Unicompartmental knee arthroplasty (UKA) is associated with a higher risk of revision compared with total knee arthroplasty (TKA). The outcomes of knee arthroplasty are typically presented as implant survival or incidence of revision after a set number of years, which can be difficult for patients and clinicians to conceptualise. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more relatable estimate of risk projection over a patient's remaining lifetime, and make comparisons to TKA. All primary UKAS performed from 1999 to 2019 (n=13,481) captured by the New Zealand Joint Registry (NZJR) were included. The lifetime risk of revision was calculated and stratified by age, gender and American Society of Anesthesiologists (ASA) status. The lifetime risk of revision for UKA was highest in the youngest patients (46-50 years; 40.4%) and lowest in the oldest patients (86-90 years; 3.7%). Lifetime risk of revision was higher for females (range 4.3%-43.4% cf. males 2.9%-37.4%) and patients with higher ASA status (ASA 3-4 range 8.8%-41.2% cf. ASA 1 1.8%-29.8%), regardless of age. The lifetime risk of UKA was two-fold higher than TKA (ranging from 3.7%-40.4% UKA, 1.6%-22.4% TKA) across all age groups. Increased risk of revision in the younger patients was associated with aseptic loosening in both males and females, and pain in females. Periprosthetic joint infections (PJI) accounted for 4% of all UKA revisions, in contrast to 27% for TKA; risk of PJI was higher for males than females for both procedures. The lifetime risk of revision is a more meaningful measure of arthroplasty outcomes and can aid with patient counselling prior to UKA. Findings from this study show the increased lifetime risk of UKA revision for younger patients, females and those with higher ASA status

To determine risk factors of infection in total knee arthroplasty. This descriptive study was conducted in the Department of Orthopedics for a duration of three years from January 2016 to January 2019. All patients undergoing primary total knee replacement were included in the study. Exclusion criteria were all patients operated in another hospital and revision total knee replacement. All patients were followed up at 2, 4, 8, 12 and 24 weeks post-operatively. Signs of inflammation and inflammatory markers such as total leukocyte count (TLC), C-reactive protein (CRP) and ESR were measured. Risk factors like age, body mass index (BMI), ASA, co-morbid conditions were also noted. A total of 78 patients underwent primary unilateral Total Knee Replacement (TKR) during the study period. Of these, 30 (34.09%) were male and 48 (61.54%) female patients. Mean age of patients was 68.32 ± 8.54 years. Average BMI 25.89 Kg/m2 .Osteoarthritis was the pre-dominant cause of total knee replacement (94.87%). Among co-morbid factors 33.33% were diabetic, 28.20% having ischemic heart disease and 12.82% with chronic lung disease. Upon anaesthesia fitness pre-operatively, 91.02% patients had an American society of anaesthesiologist score (ASA) between 0–2 while 07 (8.97%) between 3- 5. Average duration of surgery was 85.62± 4.11 minutes. 6.41% cases got infected. In majority of the infected cases (60%), Staphylococcus aureus was the infective organism. Diabetes Mellitus (p=0.01) and Obesity (p=0.02) had a significant relation to post-operative infection. Pre-operative risk evaluation and prevention strategies along with early recognition of infection and control can greatly reduce the risk of joint infection post-TKR which will not only improve the mobility of patient but also its morbidity and mortality as well. Key Words:. C-reactive protein (CRP), Erythrocyte Sedimentation Rate (ESR), Staphylococcus aureus, Total Knee Arthroplasty (TKA)

