compared to CoC and control groups, in which no differences in quantified levels were detected. Further analysis revealed no significant differences in IGFBP-1 between cemented and non-cemented MoP bearings. We performed a ROC curve to evaluate the accuracy of serum IGFBP-1 in discriminating MoP from the rest of patients (area under the curve: 0.7; 95% confidence interval: 0,6-0.8; p<0.05) and established a cut-off value of 10.2 ng/ml, according to the Youden´s Index. Logistic regression analysis showed that patients with MoP bearing surfaces had a higher risk of increased IGFBP- 1 levels in serum (p<0.05, Odds Ratio: 6.7, 95% Confidence Interval 3.1 to 14.8). Conclusion. IGFBP- 1 levels are significantly elevated in THA patients with MoP bearing surfaces, suggesting that this protein might be a reliable biomarker for the outcome of patients implanted with MoP

Quantitative ultrasound (QUS) is a promising tool to estimate bone structure characteristics and predict fragile fracture. The aim of this pilot cross-sectional study was to evaluate the performance of a multi-channel residual network (MResNet) based on ultrasonic radiofrequency (RF) signal to discriminate fragile fractures retrospectively in postmenopausal women. Methods. RF signal and speed of sound (SOS) were obtained using an axial transmission QUS at one‐third distal radius for 246 postmenopausal women. Based on the involved RF signal, we conducted a MResNet, which combines multi-channel training with original ResNet, to classify the high risk of fragility fractures patients from all subjects. The bone mineral density (BMD) at lumber, hip and femoral neck acquired with DXA was recorded on the same day. The fracture history of all subjects in adulthood were collected. To assess the ability of the different methods in the discrimination of fragile fracture, the odds ratios (OR) calculated using binomial logistic regression analysis and the area under the receiver operator characteristic curves (AUC) were analyzed. Results. Among the 246 postmenopausal women, 170 belonged to the non-fracture group, 50 to the vertebral group, and 26 to the non-vertebral fracture group. MResNet was discriminant for all fragile fractures (OR = 2.64; AUC = 0.74), for Vertebral fracture (OR = 3.02; AUC = 0.77), for non-vertebral fracture (OR = 2.01; AUC = 0.69). MResNet showed comparable performance to that of BMD of hip and lumbar with all types of fractures, and significantly better performance than SOS all types of fractures. Conclusions. the MResNet model based on the ultrasonic RF signal can significantly improve the ability of QUS device to recognize previous fragile fractures. Moreover, the performance of the proposed model modified by age, weight, and height is further optimized. These results open perspectives to evaluate the risk of fragile fracture applying a deep learning model to analyze ultrasonic RF signal

Anterior approach total hip arthroplasty (AA-THA) has a steep learning curve, with higher complication rates in initial cases. Proper surgical case selection during the learning curve can reduce early risk. This study aims to identify patient and radiographic factors associated with AA-THA difficulty using Machine Learning (ML). Consecutive primary AA-THA patients from two centres, operated by two expert surgeons, were enrolled (excluding patients with prior hip surgery and first 100 cases per surgeon). K- means prototype clustering – an unsupervised ML algorithm – was used with two variables - operative duration and surgical complications within 6 weeks - to cluster operations into difficult or standard groups. Radiographic measurements (neck shaft angle, offset, LCEA, inter-teardrop distance, Tonnis grade) were measured by two independent observers. These factors, alongside patient factors (BMI, age, sex, laterality) were employed in a multivariate logistic regression analysis and used for k-means clustering. Significant continuous variables were investigated for predictive accuracy using Receiver Operator Characteristics (ROC). Out of 328 THAs analyzed, 130 (40%) were classified as difficult and 198 (60%) as standard. Difficult group had a mean operative time of 106mins (range 99–116) with 2 complications, while standard group had a mean operative time of 77mins (range 69–86) with 0 complications. Decreasing inter-teardrop distance (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95–0.99, p = 0.03) and right-sided operations (OR 1.73, 95% CI 1.10–2.72, p = 0.02) were associated with operative difficulty. However, ROC analysis showed poor predictive accuracy for these factors alone, with area under the curve of 0.56. Inter-observer reliability was reported as excellent (ICC >0.7). Right-sided hips (for right-hand dominant surgeons) and decreasing inter-teardrop distance were associated with case difficulty in AA-THA. These data could guide case selection during the learning phase. A larger dataset with more complications may reveal further factors

