Thrombelastography (TEG) is a point-of-care tool that can measure clot formation and breakdown using a whole blood sample. We have previously used serial TEG analysis to define hypercoagulability and increased venous thromboembolism (VTE) risk following a major fracture requiring surgical treatment. Additionally, we have used serial TEG analysis to quantify the prolonged hypercoagulable state and increased VTE risk that ensues following a hip fracture. Recently developed cartridge-based platelet mapping (PLM) using TEG analysis can be used to activate platelets at either the adenosine diphosphate (ADP) receptor or at the Thromboxane A2 (AA) receptor, in order to evaluate clot strength when platelets are activated only through those specific receptors. This study aim was to evaluate platelet contribution to hypercoagulability, in order to identify potential therapeutic targets for VTE prevention. We hypothesized that there would be a platelet-predominant contribution to hypercoagulability following a hip fracture. Patients aged 50 years or older with a hip fracture treated surgically were enrolled in this prospective cohort study. Exclusion criteria were: prior history of VTE, active malignancy, or pre-injury therapeutic dose anticoagulation. Serial TEG and PLM analyses were performed at admission, post-operative day (POD) 1, 3, 5, 7 and at 2-, 4-, 6- and 12-weeks post-operatively. All patients received thromboprophylaxis with low molecular weight heparin (LMWH) for 28 days post-operatively. Hypercoagulability was defined as maximal amplitude (MA; a measure of clot strength) over 65mm based on TEG analysis. Independent samples
Aim. To date, the value of culture results after a debridement, antibiotics and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At one year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIRs after primary total hip or knee arthroplasty. The secondary aim was to explore differences in patient characteristics, infection characteristics and outcomes between these two groups. Methods. A retrospective regional registry study was performed in a group of 359 patients (positive cultures: n = 299, negative cultures n = 60) undergoing DAIR for high suspicion of early PJI in the period from 2014 to 2019. Differences in patient characteristics, deceased patients and number of subsequent DAIRs between the positive and negative DAIR groups were analyzed using independent
Intraoperative range of motion (ROM) radiographs are routinely taken during scaphoidectomy and four corner fusion surgery (S4CF) at our institution. It is not known if intraoperative ROM predicts postoperative ROM. We hypothesize that patients with a greater intra-operativeROM would have an improved postoperative ROM at one year, but that this arc would be less than that achieved intra- operatively. We retrospectively reviewed 56 patients that had undergone S4CF at our institution in the past 10 years. Patients less than 18, those who underwent the procedure for reasons other than arthritis, those less than one year from surgery, and those that had since undergone wrist arthrodesis were excluded. Intraoperative ROM was measured from fluoroscopic images taken in flexion and extension at the time of surgery. Patients that met criteria were then invited to take part in a virtual assessment and their ROM was measured using a goniometer.
Advances in algorithms developed with sensor data from smart phones demonstrates the capacity to passively collect qualitative gait metrics. The purpose of this feasibility study was to assess the recovery of these metrics following joint reconstruction. A secondary data analysis of an ethics approved global, multicenter, prospective longitudinal study evaluating gait quality data before and after primary total knee arthroplasty (TKA, n=476), partial knee arthroplasty (PKA, n=139), and total hip arthroplasty (THA, n=395). A minimum 24 week follow-up was required (mean 45±12, range 24 - 78). Gait bouts and gait quality metrics (walking speed, step length, timing asymmetry, and double support percentage) were collected from a standardized smartphone operating system. Pre- and post-operative values were compared using paired-samples
Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia. We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired
Preoperative ligament laxity can be characterized intraoperatively using digital robotic tensioners. Understanding how preoperative knee joint laxity affects preoperative and early post-operative patient reported outcomes (PROMs) may aid surgeons in tailoring intra-operative balance and laxity to optimize outcomes for specific patients. This study aims to determine if preoperative ligament laxity is associated with PROMs, and if laxity thresholds impact PROMs during early post-operative recovery. 106 patients were retrospectively reviewed. BMI was 31±7kg/m. 2. Mean age was 67±8 years. 69% were female. Medial and lateral knee joint laxity was measured intraoperatively using a digital robotic ligament tensioning device after a preliminary tibial resection. Linear regressions between laxity and KOOS12-function were performed in extension (10°), midflexion (45°), and flexion (90°) at preoperative, 6-week, and 3-month time points. Patients were separated into two laxity groups: ≥7 mm laxity and <7 mm laxity. Student's