Abstract. Objectives. The aim of this study was to investigate whether mechanical loading induced by physical activity can reduce risk of sarcopenia in middle-aged adults. Methods. This was a longitudinal study based on a subset of UK Biobank data consisting of 1,918 participants (902 men and 1,016 women, mean age 56 years) who had no sarcopenia at baseline (assessed between 2006 and 2010). The participants were assessed again after 6 years at follow-up, and were categorized into no sarcopenia, probable sarcopenia, or sarcopenia according to the definition and algorithm developed in 2018 by European Working Group on Sarcopenia in Older People (EWGSOP). Physical activity was assessed at a time between baseline and follow-up using 7-day acceleration data obtained from wrist worn accelerometers. Raw acceleration data were then analysed to study the mechanical loading of physical activity at different intensities (i.e. very light, light, moderate-to-vigorous). Multinominal logistic regression was employed to examine the association between the incidence of sarcopenia and physical activity loading, between baseline and follow up, controlled for other factors at baseline including age, gender, BMI, smoking status, intake of alcohol, vitamin D and calcium, history of rheumatoid arthritis, osteoarthritis, secondary osteoporosis, and type 2 diabetes. Results. Among the 1918 participants with no sarcopenia at baseline, 230 (69 men and 161 women) developed probable sarcopenia and 37 (14 men and 23 women) developed sarcopenia at follow-up. Physical activity loading at moderate-to-vigorous intensity was higher in men (p<0.05), while women had higher physical activity loading at very light intensity (p<0.05). No significant difference was found in physical activity loading at light intensity between men and women (p>0.05). Logistic regression models showed that increase in physical activity loading at moderate-to-vigorous intensity significantly reduced the risk of sarcopenia (odds ratio = 0.368, p<0.05), but not probable sarcopenia (odds ratio = 0.974, p>0.05), while loading at light or very light activity intensity were not associated with the risk of sarcopenia or probable sarcopenia (p>0.05). Conclusion. Loading of physical activity at moderate-to-vigorous intensity could reduce risk of sarcopenia in middle-aged adults. 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

Fracture related infections (FRI) are debilitating complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. This study aims to determine risk factors associated with FRI treatment failure, allowing clinicians to optimise them prior to treatment and identify patients at higher risk. A major trauma centre database was retrospectively reviewed over a six-year period. Of the 102 patients identified with a FRI (66 male, 36 female), 29.4% (n=30) had acute infections (onset <6 weeks post-injury), 34.3% (n=35) had an open fracture. Open fractures were classified using Gustilo-Anderson (GA) classification (type 2:n=6, type 3A:n=16, type 3B:n=10, type 3C:n=3). Patients with periprosthetic infections of the hip and knee joint, those without prior fracture fixation, soft tissue infections, diabetic foot ulcers, pressure sore infections, patients who died within one month of injury, <12 months follow-up were excluded. FRI treatment failure was defined as either infection recurrence, non-union, or amputation. Lifestyle, clinical, and intra-operative data were documented via retrospective review of medical records. Factors with a P-value of p<0.05 in univariate analysis were included in a stepwise multivariate logistic regression model. FRI treatment failure was encountered in 35.3% (n=36). The most common FRI site was the femoral shaft (16.7%; n=17), and 15.7% (n=16) presented with signs of systemic sepsis. 20.6% (n=21) had recurrent infection, 9.8% (n=10) had non-union, and 4.9% (n=5) required an amputation. The mean age at injury was 49.71 years old. Regarding cardiovascular risk factors, 37 patients were current smokers (36.3%), 31 patients were diabetics (30.4%), and 32 patients (31.4%) were obese (BMI≥30.0). Average follow-up time was 2.37 (range: 1.04-5.14) years. Risk factors for FRI treatment failure were BMI>30, GA type 3c, and implant retention. Given that FRI treatment in 35.3% (36/102) ended up in failure, clinicians need to take into account the predictive variables analysed in this study, and implement a multidisciplinary team approach to optimise these factors. This study could aid clinicians to redirect efforts to improve high risk patient management, and prompt future studies to trial adjuvant technologies for patients at higher risk of failure

Osteoarthritis (OA) is the most common disorder of the Sternoclavicular Joint (SCJ). In our case-control study, we evaluated the relationship between clavicular length and OA at the SCJ. CT scans of adults presenting to the Emergency Department of our hospital were examined to look for OA, defined as the presence of osteophytes, subchondral cysts, or cortical sclerosis at the SCJ. Medial-most and lateral-most points of the clavicle were marked on the slices passing through the SC and AC joints respectively. Using x, y, and z-axis coordinates from the DICOM metadata, clavicular length was calculated as the distance between these two points with 3D geometry. Preliminary data of 334 SCJs from 167 patients (64% males, 36% females) with a mean age of 48.5 ± 20.5 years were analysed. Multivariate regression models revealed that age and clavicular length were independent risk factors for OA while gender did not reach statistical significance. A 1mm increase in length was associated with 9% and 7% reduction in the odds of developing OA on the left and the right respectively. Comparing the mean clavicular length using t-test showed a significantly shorter clavicle in the group with OA (145.8 vs 152.7, p=0.0001, left and 144.2 vs 150.3, p=0.0007, right). Our data suggest that the risk of developing OA at the SCJ is higher for shorter clavicles. This could be of clinical relevance in cases of clavicular fracture where clavicular shortening might lead to a higher risk of developing OA. Biomechanical studies are needed to find out the mechanism of this effect