Results in patients undergoing total hip arthroplasty (THA) for femoral head osteonecrosis (ON) when compared with primary osteoarthritis (OA) are controversial. Different factors like age, THA type or surgical technique may affect outcome. We hypothesized that patients with ON had an increased revision rate compared with OA. We analysed clinical outcome, estimated the survival rate for revision surgery, and their possible risk factors, in two groups of patients. In this retrospective cohort analysis of our prospective database, we assessed 2464 primary THAs implanted between 1989 and 2017. Patients with OA were included in group 1, 2090 hips; and patients with ON in group 2, 374 hips. In group 2 there were more men (p<0.001), patients younger than 60 years old (p<0.001) and with greater physical activity (p<0.001). Patients with lumbar OA (p<0.001) and a radiological acetabular shape type B according to Dorr (p<0.001) were more frequent in group 1. Clinical outcome was assessed according to the Harris Hip Score and radiological analysis included postoperative acetabular and femoral component position and hip reconstruction. Kaplan-Meier survivorship analysis was used to estimate the cumulative probability of not having revision surgery for different reasons. Univariate and multivariate Cox regression models were used to assess risk factors for revision surgery. Clinical improvement was better in the ON at all intervals. There were 90 hips revised, 68 due to loosening or wear, 52 (2.5%) in group 1, and 16 (4.3%) in group 2. Overall, the survival rate for revision surgery for any cause at 22 years was 88.0 % (95% CI, 82-94) in group 1 and 84.1% (95% CI, 69 – 99) in group 2 (p=0.019). Multivariate regression analysis showed that hips with conventional polyethylene (PE), compared with highly-cross linked PEs or ceramic-on-ceramic bearings, (p=0.01, Hazard Ratio (HR): 2.12, 95% CI 1.15-3.92), and cups outside the Lewinnek´s safe zone had a higher risk for revision surgery (p<0.001, HR: 2.57, 95% CI 1.69-3.91). Modern highly-cross linked PEs and ceramic-on-ceramic bearings use, and a proper surgical technique improved revision rate in patients undergoing THA due to ON compared with OA

Introduction and Objective. To estimate the prevalence of acetabular ossifications in the adult population with asymptomatic, morphologically normal hips at CT and to determine whether the presence of labral ossifications is associated with patient-related (sex, age, BMI), or hip-related parameters (joint space width, and cam- and pincer-type femoroacetabular impingement morphotype). Materials and Methods. We prospectively included all patients undergoing thoracoabdominal CT over a 3-month period. After exclusion of patients with a clinical history of hip pathology and/or with signs of osteoarthritis on CT, we included a total of 150 hips from 75 patients. We analyzed the presence and the size of labral ossifications around the acetabular rim. The relationships between the size of labral ossifications and patient- and hip-related parameters were tested using multiple regression analysis. Results. The prevalence of labral ossifications in this population of asymptomatic, non-OA hips was 96% (95%CI=[80.1; 100.0]). The presence of labral ossifications and their size were correlated between right and left hips (Spearman coefficient=0.64 (95%CI=[0.46; 0.79]), p<0.05)). The size of labral ossifications was significantly associated with age (p<0.0001) but not with BMI (p=0.35), gender (p=0.05), joint space width (p≥0.53 for all locations) or any of the qualitative or quantitative parameters associated with femoroacetabular morphotype (all p≥0.34). Conclusions. Labral ossifications are extremely common in asymptomatic, non-osteoarthritic hips. Their size is not correlated with any patient-, or hip-related parameters except for the age. These findings suggest that the diagnosis of osteoarthritis or femoroacetabular impingement morphotype should not be made based on the sole presence of acetabular labral ossifications