In multilevel posterior cervical instrumented fusions, extending the fusion across the cervico-thoracic junction at T1 or T2 (CTJ) has been associated with decreased rate of re-operation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient reported outcomes (PROs) remains unclear. The primary objective was to determine whether extending the fusion through the CTJ influenced PROs at 3 and 12 months after surgery. Secondary objectives were to compare the number of patients reaching the minimally clinically important difference (MCID) for the PROs and mJOA, operative time duration, intra-operative blood loss (IOBL), length of stay (LOS), discharge disposition, adverse events (AEs), re-operation within 12 months of the surgery, and patient satisfaction. This is a retrospective analysis of prospectively collected data from a multicenter observational cohort study of patients with degenerative cervical myelopathy. Patients who underwent a posterior instrumented fusion of 4 levels of greater (between C2-T2) between January 2015 and October 2020 with 12 months follow-up were included. PROS (NDI, EQ5D, SF-12 PCS and MCS, NRS arm and neck pain) and mJOA were compared using ANCOVA, adjusted for baseline differences. Patient demographics, comorbidities and surgical details were abstracted. Percentafe of patient reaching MCID for these outcomes was compared using chi-square test. Operative duration, IOBL, AEs, re-operation, discharge disposittion, LOS and satisfaction were compared using chi-square test for categorical variables and independent samples
Smartphone-based apps that measure step-count and patient reported outcomes (PROMs) are being increasingly used to quantify recovery in total hip arthroplasty (THA). However, optimum patient-specific activity level before and during THA early-recovery is not well characterised. This study investigated 1) correlations between step-count and PROMs and 2) how patient demographics impact step-count preoperatively and during early postoperative recovery. Smartphone step-count and PROM data from 554 THA patients was retrospectively reviewed. Mean age was 64±10yr, BMI was 29±13kg/m2, 56% were female. Mean daily step count was calculated over three time-windows: 60 days prior to surgery (preop), 5–6 weeks postop (6wk), and 11–12 weeks postop (12wk). Linear correlations between step-count and HOOS12 Function and UCLA activity scores were performed. Patients were separated into three step-count levels: low (<2500steps/day), medium (2500-5500steps/day), and high (>5500steps/day). Age >65years, BMI >30, and sex were used for demographic comparisons. Student's
Passive smartphone-based apps are becoming more common for measuring patient progress after total knee arthroplasty (TKA). Optimum activity levels during early TKA recovery haven't been well documented. This study investigated correlations between step-count and patient reported outcome measures (PROMs) and how demographics impact step-count preoperatively and during early post-operative recovery. Smartphone capture step-count data from 357 TKA patients was retrospectively reviewed. Mean age was 68±8years. 61% were female. Mean BMI was 31±6kg/m2. Mean daily step count was calculated over three time-windows: 60 days prior to surgery (preop), 5-6 weeks postop (6wk), and 11-12 weeks postop (12wk). Linear correlations between step-count and KOOS12-function and UCLA activity scores were performed. Patients were separated into three step-count levels: low (<1500steps/day), medium (1500-4000steps/day), and high (>4000steps/day). Age >65years, BMI >30kg/m2, and sex were used for demographic comparisons. Student's
In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown. A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student
Conferences centered around surgery suffers from gender disparity with male faculty having a more dominant presence in meetings compared to female faculty. Orthopedic Surgery possibly suffers the most from this problem of all surgical specialties, and is reflective of a gender disparity in the field. The objective of this study was to investigate the prevalence of “manels”, or male-only sessions, in eight major Orthopedic Surgery meetings hosted in 2021 and to quantify the differences in location of practice, academic position, years of practice, and research qualifications between male and female faculty. Eight Orthopedic conferences organized by major Orthopedic associations (AAOS, COA, OTA, EFORT, AAHKS, ORS, NASS, and AOSSM) from February 2021 to November 2021 were analyzed. Meeting information was retrieved from the conference agendas, and details of chairs and speakers were obtained from Linkedin, Doximity, CPSO, personal websites, and Web of Science. Primary outcomes included: one) percentage of male faculty in all included sessions and two) overall percentage of manels. Secondary outcomes included one) percentage of male speakers and chairs in all included sessions, two) overall percentage of male-chair and male-speaker only sessions. Comparisons for outcomes were made between conferences and session topics (adult reconstruction hip, adult reconstruction knee, practice management/rehabilitation, trauma, sports, general, pediatrics, upper extremity, musculoskeletal oncology, foot and ankle, spine, and miscellaneous). Mean number of sessions for male and female were compared after being stratified into quartiles based on publications, sum of times cited, and H-indexes. Data was analyzed with non-parametric analysis, chi-square tests, or independent samples
Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation. After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples
Hip instability is one of the most common causes for total hip arthroplasty (THA) revision surgery. Studies have indicated that lumbar fusion (LF) surgery is a risk factor for hip dislocation. Instrumented spine fusion surgery decreases pelvic tilt, which might lead to an increase in hip motion to accommodate this postural change. To the best of our knowledge, spine-pelvis-hip kinematics during a dynamic activity in patients that previously had both a THA and LF have not been investigated. Furthermore, patients with a combined THA and LF tend to have greater disability. The purpose was to examine spine-pelvis-hip kinematics during a sit to stand task in patients that have had both THA and LF surgeries and compare it to a group of patients that had a THA with no history of spine surgery. The secondary purpose was to compare pain, physical function, and disability between these patients. This cross-sectional study recruited participants that had a combined THA and LF (n=10; 6 females, mean age 73 y) or had a THA only (n=11; 6 females, mean age 72 y). Spine, pelvis, and hip angles were measured using a TrakSTAR motion capture system sampled at 200 Hz. Sensors were mounted over the lateral thighs, base of the sacrum, and the spinous process of the third lumbar,12th thoracic, and ninth thoracic vertebrae. Participants completed 10 trials of a standardized sit-to-stand-to-sit task. Hip, pelvis, lower lumbar, upper lumbar, and lower thoracic sagittal joint angle range of motion (ROM) were calculated over the entire task. In addition, pain, physical function, and disability were measured with clinical outcomes: Hip Disability Osteoarthritis Outcome Score (pain and physical function), Oswestry Low Back Disability Questionnaire (disability), and Harris Hip Score (pain, physical function, motion). Physical function performance was measured using 6-Minute Walk Test, Stair Climb Test, and 30s Chair Test. Angle ROMs during the sit-to-stand-to-sit task and clinical outcomes were compared between THA+LF and THA groups using independent
Individuals with multi-compartment knee osteoarthritis (KOA) frequently experience challenges in activities of daily living (ADL) such as stair ambulation. The Levitation “Tri-Compartment Offloader” (TCO) knee brace was designed to reduce pain in individuals with multicompartment KOA. This brace uses novel spring technology to reduce tibiofemoral and patellofemoral forces via reduced quadriceps forces. Information on brace utility during stair ambulation is limited. This study evaluated the effect of the TCO during stair descent in patients with multicompartment KOA by assessing knee flexion moments (KFM), quadriceps activity and pain. Nine participants (6 male, age 61.4±8.1 yrs; BMI 30.4±4.0 kg/m2) were tested following informed consent. Participants had medial tibiofemoral and patellofemoral OA (Kellgren-Lawrence grades two to four) diagnosed by an orthopaedic surgeon. Joint kinetics and muscle activity were evaluated during stair descent to compare three bracing conditions: 1) without brace (OFF); 2) brace in low power (LOW); and 3) brace in high power (HIGH). The brace spring engages from 60° to 120° and 15° to 120° knee flexion in LOW and HIGH, respectively. Individual brace size and fit were adjusted by a trained researcher. Participants performed three trials of step-over-step stair descent for each bracing condition. Three-dimensional kinematics were acquired using an 8-camera motion capture system. Forty-one spherical reflective markers were attached to the skin (on each leg and pelvis segment) and 8 markers on the brace. Ground reaction forces and surface EMG from the vastus medialis (VM) and vastus lateralis (VL) were collected for the braced leg. Participants rated knee pain intensity performing the task following each bracing condition on a 10cm Visual Analog Scale ranging from “no pain” (0) to “worst imaginable pain” (100). Resultant brace and knee flexion angles and KFM were analysed during stair contact for the braced leg. The brace moment was determined using brace torque-angle curves and was subtracted from the calculated KFM. Resultant moments were normalized to bodyweight and height. Peak KFMs were calculated for the loading response (Peak1) and push-off (Peak2) phases of support. EMG signals were normalized and analysed during stair contact using wavelet analysis. Signal intensities were summed across wavelets and time to determine muscle power. Results were averaged across all 3 trials for each participant. Paired
This study used model-based radiostereometric analysis (MBRSA) to compare migration of a recently introduced cementless hip stem to an established hip stem of similar design. Novel design features of the newer hip stem included a greater thickness of hydroxyapatite coating and a blended compaction extraction femoral broach. Fifty-seven patients requiring primary total hip arthroplasty (THA) were enrolled at a single centre. Patients were randomized to receive either an Avenir collarless stem and Trilogy IT cup (ZimmerBiomet) or a Corail collarless stem and Pinnacle cup (DePuy Synthes) via a posterior or lateral approach. Both stems are broach-only femoral bone preparation. RSA beads (Halifax Biomedical) were inserted into the proximal femur during surgery. Patients underwent supine RSA imaging a 6 weeks (baseline), 6, 12, and 24 months following surgery. The primary study outcome was total subsidence of the hip stem from baseline to 24 months as well as progression of subsidence between 12 and 24 months. These values were compared against published migration thresholds for well-performing hip stems (0.5mm). The detection limit, or precision, of MBRSA was calculated based on duplicate examinations taken at baseline. Patient reported outcome measures were collected throughout the study and included the Oxford-12 Hip Score (OHS), EuroQoL EQ-5D-5L, Hip Osteoarthritis Score (HOOS) as well as visual analogue scales (VAS) for thigh pain and satisfaction. Analysis comprised of paired and unpaired
Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples
Major orthopaedic fractures are an independent risk factor for the development of venous thromboembolism (VTE), which are significant causes of preventable morbidity and mortality in trauma patients. Despite thromboprophylaxis, patients who sustain a pelvic or acetabular fracture (PA) continue to have high rates of VTE (12% incidence). Thrombelastography (TEG) is a whole-blood, point-of-care test which provides an overview of the clotting process. Maximal amplitude (MA), from TEG analysis, is the measure of clot strength and values ≥65mm have been used to quantify hypercoagulability and increased VTE risk. Therefore, the primary aim was to use serial TEG analysis to quantify the duration of hypercoagulability, following surgically treated PA fractures. This is a single centre, prospective cohort study of adult patients 18 years or older with surgically treated PA fractures. Consecutive patients were enrolled from a Level I trauma centre and blood draws were taken over a 3-month follow-up period for serial TEG analysis. Hypercoagulability was defined as MA ≥65mm. Exclusion criteria: bleeding disorders, active malignancy, current therapeutic anticoagulation, burns (>20% of body surface) and currently, or expecting to become pregnant within study timeframe. Serial TEG analysis was performed using a TEG6s hemostasis analyzer (Haemonetics Corp.) upon admission, pre-operatively, on post-operative day (POD) 1, 3, 5, 7 (or until discharged from hospital, whichever comes sooner), then in follow-up at 2-, 4-, 6-weeks and 3-months post-operatively. Patients received standardized thromboprophylaxis with low molecular weight heparin for 28 days post-operatively. VTE was defined as symptomatic DVT or PE, or asymptomatic proximal DVT, and all participants underwent a screening post-operative lower extremity Doppler ultrasound on POD3. Descriptive statistics were used to determine the association between VTE events and MA values. For the primary outcome measure, the difference between the MA threshold value (≥65mm) and serial MA measures, were compared using one-sided
Femoroacetabular impingement (FAI) – enlarged, aspherical femoral head deformity (cam-type) or retroversion/overcoverage of the acetabulum (pincer-type) – is a leading cause for early hip osteoarthritis. Although anteverting/reverse periacetabular osteotomy (PAO) to address FAI aims to preserve the native hip and restore joint function, it is still unclear how it affects joint mobility and stability. This in vitro cadaveric study examined the effects of surgical anteverting PAO on range of motion and capsular mechanics in hips with acetabular retroversion. Twelve cadaveric hips (n = 12, m:f = 9:3; age = 41 ± 9 years; BMI = 23 ± 4 kg/m2) were included in this study. Each hip was CT imaged and indicated acetabular retroversion (i.e., crossover sign, posterior wall sign, ischial wall sign, retroversion index > 20%, axial plane acetabular version < 15°); and showed no other abnormalities on CT data. Each hip was denuded to the bone-and-capsule and mounted onto a 6-DOF robot tester (TX90, Stäubli), equipped with a universal force-torque sensor (Omega85, ATI). The robot positioned each hip in five sagittal angles: Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°; and performed hip internal-external rotations and abduction-adduction motions to 5 Nm in each position. After the intact stage was tested, each hip underwent an anteverting PAO, anteverting the acetabulum and securing the fragment with long bone screws. The capsular ligaments were preserved during the surgery and each hip was retested postoperatively in the robot. Postoperative CT imaging confirmed that the acetabular fragment was properly positioned with adequate version and head coverage. Paired sample
Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples
Introduction. Current undergraduate trauma and life-support training inadequately equips medical students with the knowledge, practical skills and confidence to manage trauma patients. Often first to the scene of medical emergencies, it is imperative junior doctors feel confident and competent from day one. No UK university currently includes advanced trauma and life support (ATLS) in their curriculum. This study piloted an ATLS course for Cardiff final-year medical students to improve confidence and knowledge in management of the trauma patient. Aim. To assess the immediate effect of a one-day undergraduate ATLS course on medical student's confidence in management of the trauma patients. Methods. Twelve final-year students attended a one-day, practical-skills based and interactive course led by trauma surgeons. Students' confidence managing a trauma patient were assessed pre and post-course using a six-item-MCQ with a 5-point Likert scale. Paired