Osteoarthritis (OA) of the knee joint is a complex peripheral joint disorder with multiple risk factors. We aimed to examine the relationship between the grade of knee OA and anterior thigh length (ATL). A total of 64 geriatric patients who had no total hip or knee replacement with a BMI of ≥30 were evaluated. Patients' OA severity was determined by two independent experts from bilateral standing knee radiographs according to the Kellgren-Lawrence (KL) grade. Joint cartilage structure was assessed using ultrasonography (US). The ATL, the gastrocnemius medialis (GC), the rectus femoris (RF) and the rectus abdominis (RA) skeletal muscle thicknesses as well as the RF cross-sectional area (CSA) were measured with US. Sarcopenia was diagnosed using the handgrip strength (HGS), 5× sit-to-stand test (5xSST) and bioelectrical impedance analysis. The median (IQR) age of participants was 72 (65–88) years. Seventy-one per cent of the patients (n=46) were female. They were divided into the sarcopenic obese (31.3 %) and the non-sarcopenic obese (68.8%) groups. KL grade of all patients correlated negatively with the ATL (mm) and the thickness of GC (mm) (r= -0,517, p<0.001 and r= -0.456, p<0.001, respectively). In the sarcopenic obese and the non-sarcopenic obese groups, KL grade of the all patients was negatively correlated with ATL (mm) and thickness of GC (mm) (r= -0,986, p<0.001; r= -0.456, p=0.05 and r= -0,812, p=0.002; r= −0,427, p=0.006). KL grade negatively correlated with the RF thickness in the sarcopenic obese group (r= -0,928, p=0.008). In conclusion, OA risk may decrease as the lower extremity skeletal muscle mass increases. Acknowledgments: Feza Korkusuz MD is a member of the Turkish Academy of Sciences (TÜBA)

Despite past advances of implant technologies, complication rates of fixations remain high at challenging sites such as the proximal humerus [1]. These may not only be owed to the implant itself but also to dissatisfactory surgical execution of fracture reduction and implant positioning. Therefore, the aim of this study was to quantify the instrumentation accuracy of a highly standardised and guided procedure and its influence on the biomechanical outcome and predicted failure risk. Preoperative planning of osteotomies creating an unstable 3-part fracture and fixation with a locking plate was performed based on CT scans of eight pairs of low-density proximal humerus samples from elderly female donors (85.2±5.4 years). 3D-printed subject-specific guides were used to osteotomise and instrument the samples according to the pre-OP plan. Instrumentation accuracies in terms of screw lengths and orientations were evaluated by comparing post-OP CT scans with the pre-OP plan. The fixation constructs were biomechanically tested until cyclic cut-out failure [2]. Failure risks of the planned and the post-OP configurations were predicted using a validated sample-specific finite element (FE) simulation approach [2] and correlated with the experimental outcomes. Small deviations were found for the instrumented screw trajectories compared to the planned configuration in the proximal-distal (0.3±1.3º) and anterior-posterior directions (-1.7±1.8º), and for screw tip to joint distances (-0.3±1.1 mm). Significantly higher failure risk was predicted for the post-OP compared to the planned configurations (p<0.01) via FE. When incorporating the instrumentation inaccuracies, the biomechanical results could be predicted well with FE (R. 2. =0.70). Despite the high instrumentation accuracy achieved using sophisticated subject-specific 3D-printed guides, even minor deviations from the pre-OP plan significantly increased the FE-predicted risk of failure. This underlines the importance of intraoperative guiding technology [3] in tandem with careful pre-OP planning to assist surgeons to achieve optimal outcomes. Acknowledgements. This study was performed with the assistance of the AO Foundation via the AOTRAUMA Network