Introduction and Objective. An important subset of patients is dissatisfied after total joint arthroplasty (TJA) due to residual functional impairment. This study investigated the assessment of objectively measured step-up performance following TJA, to identify patients with poor functional improvement after surgery, and to predict residual functional impairment during early postoperative rehabilitation. Secondary, longitudinal changes of block step-up (BS) transfers were compared with functional changes of subjective patient reported outcome measures (PROMs) following TJA. Materials and Methods. Patients with end stage hip or knee osteoarthritis (n = 76, m/f = 44/32; mean age = 64.4 standard deviation 9.4 years) were measured preoperatively and 3 and 12 months postoperatively. PROMs were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscore. BS transfers were assessed by wearable-derived measures of time. In our cohort, subgroups were formed based on either 1) WOMAC function score or 2) BS performance, isolating the worst performing quartile (impaired) of each measure from the better performing others (non-impaired). Subgroup comparisons were performed with the Man-Whitney-U test and Wilcoxon Signed rank test resp. Responsiveness was calculated by the effect size, correlations with Pearson's correlation coefficient. A regression analysis was conducted to investigate predictors of poor functional outcome. Results. WOMAC function scores were strongly correlated to WOMAC pain scores (Pearson's r=0.67–0.84) and moderately correlated to BS performance (Pearson's r = 0.31–0.54). Prior to surgery, no significant differences for WOMAC function scores and BS performance were found between the impaired and non-impaired subgroups. One year after TJA, our cohort performed significantly better at WOMAC and BS with largest effect size for the non-impaired subgroups (0.62 and 0.43 resp.) At 12 months postop, 56% of patients allocated to the impaired subgroup defined by WOMAC, represented the impaired subgroup defined by BS. Allocation to the impaired subgroup at 3 months postop, raised the odds for belonging to the impaired subgroup at 12 months for WOMAC with an odds ratio=19.14 (67%) and for BS with an odds ratio=4.41 (42%). Conclusions. Assessment of BS performance following TJA reveals residual functional impairment that is not captured by pain-dominated PROMs. Its additional use may help to early identify those patients at risk for a poor outcome

Abstract. Objectives. Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and patient information. This study aimed to ascertain if BMI, pre-operative scores, demographic data and concomitant injuries in patients undergoing ACLR affected patient-reported functional outcomes. Methods. A prospective review collected data from a single surgeon series of 278 patients who underwent arthroscopic ACLR. BMI, age, gender, graft choice, pre-op Lysholm score, meniscal and chondral injuries were recorded. The Lysholm score, hop test and KT1000 were used to measure post-op functional outcome at one year. Multiple regression analysis was used to determine factors that predicted Lysholm scores at one year. Results. The mean age was 29 years, with 58 female and 220 male patients. The mean pre-op Lysholm score was 53.8. One hunded and seventy-nine patients had meniscal injuries, of which 81 were medial, 60 lateral, and 38 bilateral. Eighteen patients also had chondral injury and 106 patients had no other associated injury. Age, gender, graft type and presence of meniscal or chondral injuries did not affect one-year post-operative Lysholm scores. A BMI greater than 30, physio compliance and preoperative Lysholm scores helped predict one-year post-operative Lysholm scores (p=0.02). Pearson's correlation found a direct link between BMI and post-operative Lysholm (p=0.03). Conclusions. BMI, physio compliance and pre-operative Lysholm scores are the most significant determinants of short-term functional outcome after ACLR. However, the effects of associated injuries may be apparent in the long-term as degenerative changes set in or the continued detriment resulting from the concomitant injury affect outcome. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Summary. In this study we validate that weight-bearing images are needed for accurate polyethylene liner wear measurement in total knee prostheses by measuring the difference in minimum joint space width between weight-bearing and non-weight-bearing RSA views. Introduction. Recent studies show that Model-based Roentgen Stereophotogrammetric Analysis is superior to the conventional in vivo measurements of polyethylene liner wear in total knee prostheses. Although it is generally postulated that weight-bearing (standing) views are required to detect liner wear, most RSA images are acquired in non-weight-bearing (supine) view for practical reasons. Therefore, it would be of interest to know if supine views would be sufficient for measuring TKA liner wear, defined as a change in minimum joint space width (mJSW). As a difference in mJSW between weight-bearing and non-weight-bearing RSA images has never been validated, the aim of this study is to compare the outcome of in vivo measurements of mJSW in total knee prosthesis when conducted with weight-bearing and non-weight-bearing RSA views. Method. We selected the first 16 patients with a Triathlon total knee prosthesis from a clinical study for which subsequently a weight-bearing eand a non-weight-bearing RSA image pair were acquired at one year follow up. For both images the mJSW and the corresponding contact point locations in terms of mediolateral (ML) and anterioposterior (AP) coordinates were measured. In addition, the ML stability was scored to assess knee laxity. The size of the mJSW difference between non-weight-bearing and weight-bearing views was determined and a regression analysis was conducted to investigate the effect of knee laxity to this difference, while correcting for differences between the contact point locations. Results. On average, the measured mJSW was 0.22 mm larger in the non-weight-bearing views (T-test, p < 0.05). The standard deviation of the difference was 0.22 mm. The regression analysis showed that a difference in the ML position of the contact location was an important covariate (beta = 0.255±0.054, Wald 95% CI). 13 patients had a high ML stability (< 5 deg) and three had a medium stability (5–10 deg). The regression analysis showed that on average patients with medium ML stability had a 0.17 mm larger difference in mJSW than patients with a high ML stability. Conclusion. The study shows that the mJSW is larger in non-weight-bearing views. The differences found are clinically relevant, as wear rates in practice are as small as 0.1 mm per year. Hereby it is validated that weight-bearing RSA images are more capable of detecting the mJSW in total knee prostheses. The size of the difference in mJSW between the views seems to be in relation with the knee laxity