A hot swollen joint is a commonly encountered condition in clinical practice. With a broad range of differentials, septic arthritis (SA) is perhaps one of the most concerning. Treated by culture-specific antibiotics and arthroscopic lavage, some patients require multiple washouts. We aimed to determine:. (1) What are the risk factors for development of SA?. (2) What are the risk factors for repeat washout in SA patients?. (3) What are the important clinical differences between a periprosthetic joint infection (PJI) and SA cohort?. All patients presenting to the emergency department, orthopaedic, and rheumatology clinics between January 2020 to January 2021 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma on the ipsilateral joint, with data missing from their medical records in any of the variables required for analysis, <24 months follow-up were excluded. Variables of interest in the three-month period preceding the diagnosis of SA were compared between SA and non-SA patients. Factors with a p-value of p<0.100 in univariate analysis were included in a stepwise multivariate logistic regression model. Similar analyses were performed to compare SA patients with multiple washouts with those needing one washout. Demographical and clinical data for PJI patients were collected to delineate important differences with SA cohort. 211 patients were included (SA:28;PJI:24;pseudogout:32;gout:26;others:101). Multivariate analysis showed rheumatoid arthritis (RA), skin infection, and liver disease were risk factors for SA. Amongst patients with septic arthritis, multivariate analysis showed that WBC levels above normal limits (3.6-10.5×109 cells/L) and RA were risk factors for multiple washouts. Between the SA and PJI cohorts, BMI (p=0.002) was significantly lower in the former, whilst WBC level (p=0.023) and CRP (p<0.0001) was significantly higher in the former. Early diagnosis of septic arthritis requires understanding the risk factors, namely RA, skin infection, and liver disease. Considering PJI and septic arthritis as the same entity can lead to wrong clinical judgement, and clinicians should be aware of important differences. We believe that the models in this study are of prognostic value to clinicians who are presented with the common presenting compliant of a hot swollen joint

Partial meniscectomy patients have a greater likelihood for the development of early osteoarthritis (OA). To prevent the onset of early OA, patient-specific treatment algorithms need to be created that predict patient risk to early OA after meniscectomy. The aim of this work was to identify patient-specific risk factors in partial meniscectomy patients that could potentially lead to early OA. Partial meniscectomy patients operated between 01/2017 and 12/2019 were evaluated in the study (n=317). Exclusion criteria were other pathologies or surgeries for the evaluated knee and meniscus (n = 114). Following informed consent, an online questionnaire containing demographics and the “Knee Injury and Osteoarthritis Outcome Score” (KOOS) questionnaire was sent to the patient. Based on the KOOS pain score, patients were classified into “low” (> 75) and “high” (< 75) risk patients, indicating risk to symptomatic OA. The “high risk” patients also underwent a follow-up including an MRI scan to understand whether they have developed early OA. From 203 participants, 96 patients responded to the questionnaire (116 did not respond) with 61 patients considered “low-risk” and 35 “high-risk” patients. Groups that showed a significant increased risk for OA were patients aged > 40 years, females, overweight (BMI >25 kg/m2 ≤ 30 kg/m2), and smokers (*p < 0.05). The “high-risk”-follow-up revealed a progression of early osteoarthritic cartilage changes in seven patients, with the remaining nineteen patients showing no changes in cartilage status or pain since time of operation. Additionally, eighteen patients in the high-risk group showed a varus or valgus axis deviation. Patient-specific factors for worse postoperative outcomes after partial meniscectomy and indicators for an “early OA” development were identified, providing the basis for a patient-specific treatment approach. Further analysis in a multicentre study and computational analysis of MRI scans is ongoing to develop a patient-specific treatment algorithm for meniscectomy patients

The most common reasons for total joint arthroplasty (TJA) failure are aseptic loosening (AL) and prosthetic joint infection (PJI). There is a big clinical challenge to identify the patients with high risk of AL/PJI before the TJA surgery. Although there is evidence that genetic factors contribute to the individual susceptibility to AL/PJI, a predictive model for identification of patients with a high genetic risk of TJA failure has not been developed yet. We aimed to develop a risk evaluation tool utilising the AL/PJI-associated polymorphisms for identification of patients with high genetic risk of TJA failure based on inflammation-gene polymorphism panel. Based on allele and genotype frequencies of twenty-five single nucleotide polymorphisms (SNPs) in TNF, IL2, IL6, IL10, IL1b, IL-1Ra, MBL2, MMP1, FTO genes and those influencing the serum levels of biomarkers of TJA outcomes (IL6, CCL2/MCP-1, CRP, ESR) in peripheral blood obtained from patients with TJA (AL, n=110; PJI, n=93; no complications, n=123), we calculated a hazard ratio and a relative entropy of alleles and genotypes associated with AL and PJI and their combinations in patient subgroups. We conducted a risk evaluation tool based on the presence of risk alleles and genotypes in TNF (rs361525, rs1800629), DARC (rs12075), MBL2 (rs11003125) and FTO (rs9939609, rs9930506) genes associated with implant failure (AL/PJI). Of these, FTO gene variations (rs9939609, rs9930506) were associated mainly with PJI (P=0.001, OR=2.04, 95%CI=1.132–2.603; P=0.011, OR=1.72, 95%CI=1.338–3.096) and DARC (rs12075) with AL (P=0.005, OR=1.79, 95%CI=1.193–2.696). This tool calculates a hazard ratio of a combination of SNPs associated with AL and PJI for identification of patients with high and low risk of AL/PJI TJA failure. We proposed a risk evaluation tool for stratification of patients before the TJA surgery based on the genetic risk of AL/PJI development. The effect size for each genotype combination described in the study is small. Further multiparametric data analysis and studies on an extended patient cohort and other non-genetic and genetic parameters are ongoing. Grant support: AZV MZ CR VES16-131852A, VES15-27726A, IGA LF UP_2016_011

Determine the infection risk of nonoperative versus operative repair of extraperitoneal bladder ruptures in patients with pelvic ring injuries. Pelvic ring injuries with extraperitoneal bladder ruptures were identified from a prospective trauma registry at two level 1 trauma centers from 2014 to 2020. Patients, injuries, treatments, and complications were reviewed. Using Fisher's exact test with significance at P value < 0.05, associations between injury treatment and outcomes were determined. Of the 1127 patients with pelvic ring injuries, 68 (6%) had a concomitant extraperitoneal bladder rupture. All patients received IV antibiotics for an average of 2.5 days. A suprapubic catheter was placed in 4 patients. Bladder repairs were performed in 55 (81%) patients, 28 of those simultaneous with ORIF anterior pelvic ring. The other 27 bladder repair patients underwent initial ex-lap with bladder repair and on average had pelvic fixation 2.2 days later. Nonoperative management of bladder rupture with prolonged Foley catheterization was used in 13 patients. Improved fracture reduction was noted in the ORIF cohort compared to the closed reduction external fixation cohort (P = 0.04). There were 5 (7%) deep infections. Deep infection was associated with nonoperative management of bladder rupture (P = 0.003) and use of a suprapubic catheter (P = 0.02). Not repairing the bladder increased odds of infection 17-fold compared to repair (OR 16.9, 95% CI 1.75 – 164, P = 0.01). Operative repair of extraperitoneal bladder ruptures substantially decreases risk of infection in patients with pelvic ring injuries. ORIF of anterior pelvic ring does not increase risk of infection and results in better reductions compared to closed reduction. Suprapubic catheters should be avoided if possible due to increased infection risk later. Treatment algorithms for pelvic ring injuries with extraperitoneal bladder ruptures should recommend early bladder repair and emphasize anterior pelvic ORIF

Distal radius fractures are common, particularly in post-menopausal women. Several factors have been identified such as osteopenia and an increased risk of falling. We hypothesised that increased soft tissue padding from muscle and fat in the volar hand may confer an element of protection against fractures more in men than women and more in younger than older patients. The aim of the study was to assess for thenar and hypothenar thickness and assess whether it varies between sexes and changes with age. We retrospectively evaluated hand MRI scans performed for non-acute conditions in adults without previous injury or surgery. Using the Patient Archiving and Communication System (PACS) we measured the distance (mm) from the volar surface of the trapezium to the skin, the hook of the hamate to skin and the pisiform to skin as measures of thenar and hypothenar thickness. We also recorded the sex and age of the subjects. Soft tissue thickness was corrected for hand size by dividing by capitate length which we measured; we have already established this as a surrogate measure of hand size. The scans of 51 men (mean age 35, range 19–66) years and 27 women (mean age 49, range 19–79) years were reviewed. Men had significantly thicker soft tissues compared to women over both the thenar and hypothenar eminences (p=0.0001). Soft tissue thickness did not change significantly with age (p> 0.05). The study confirms a significant difference in volar hand soft tissue thickness between men and women accounting for differences in hand size. Our previous research has shown how we fall onto our outstretched hands in the upper limb falling reflex and we have shown that padding the thenar and hypothenar eminences reduces force transmission to the forearm bones. In theory thicker thenar and hypothenar musculature would help protect against distal radius fractures following a fall on an outstretched hand. The thinner musculature on women may further predispose them to an increased risk of distal radius fractures. Further research is needed to assess for any loss of volar hand soft tissue thickness beyond age 75 years