Introduction. Patellofemoral pain and instability can be quantified by using the tibial tuberosity to trochlea groove (TT-TG) distance with more than or equal to 20mm considered pathological requiring surgical correction. Aim of this study is to determine if knee joint rotation angle is predictive of a pathological TT-TG. Methods. One hundred limbs were imaged from the pelvis to the foot using Computer Tomography (CT) scans in 50 patients with patellofemoral pain and instability. The TT-TG distance, femoral version, tibial torsion and knee joint rotation angle ((KJRA) were measured. Limbs were separated into pathological and non-pathological TT-TG. Significant differences in the measured angles between the pathological and non-pathological groups were estimated using the t test. The inter- and intraobserver variability of the measurement was performed. Logistic regression analysis was used to find the best combination of rotational angle predictors for a pathological TT-TG. Results. The intraclass correlation coefficients for inter- and intraobserver variability of the measured parameters was higher than 0.94 for all measurements. A statistically significant difference (P=0.024) was found between the KJRA between the pathological (mean=10.6, SD=7.79 degrees) and the non-pathological group (mean=6.99, SD=5.06 degrees). Logistic regression analysis showed that both femoral version (P=0.03, OR = 0.95) and KJRA (P=0.004, OR=1.15) were, in combination, significant predictors of an abnormal TT-TG. Tibial torsion was not a significant predictor. Conclusion. The KJRA can be used as an alternative measurement when the TT-TG distance cannot be measured as in cases of severe trochlea dysplasia and may act as a surrogate for pathological TT-TG

Acute lateral ankle sprain accounts for 85% of sprains. The lateral sprain is associated with other ligament injuries e.g. medial and syndesmosis sprain. Long-term, approximately 20% of acute lateral sprains develop into chronic lateral ankle instability (CLAI) which includes persistent pain, and recurring ankle sprains. This study evaluated the grade of an ankle ligament injury by ultrasonography (US) and compared the findings to the outcome of patient-reported questionnaires. 48 subjects (18–40 years) diagnosed with an ankle sprain attended a clinical and US examination of ankle ligaments within two weeks after the sprain. Evaluation was done by US of acute lateral ligament injuries (ATFL, CFL), syndesmosis injury (AiTFL), and medial injury (dPT, TCt) only in participants with the positive clinical signs of medial injury. Participants were then mailed a questionnaire (PROMQ) every third month for a year. 29 women and 19 men participated with a mean age at 26.50 years. One-year follow-ups need to be analyzed further for final results. Temporary results include data based on the initial 26 patients: Two clinical signs statistically correlated. Multiple logistic regression analysis confirmed the results. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and reported pain during active plantar flexion of ankle predicted with normal CFL confirmed by the US. Patients with partial rupture of ATFL presented with tenderness at AiTFL point. Patients presenting with intact CFL reported pain during active plantar flexion. Compared to the US findings, the overall examinations were inconclusive in predicting ATFL, CFL, AiTFL, and medial ligament injuries

Backgroud: Allogeneic transfusion rates after primary hip and knee arthroplasty are used as quality indicators for hospitals, but hospital comparisons may be hampered by low event rates. Extended hospital stay is often used and may be more suitable as an alternative. This study aims to assess whether transfusion rates and extended hospital stay can be used to reliably rank hospitals. Methods. We used the baseline data from the LISBOA implementation trial, where data on patient characteristics and outcomes were collected in a sample of approximately 100 patients undergoing elective primary total hip or knee arthroplasty for each of the 23 participating hospitals. We calculated the reliability of ranking (Rankability) of transfusion rates and extended hospital stay (> 4 postoperative days), using fixed and random effects logistic regression analysis, by dividing the between-hospital variation to the sum of within and between-hospital variation. Rankability thus shows which part of the hospital differences are true differences and not due to random variation. Results. 1163 total hip and 986 total knee procedures were assessed. After adjustment for patient characteristics the odds ratio (OR) of receiving a transfusion in a hospital after total hip ranged from 0.72 to 1.38 and from 0.30 to 3.30 in total knee. Rankability was 17% for hip and 36% for knee arthroplasty, meaning that only 17% and 36% are true hospital differences. Larger hospital variation was found for extended hospital stay (OR range [0.28–3.51] for hip and [0.10–9.95] for knee arthroplasty), and better rankability. Conclusion. Although allogeneic transfusion rates are useful for monitoring quality within hospitals, they should not be used for ranking hospitals. A large proportion of differences in transfusion rates between hospitals is due to random variation, suggesting that this outcome is not suitable for ranking hospitals contrary to extended hospital stay. Level of evidence. Level 2. Financial disclosure. This study was funded by a grant from The Netherlands Organisation for Health Research and Development and by a grant from Sanquin Blood Supply. Conflict of interest. The authors declare that there are no conflicts of interest. Approval. The Medical Ethical Committee of the Leiden University Medical Center decided that ethical approval was not required under Dutch National law for this type of study

Valgus unloader knee braces are a conservative treatment option for medial compartment knee osteoarthritis (OA). These braces are designed to reduce painful, and potentially injurious compressive loading on the damaged medial side of the joint through application of a frontal-plane abduction moment. While some patients experience improvements in pain, function, and joint loading, others see little to no benefit from bracing [1]. Previous biomechanical studies investigating the mechanical effectiveness of bracing have been limited in either their musculoskeletal detail [2] or incorporation of altered external joint moments and forces [3]. The first objective was to model the relative contributions of gait dynamics, muscle forces, and the external brace abduction moment to reducing medial compartment knee loads. The second objective was to determine what factors predict the effectiveness of the valgus unloading brace. Seventeen people with knee OA (8 Female age 54.4 +/− 4.2, BMI 30.00 +/− 4.0 kg/m. 2. , Kellgren-Lawrence range of 1–4 with med. = 3) and 20 healthy age-matched controls participated in this study which was approved by the institutional ethics review board. Subjects walked across a 20m walkway with and without a Donjoy OA Assist knee brace while marker trajectories, ground reaction forces, and lower limb electromyography were recorded. The external moment applied by the brace was estimated by multiplying the brace deformation by is pre-determined brace-stiffness. For each subject, a representative stride was selected for each brace condition. A generic musculokeletal model with two legs, a torso, and 96 muscles was modified to include subject-specific frontal plane alignment and medial and lateral contact locations [4]. Muscle forces, and tibiofemoral contact forces were estimated using static optimization [4]. We defined brace effectiveness as the difference in the peak medial contact force between the braced and the unbraced conditions. A stepwise regression analysis was performed to predict brace effectiveness based on: X-ray frontal plane alignment, medial joint space, KL grade, mass, WOMAC scores, unbraced walking speed, trunk, hip and knee joint angles and moments. The OA Assist brace reduced medial joint loading by approximately 0.1 to 0.2 BW or roughly 10%, during stance. This decrease was primarily due to the external brace abduction moment, and not changes in gait dynamics, or muscle forces. The brace effectiveness could be predicted (R. 2. =0.77) by the KL grade, and the magnitude of the hip adduction moment in early stance (unbraced). The brace was more effective for those that had larger hip adduction moments and for those with more severe OA. The valgus knee brace was found to reduce the medial joint contact force by approximately 10% as estimated using a musculoskeletal model. Bracing resulted in a greater reduction in joint contact force for those who had more severe OA while still maintaining a hip adduction moment similar to that of healthy controls

Increase in heel height increases peak pressure under the forefoot. Customized shoe inlays with metatarsal lift, arch support has demonstrated lowered forefoot pressure and increase in the subjective comfort. A commercial shoe brand (Roccamore) has introduced an off-the-rack stiletto with a slim (1 cm. 2. ) 8 cm heel plus 2 cm platform with metatarsal lift, arch support and heel cap claiming it will reduce the discomfort associated with high heels. The primary aim of this study was to compare the pressure under the forefoot, arch, heel and toes in this “orthopaedic” stiletto (OS) to a standard stiletto of the same heel height without inlays (SS) and a control sneaker (SN). Secondary aims were to measure the comfort under the forefoot, heel and arch during everyday use. Finally to investigate if any pressure measurements were correlated to comfort or any anatomical/clinical feature of the foot. 22 women, aged 40 (21–62), accustomed to stilettos, walked at 4 km/hr on a level treadmill in all three shoe types. Peak pressure (kPa) and pressure-time integral (kPa/sec) under 2+3rd and first metatarsal heads, the arch/midfoot and heel were measured during 10 consecutive steps at 50 Hz using Novel Pedar-X pressure distribution insoles. Standing X-rays and a standardized clinical examination were carried out. Mundermanns comfort VAS and daily steps were recorded for each shoe type during 3 full days. (0= worst to 150 mm= most comfortable). Data were compared with paired t-tests and regression analysis. Statistical significance is reported as p<0.05=, p<0.01=, p<0.001=. Peak pressure: Compared to SS the peak pressure under the 2+3 metatarsals was reduced to 82% in the OS and 60% in the SN. Under the first metatarsal it was reduced to 73% and 40%, respectively. Under the arch it was similar for SN and OS and 30% lower for the SS. Under the heel the OS was 27–28% lower than SS and SN. The same reductions, as well as similarities in the arch were seen in the pressure-time integrals, although with smaller difference between OS and SS, and conversely larger reductions in the SN to 49% under 2+3 metatarsals and 43% under the first. For forefoot, arch and heel, the comfort was rated highest for the SN and lowest for the SS. No statistical difference between OS and SS in the arch. For each mm the second metatarsal was longer than the first, the peak pressure under MT2+3 rose 13 kPa (95%CI: 7 to 19) and the pressure time integral 3 kPa/s (1–5). No effect of first ray ROM or stability. The forefoot VAS score dropped (less comfortable) 0.3 mm for each kPa/s the pressure time integral rose under the MT2+3. Peak pressure parameters or daily steps were not statistically significantly related to the forefoot comfort. A mass produced “orthopaedic” stiletto can reduce the pressure approaching those achieved in a sneaker and increase comfort for the user. An increase in pressure-time integral under 2+3 metatarsals increases the discomfort and the pressure is increased in index-minus feet

Introduction. Acute kidney injury is a recognised post-operative complication in primary joint replacement. Recently it has been demonstrated that antibiotic regimen can significantly impact on the proportion of patients who develop acute kidney impairment post-operatively. Within our unit an increased rate of acute kidney injury had been noted post-operatively over the last 5 years. This increase followed the introduction of a rapid recovery protocol for arthroplasty patients. Our aim was determine whether we could identify a causative factor or those who were at increased risk of post-operative renal impairment. Methods. Data were collected for 413 patients initially retrospectively but continued prospectively. Univariable and multivariable analysis was performed to determine any causative factors. The primary increase was 150% increase in baseline creatinine, but as some authors recognise an increase in 125% this was also analysed. Results. Within the 12 month period studied 23.3% of patients developed acute kidney injury, with an increase of 125% of their baseline creatinine. 8.23% of patients developed an increase of 150% in their creatinine levels. Age, previous renal failure and the pre-operative use of an ACE inhibitor were found to be statistically higher in the renal failure group. The uni-variable analysis also demonstrated that patients who received a small volume of post-operative intravenous fluids had a lower rate of renal failure than those who received no fluids (10% vs. 23%; p = 0.04). The multivariable regression analysis demonstrated that age was the only statistically significant positive predictive factor in developing renal failure. Antibiotic regimen had no effect. Discussion. Renal impairment has significant impact on patient morbidity and post-operative management. It increases the length of stay, and may potentially require more invasive therapy. We have demonstrated that the identified risk factors are non-modifiable but that a gentamicin and teicoplanin regimen was not an implicated causative factor

INTRODUCTION. This study investigates the relationship between direct measurement of outcome and patient report of that outcome via the OKS. The stability of this relationship over time following surgery is also assessed. METHODS. 183 TKA patients were assessed pre-operatively and at 6, 26 and 52 weeks post-op. Oxford Knee Score was obtained along with measures of pain intensity, knee flexion, lower limb power and timed functional assessment. Correlation of performance variables with the OKS was assessed, and regression analysis performed on those that formed significant associations. Significance was accepted at p = 0.05. RESULTS. Pain intensity and functional ability improved with time post-op. Functional scores correlated modestly with OKS, consistently over the assessment period. Pain correlated poorly pre-op but well post-op. Regression modelling was able to explain differing amounts of the variation in OKS at the 4 time points; 34.8% pre-operatively, 44.0% at 6 weeks, 56.9% at 26 weeks and 62.3% at 52 weeks post-op. Pain was the dominant factor in deriving all of these models. DISCUSSION. Substantial variation was found in objective assessment of function and patient report of that function through the OKS. This relationship changed with time post-operatively. The explanatory power of the models improved as pain intensity reduced. CONCLUSION. These results question the accuracy of PROMS in representing the observed ability to perform functional tasks, which has implications for assessing outcome

Objectives. This study aims to assess the correlation of CT-based structural rigidity analysis with mechanically determined axial rigidity in normal and metabolically diseased rat bone. Methods. A total of 30 rats were divided equally into normal, ovariectomized, and partially nephrectomized groups. Cortical and trabecular bone segments from each animal underwent micro-CT to assess their average and minimum axial rigidities using structural rigidity analysis. Following imaging, all specimens were subjected to uniaxial compression and assessment of mechanically-derived axial rigidity. Results. The average structural rigidity-based axial rigidity was well correlated with the average mechanically-derived axial rigidity results (R. 2. = 0.74). This correlation improved significantly (p < 0.0001) when the CT-based Structural Rigidity Analysis (CTRA) minimum axial rigidity was correlated to the mechanically-derived minimum axial rigidity results (R. 2. = 0.84). Tests of slopes in the mixed model regression analysis indicated a significantly steeper slope for the average axial rigidity compared with the minimum axial rigidity (p = 0.028) and a significant difference in the intercepts (p = 0.022). The CTRA average and minimum axial rigidities were correlated with the mechanically-derived average and minimum axial rigidities using paired t-test analysis (p = 0.37 and p = 0.18, respectively). Conclusions. In summary, the results of this study suggest that structural rigidity analysis of micro-CT data can be used to accurately and quantitatively measure the axial rigidity of bones with metabolic pathologies in an experimental rat model. It appears that minimum axial rigidity is a better model for measuring bone rigidity than average axial rigidity

Patient reported outcome measures (PROMs) are important for assessing the results of lower limb arthroplasty. Unrealistic or uneducated expectations may have a significant negative impact on PROMs even when surgery is technically successful. This study's aim was to quantify pre-operative expectations of Scottish patients undergoing total hip and knee replacement (THR/TKR). 100 THR and 100 TKR patients completed validated questionnaires (from the Hospital for Special Surgery) prior to their operation after receiving standard pre-operative information (booklet, DVD, consultations). Each patient rated expectations from very important to not having the expectation. A total score was calculated using a numerical scale for the grading of each expectation. Univariate regression analysis was used to investigate the relationship between demographics and expectation score. The THR cohort had mean age 66.2 (SD 10.5), 53% female, mean BMI 29.0 (SD 5.1) and mean Oxford score 44 (SD 7). The TKR cohort had mean age 67.6 (SD 8.5), 59% female, mean BMI 32.8 (SD 5.8) and mean Oxford score 44 (SD 8). 100% THR and 96% TKR patients had 10 or more expectations of their operation. All expected pain relief. Other improvements expected were: walking for 100% THA and 99% TKA patients; daily activities for 100% THAs and 96% TKAs; recreational activities for 96% THAs and 93% TKAs; sexual activity for 66% THAs and 59% TKAs; psychological well-being for 98% THAs and 91% TKAs. Regression analysis showed increasing age lowered expectations in both THR (p=0.025) and TKR (p=0.031) patients but that gender, BMI and Oxford score were not significantly related to expectations. This study highlights that patients expect far more than pain relief and improved post-operative mobility from their operation. It is important to discuss and manage these expectations with patients prior to surgery. By doing so, patient satisfaction and PROMs should further improve

Objectives

Intramedullary fixation is considered the most stable treatment for pertrochanteric fractures of the proximal femur and cut-out is one of the most frequent mechanical complications. In order to determine the role of clinical variables and radiological parameters in predicting the risk of this complication, we analysed the data pertaining to a group of patients recruited over the course of six years.