Abstract. Objectives. There is renewed interest in bi-unicondylar arthroplasty (Bi-UKA) for patients with medial and lateral tibiofemoral osteoarthritis, but a spared patellofemoral compartment and functional cruciate ligaments. The bone island between the two tibial components may be at risk of tibial eminence avulsion fracture, compromising function. This finite element analysis compared intraoperative tibial strains for Bi-UKA to isolated medial unicompartmental arthroplasty (UKA-M) to assess the risk of avulsion. Methods. A validated model of a large, high bone-quality tibia was prepared for both UKA-M and Bi-UKA. Load totalling 450N was distributed between the two ACL bundles, implant components and collateral ligaments based on experimental and intraoperative measurements with the knee extended and appropriately sized bearings used. 95th percentile maximum principal elastic strain was predicted in the proximal tibia. The effect of overcuts/positioning for the medial implant were studied; the magnitude of these variations was double the standard deviation associated with conventional technique. Results. For all simulations, strains were an order of magnitude lower than that associated with bone fracture. Highest strain occurred in the spine, under the anteromedial ACL attachment, adjacent to transverse overcut of the medial component. Consequently, Bi-UKA had little effect on strain: <10% increases were predicted when compared to UKA-M with equivalent medial cuts/positioning. However, surgical overcutting/positional variation that resulted in loss of anteromedial bone in the spine increased strain. The biggest increase was for lateral translation of the medial component: 44% and 42% for UKA-M and Bi-UKA, respectively. Conclusions. For a large tibia with high bone quality, Bi-UKA with a well-positioned lateral implant had no tangible effect on the risk of tibial eminence avulsion fracture compared to UKA-M. Malpositioning of the medial component that removes bone from the anterior spine could prove problematic for smaller tibiae. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Tip-apex distance (TAD) has long been discussed as a metric for determining risk of failure in fixation of peritrochanteric hip fractures. This study seeks to investigate risk factors including TAD for hospital readmission one year after hip fixation surgery. A retrospective review of proximal hip fractures treated with single screw intramedullary devices between 2016 and 2020 was performed at a 327 bed regional medical center. Patients included had a postoperative follow-up of at least twelve months or surgery-related complications developing within that time. 44 of the 67 patients in this study met the inclusion criteria with adequate follow-up post-surgery. The average TAD in our study population was 19.57mm and the average one year readmission rate was 15.9%. 3 out of 6 patients (50%) with a TAD > 25mm were readmitted within one year due to surgery-related complications. In contrast, 3 out of 38 patients (7.9%) with a TAD < 25mm were readmitted within one year due to surgery-related complications (p=0.0254). Individual TAD measurements, averaging 22.05mm in patients readmitted within one year of surgery and 19.18mm in patients not readmitted within one year of surgery were not significantly different between the two groups (p=0.2113). Our data indicate a significant improvement in hospital readmission rates up to one year after hip fixation surgery in patients with a TAD < 25mm with a decrease in readmissions of over 40% (50% vs 7.9%). This result builds upon past investigations by extending the follow-up time to one year after surgery and utilizing hospital readmissions as a metric for surgical success. With the well-documented physical and financial costs of hospital readmission after hip surgery, our study highlights a reduction of TAD < 25mm as an effective method of improving patient outcomes and reducing financial costs to patients and medical institutions

Abstract. Objectives. Total hip replacement (THR) is one of the most successful and cost-effective interventions in orthopaedic surgery. Dislocation is a debilitating complication of THR and managing an unstable THR constitutes a significant clinical challenge. Stability in THR is multifactorial and is influenced by surgical, patient and implant related factors. It is established that larger diameter femoral heads have a wider impingement-free range of movement and an increase in jump distance, both of which are relevant in reducing the risk of dislocation. However, they can generate higher frictional torque which has led to concerns related to increased wear and loosening. Furthermore, the potential for taper corrosion or trunnionosis is also a potential concern with larger femoral heads, particularly those made from cobalt-chrome. These concerns have meant there is hesitancy among surgeons to use larger sized heads. This study presents the comparison of clinical outcomes for different head sizes (28mm, 32mm and 36mm) in primary THR for 10,104 hips in a single centre. Methods. A retrospective study of all consecutive patients who underwent primary THR at our institution between 1st April 2003 and 31st Dec 2019 was undertaken. Institutional approval for this study was obtained. Demographic and surgical data were collected. The primary outcome measures were all-cause revision, revision for dislocation, and all-cause revision excluding dislocation. Continuous descriptive statistics used means, median values, ranges, and 95% confidence intervals where appropriate. Kaplan-Meier survival curves were used to estimate time to revision. Cox proportional hazard regression analysis was used to compare revision rates between the femoral head size groups. Adjustments were made for age at surgery, gender, primary diagnosis, ASA score, articulation type, and fixation method. Results. 10,104 primary THRs were included; median age 68.6 years with 61.5% females. A posterior approach was performed in 71.6%. There were 3,295 hips with 28 mm heads (32.6%), 4,858 (48.1%) with 32 mm heads and 1,951 (19.3%) with 36 mm heads. Overall rate of revision was 1.7% with the lowest rate recorded for the 36mm group (2.7% vs. 1.3% vs. 1.1%). Cox regression analysis showed a decreased risk of all-cause revision for 32mm & 36mm head sizes as compared to 28mm; this was statistically significant for the 32mm group (p = 0.01). Risk of revision for dislocation was significantly reduced in both 32mm (p = 0.03) and 36mm (p = 0.03) head sizes. Analysis of all cause revision excluding dislocation showed no significant differences between head sizes. Conclusion. There was a significantly reduced risk of revision for all causes, but particularly revision for dislocation with larger head sizes (36mm & 32mm vs. 28mm). Concerns regarding increased risk of early revision for aseptic loosening, polyethylene wear or taper corrosion with larger heads appear to be unfounded in this cohort of 10,104 patients with a mean of 6.0-year follow-up. 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

Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”. To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients. Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of iatrogenic injury was noted and a new line was drawn from the same portal to the border of the PN. The danger area was measured from the first line to the new direct line along the joint capsule. In 28 adult patients, the closest distances from each line to the PN in standard knee MRI images were significantly shorter than arthroscopic position MRI images (all p-values < 0.05). All danger areas assessed in the actual arthroscopic position MRIs were included within the danger areas as assessed by the standard knee MRIs. We found that the standard knee MRIs can be used to determine the risk of peroneal nerve injury in arthroscopic lateral meniscal repair, although the risks are slightly overestimated

Femoro-acetabular impingement involves a deformity of the hip joint and is associated with hip osteoarthritis. Although 15% of the asymptomatic population exhibits a deformity, it is not clear who will develop symptoms. Current diagnostic imaging measures have either low specificity or low sensitivity and do not consider the dynamic nature of impingement during daily activities. The goal of this study is to determine stresses in the cartilage, subchondral bone and labrum of normal and impinging hips during activities such as walking and sitting down. Quantitative CT scans were obtained of a healthy Control and a participant with a symptomatic femoral cam deformity (‘Bump’). 3D models of the hip were created from automatic segmentation of CT scans. Cartilage layers were added so the articular surface was the mid-line of the joint. Finite element meshes were generated in each region. Bone elastic modulus was assigned element-by-element, calculated from CT intensity converted to bone mineral density using a calibration phantom. Cartilage was modelled as poroelastic, E=0.467 MPa, v=0.167, and permeability 3×10. -16. m. 4. /N s. The pelvis was fixed while rotations and contact forces from Bergmann et al. (2001) were applied to the femur over one load cycle for walking and sitting in a chair. All analyses were performed in FEBio. High shear stresses were seen near the acetabular cartilage-labrum junction in the Bump model, up to 0.12 MPa for walking and were much higher than in the Control. Patient-specific modelling can be used to assess contact and tissue stresses during different activities to better understand the risk of degeneration in individuals, especially for activities that involve high hip flexion. The high stresses at the cartilage labrum interface could explain so-called bucket-handle tears of the labrum

An international Consensus Group has by a Delphi approach identified the topic of host factors affecting pin site infection to be one of the top 10 priorities in external fixator management. The aim of this study was to report the frequency of studies reporting on specific host factors as a significant association with pin site infection. Host factors to be assessed was: age, smoking, BMI and any comorbidity, diabetes, in particular. The intention was an ethological review, data was extracted if feasible, however no meta-analysis was performed. A systematic literature search was performed according to the PRISMA-guidelines. The protocol was registered before data extraction in PROSPERO. The search string was based on the PICO criterias. A logic grid with key concept and index terms was made. A search string was built assisted by a librarian. The literature search was executed in three electronic bibliographic databases, including Embase MEDLINE (1111 hits) and CINAHL (2066 hits) via Ovid and Cochrane Library CENTRAL (387 hits). Inclusion criteria: external fixation, >1 pin site infection, host factor of interest, peer-reviewed journal. Exclusion criteria: Not written in English, German, Danish, Swedish, or Norwegian, animal or cadaveric studies, location on head, neck, spine, cranium or thorax, editorials or conference abstract. The screening process was done using Covidence. A total of 3564 titles found. 3162 excluded by title and abstract screening. 140 assessed for full text eligibility. 11 studies included for data extraction. The included studies all had a retrospective design. Three identified as case-control studies. Generally the included studies was assessed to have a high risk of bias. A significant associations between pin site infection for following host factors: a) increased HbA1C level in diabetic patients; b) congestive heart failure in diabetic patients; c) less co-morbidity; d) preoperative osteomyelitis was found individually. This systematic literature search identified a surprisingly low number of studies examining for risk of pin site infection and host factors. Thus, this review most of all serves to demonstrate a gap of evidence about correlation between host factors and risk of pin site infection, and further studies are warranted

Introduction and Objective. The most common paediatric orthopaedic injury requiring hospital admission is a femoral fracture. There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12. Materials and Methods. We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications. Results. Nine randomised controlled trials (RCTs) and 19 observational studies (six prospective and 13 retrospective) fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n=161), two analysed plates (n=51) and five analysed EF (n=168). Within the observational studies, 13 analysed FIN (n=610), seven analysed plates (n=214) and six analysed EF (n=153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p=0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p=0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p=0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001). Conclusions. Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. Our findings provide valuable information to healthcare professionals who are involved in discussing the risk and benefits of different management options with patients and their families. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior

Abstract. Background. The Oxford Domed Lateral (ODL) Unicompartmental Knee Replacement (UKR) has some advantages over other lateral UKRs, but the mobile bearing dislocation rate is high (1–6%). Medial dislocations, with the bearing lodged on the tibial component wall, are most common. Anterior/posterior dislocations are rare. For a dislocation to occur distraction of the joint is required. We have developed and validated a dislocation analysis tool based on a computer model of the ODL with a robotics path-planning algorithm to determine the Vertical Distraction required for a Dislocation (VDD), which is inversely related to the risk of dislocation. Objectives. To modify the ODL design so the risk of medial dislocation decreases to that of an anterior/posterior dislocation. Methods. The components were modified using Solidworks. For each modification the dislocation analysis tool was used to determine the VDD for medial dislocation (with bearing 0–6mm from the tibial wall). This was compared with the original implant to identify the modifications that were most effective at reducing the dislocation risk. These modifications were combined into a final design, which was assessed. Results. Modifying the tibial component plateau, changing the femoral component width and making the bearing wider medially had little effect on VDD. Shifting the femoral sphere centre medially decreased VDD. Shifting the femoral sphere laterally, increasing tibial wall height and increasing bearing width laterally increased VDD. A modified implant with a femoral sphere centre 3mm lateral, wall 2.8mm higher, and bearing 2mm wider laterally, implanted so the bearing is ≤4mm from the tibial wall with a bearing thickness ≥4mm had a minimum VDD for medial dislocation of 5.75mm, which is larger than the minimum VDD for anterior/posterior dislocation of 5.5mm. Conclusions. A modified ODL design should decrease the dislocation rate to an acceptable level, however, further testing in cadavers is required. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest