Distal radius fractures are the most common upper extremity injury, and are increasingly being treated surgically with pre-contoured volar-locking plates. These plates are favored for their low-profile template while allowing for rigid anatomic fixation of distal radius fractures. The geometry of the distal radius is extremely complex, and little evidence within the medical literature suggests that current implant designs are anatomically accurate. The main objective of this study is to determine if anatomic alignment of the distal radii corresponds accurately with modern volar-locking plate designs. Additionally, this study will examine sex-linked differences in morphology of the distal radius.

Segmented CT models of ten female cadaver (mean age, 88.7 ± 4.57 years, range, 82 – 97) arms, and ten male cadaver (mean age, 86 ± 3.59 years, range, 81 – 91) arms were created. Micro CT models were obtained for the DePuy Synthes 2.4mm Extra-articular (EA) Volar Distal Radius Plate (4-hole and 5-hole head), and 2.4mm LCP Volar Column (VC) Distal Radius Plate (8-hole and 9-hole head). Plates were placed onto the distal radii models in a 3D visualization software by a fellowship-trained orthopaedic hand surgeon. The percent contact, volar cortical angle (VCA), border and overlap of the watershed line (WSL) were measured.

Both sexes showed an increase in the average VCA measure from medial to lateral columns which was statistically significant. Female VCA ranged from 28 – 36 degrees, and 38 – 45 degrees for males. WSL overlap ranged from 0 – 34.7629% for all specimens without any statistical significance. The average border distance for females was 2.58571 mm, compared to 3.52411 mm for males, with EA plates having a larger border than VC plates. The border distances had statistically significant differences between the plate types, and was approaching significance between sexes. Lastly, a maximum percent contact of 21.966 % was observed in specimen F4 at a 0.3 mm threshold. No statistical significance between plate or sex populations was observed.

This study investigated the incoherency between the volar cortical angle of the distal radius, and the pre-contoured angle of volar locking plates. It was hypothesized that if the VCA measures between plate and bone were unequal then there would be an increase in watershed line overlap, and decrease in percent contact between the surfaces. Our results agreed with literature, indicating that the VCA of bone was larger than that of the EA and VC pre-contoured plates examined in this study.

With distal radius fracture incidences and prevalence on the rise for elderly female patients, it is a necessity that volar locking plates be re-designed to factor in anatomical features of individual patients with a particular focus on sex differences. New designs should focus on providing smaller head sizes that are more accurately tailored to the natural contours of the volar distal radius. It is recommended that future studies incorporate expertise from multiple surgeons to diversify and further understand plate placement strategies.

Aims. This study assesses patient barriers to successful telemedicine care in orthopaedic practices in a large academic practice in the COVID-19 era. Methods. In all, 381 patients scheduled for telemedicine visits with three orthopaedic surgeons in a large academic practice from 1 April 2020 to 12 June 2020 were asked to participate in a telephone survey using a standardized Institutional Review Board-approved script. An unsuccessful telemedicine visit was defined as patient-reported difficulty of use or reported dissatisfaction with teleconferencing. Patient barriers were defined as explicitly reported barriers of unsatisfactory visit using a process-based satisfaction metric. Statistical analyses were conducted using analysis of variances (ANOVAs), ranked ANOVAs, post-hoc pairwise testing, and chi-squared independent analysis with 95% confidence interval. Results. The survey response rate was 39.9% (n = 152). The mean age of patients was 51.1 years (17 to 85), and 55 patients (38%) were male. Of 146 respondents with completion of survey, 27 (18.5%) reported a barrier to completing their telemedicine visit. The majority of patients were satisfied with using telemedicine for their orthopaedic appointment (88.8%), and found the experience to be easy (86.6%). Patient-reported barriers included lack of proper equipment/internet connection (n = 13; 8.6%), scheduling difficulty (n = 2; 1.3%), difficulty following directions (n = 10; 6.6%), and patient-reported discomfort (n = 2; 1.3%). Barriers based on patient characteristics were age > 61 years, non-English primary language, inexperience with video conferencing, and unwillingness to try telemedicine prior to COVID-19. Conclusion. The barriers identified in this study could be used to screen patients who would potentially have an unsuccessful telemedicine visit, allowing practices to provide assistance to patients to reduce the risk of an unsuccessful visit. Cite this article: Bone Jt Open 2021;2(9):745–751

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Early mobilization within the first 12 hours (day zero) of total joint arthroplasty (TJA) has been shown to reduce length of stay (LoS) without risking clinical outcomes, patient safety or satisfaction. The purpose of this study was to investigate associations between the degree of mobilization on day zero (i.e., standing at the bedside versus walking in the hallway) and LoS in TJA patients. In addition, we investigated predictors of LoS and day zero mobilization. A retrospective cohort study was undertaken of the health records of patients in a community hospital setting who had an elective unilateral primary TJA between June 2015 and May 2017 and had mobilized on day zero. The total sample was 283 patients (184 TKA and 99 THA) across four mobilization categories: Sat on beside (n = 76), Stood by bed/marched in place (n = 83), Walked in the room (n = 79), and Walked in hall (n = 45). Analysis of variance found no significant group differences in age, ASA score, Charlson Comorbidity Index score, anesthesia, surgeon, procedure type, pain medication, and patient reported symptoms recorded by physiotherapists. Significantly more women were in the Sat group and significantly more men were in the Hall group (p < .001). Patient reported symptoms of nausea and drowsiness were significantly greater for the Sat group (p < .001). LoS was also significantly different across the groups. Post hoc Tukey comparisons found the Walked Hall group had significantly shorter LoS (M = 2.7 days) than the Sat group (M = 3.9, p < .001), Stood group (M = 3.4, p = .011), and the Walked Room group (M = 3.5, p = .004). A hierarchical regression was performed to determine predictors of LoS. Block 1 consisted of demographic, medical status, and patient reported symptoms as variables. Mobilization was entered in Block 2. The first model was significant (p < .001) and explained 24% of variance in LoS. The final model was also significant (p < .001), accounting for a total of 26% of the variance in LoS. Thus, block 2 (i.e., mobilization) accounted for a small but significant 2% incremental variance (p = .008) beyond the block 1 variables in the prediction of LoS. With mobilization added, only male gender (p = .002), lower BMI (p = .026), and lower ASA scores (p = .006) remained significant predictors of shorter LoS, and the predictive ability of several of the block 1 variables were reduced to non-significant levels. A simultaneous regression model was then used to predict degree of mobilization. The model accounted for 24% of the variance in mobilization (p < .001). Variables significantly associated with a greater degree of mobilization included: younger age, male gender, lower BMI, and fewer symptoms, namely nausea, numbness, lightheadedness, and drowsiness. This study found length of stay was shorter when patients mobilized farther on the day of surgery. Some factors predictive of mobilization may be modifiable. Focusing on symptom management could increase opportunities for farther mobilization on the day of surgery, and thus decrease length of stay

Introduction. Re-revision due to instability and dislocation can occur in up to 1 in 4 cases following revision total hip arthroplasty (THA). Optimal placement of components during revision surgery is thus critical in avoiding re-revision. Computer-assisted navigation has been shown to improve the accuracy and precision of component placement in primary THA; however, its role in revision surgery is less well documented. The purpose of our study was to evaluate the effect of computer-assisted navigation on component placement in revision total hip arthroplasty, as compared with conventional surgery. Methods. To examine the effect of navigation on acetabular component placement in revision THA, we retrospectively reviewed data from a multi-centre cohort of 128 patients having undergone revision THA between March 2017 and January 2019. An imageless computer navigation device (Intellijoint HIP®, Intellijoint Surgical, Kitchener, ON, Canada) was utilized in 69 surgeries and conventional methods were used in 59 surgeries. Acetabular component placement (anteversion, inclination) and the proportion of acetabular components placed in a functional safe zone (40° inclination/20° anteversion) were compared between navigation assisted and conventional THA groups. Results. Mean inclination decreased post-operatively versus baseline in both the navigation (44.9°±12.1° vs. 43.0°±6.8°, p=0.65) and control (45.8°±19.4° vs. 42.8°±7.1°, p=0.08) groups. Mean anteversion increased in both study groups, with a significant increase noted in the navigation group (18.6°±8.5° vs. 21.6°±7.8°, p=0.04) but not in the control group (19.4°±9.6° vs. 21.2°±9.8°, p=0.33). Post-operatively, a greater proportion of acetabular components were within ±10° of a functional target (40° inclination, 20° anteversion) in the navigation group (inclination: 59/67 (88%), anteversion: 56/67 (84%)) than in the control group (49/59 (83%) and 41/59, (69%), respectively). Acetabular component precision in both study groups improved post-operatively versus baseline. Variance in inclination improved significantly in both control (50.6° vs. 112.4°, p=0.002) and navigation (46.2° vs. 141.1°, p<0.001) groups. Anteversion variance worsened in the control group (96.3° vs. 87.6°, p=0.36) but the navigation group showed improvement (61.2° vs. 72.7°, p=0.25). Post-operative variance amongst cup orientations in the navigation group (IN: 46.2°; AV: 61.2°) indicated significantly better precision than that observed in the control group (IN: 50.6°, p=0.36; AV: 96.3°, p=0.04). Discussion. Re-revision is required in up to 25% of revision THA cases, of which 36% are caused by instability. This places a significant burden on the health care system and highlights the importance of accurate component placement. Our data indicate that the use of imageless navigation in revision THA – by minimizing the likelihood of outliers – may contribute to lower rates of re-revision by improving component orientation in revision THA. Conclusion. Utilizing imageless navigation in revision THAs results in more consistent placement of the acetabular component as compared to non-navigated revision surgeries

Essex-Lopresti injuries are often unrecognized acutely with resulting debilitating adverse effects. Persistent axial forearm instability may affect load transmission at both the elbow and wrist, resulting in significant pain. In the setting of both acute and chronic injuries metallic radial head arthroplasty has been advocated, however there is little information regarding their outcome. The purpose of this study was to assess the efficacy of a radial head arthroplasty to address both acute and chronic Essex-Lopresti type injuries. A retrospective review from 2006 to 2016 identified 11 Essex-Lopresti type injuries at a mean follow-up of 18 months. Five were diagnosed and treated acutely at a mean of 11 days (range, 8 to 19 days) from injury, while 6 were treated in a delayed fashion at a mean of 1.9 years (range, 2.7 months to 6.2 years) from injury with a mean 1.5 (range, 0 to 4) prior procedures. The cohort included 10 males with a mean age was 44.5 years (range, 28 to 71 years). A smooth stem, modular radial head arthroplasty was used in all cases. Outcomes included range of motion and radiographic findings such as ulnar variance, capitellar erosion, implant positioning and implant lucency using a modification of the method described by Gruen. Reoperations, including the need for ulnar shortening osteotomy, were also recorded. Three patients in each group (55%) reported persistent wrist pain. The mean ulnar variance improved from +5 mm (range, 1.8 to 7 mm) to +3.7 mm (range, 1 to 6.3 mm) at the time of final follow-up or prior to reoperation. Three (50%) patients in the chronic group underwent a staged ulnar shortening osteotomy (USO) to correct residual ulnar positive variance and to manage residual wrist pain. There were no reoperations in the acute group. Following USO, the ulnar variance in those three cases improved further to +3.5, +2.1, and −1.1 mm. No radial head prostheses required removal. Capitellar erosion was noted in five (45%) elbows, and was rated severe in one, moderate in two, and mild in two. Lucency about the radial head prosthesis stem was noted in eight (73%) cases, and rated as severe in 2 (18%), based on Gruen zones. Treatment of acute and chronic Essex-Lopresti lesions with radial head arthroplasty often results in persistent wrist pain. In the chronic setting, a planned USO was often necessary to restore axial forearm stability after radial head arthroplasty. Essex-Lopresti lesions represent a rare clinical entity that are difficult treat, particularly in the chronic setting. Early recognition and management with a smooth stem modular radial head arthroplasty may provide improved outcomes compared to chronic reconstruction

Abstract. Aim. This study aims to Inter and intra observer reliability compare, use of a standard goniometer (SG) to measure intermetacarpal angle (degrees) vs use of a new technique of using a digital vernier calliper (DVC) (mm) to measure the distance between the first and second metacarpal head. Method. Maximal active abduction and extension of both thumbs was measured in 20 healthy volunteers on two occasions at least one week apart by two assessors. Results. The inter and intra-observer agreement was higher & the variance of the data was lower using the DVC with the new technique than the SG for both thumb abduction and extension. Additionally, the correlation between measurement of extension and abduction was higher using the DVC than the SG. Conclusion. Whilst both tools provide acceptable intra and inter-observer agreement, the new technique using a DVC is consistently better and more reliable than a SG in measuring thumb abduction and extension. The study also supports our hypothesis that the thumb rotates around the second metacarpal head with a consistent radius

Ulnocarpal impaction (UCI) is a common cause of ulnar-sided wrist pain. UCI typically occurs in wrists with positive ulnar variance, which causes altered loading mechanics between the ulnar head, lunate and triquetrum. However, many individuals with positive ulnar variance never develop UCI, and some with neutral or negative ulnar variance do experience UCI. This suggests that other variables contribute to the development of UCI. Suspected culprits include lunate morphology, and dynamic changes with loaded (grip) pronation. If these anatomic variations are contributing to UCI, we expect them to influence functional impairment scores. Therefore, the objective of this study was to evaluate the relationship between radiographic parameters and pre-surgical upper extremity patient-rated outcomes scores (PROS) in patients with a diagnosis of UCI. Retrospective cohort study of patients undergoing ulnar shortening osteotomy or arthroscopic wafer procedure for UCI. Data derived from prospectively collected departmental database that captured demographic, clinical, functional and radiographic information. Radiographic parameters evaluated were: lunate morphology [presence vs. absence of hamate facet; Antuna-Zapico (A-Z) classification], and dynamic changes on grip view [difference in lunate-ulnar head distance (LUD); difference in lunate uncovering index (LUI)]. PROS assessed were QuickDASH and Patient-Rated Wrist Evaluation (PRWE) scores, collected at patient enrolment. ANOVA was used to assess for differences in PROS between A-Z classification groups. Student's t-test was used to assess for differences in PROS based on presence/absence of a hamate facet. Regression analysis evaluated a relationship between change in LUD with grip and PROS, and change in LUI with grip and PROS. Preliminary analysis included 23 wrists, with a mean patient age of 48.9 years [standard deviation (SD) 14.5 years]. Forty-eight percent were male, and the dominant limb was involved in 52.2% of cases. Average QuickDASH and PRWE scores at enrolment were 50.9 (SD 22.2) and 62.2 (SD 22.0), respectively. Assessment of radiographs revealed 17 patients (73.9%) without a hamate facet. Five patients (21.7%) had A-Z Type I lunate morphology, and nine (39.1%) had Type II and Type III morphology, respectively. ANOVA revealed no differences in enrolment QuickDASH (p = 0.185) or PRWE (p = 0.256) scores between A-Z classification groups. Similarly, Student's t-test found no difference based on presence/absence of a hamate facet (QuickDASH p = 0.594; PRWE p = 0.573). Regression analysis revealed no relationship between change in LUD with grip and PROS (QuickDash R2 = 0.020, p = 0.619; PRWE R2 = 0.009, p = 0.733), and no relationship between change in LUI with grip and PROS (QuickDash R2 = 0.000, p = 0.913; PRWE R2 = 0.010, p = 0.722). Preliminary results suggest no relationship between A-Z classification lunate morphology, presence/absence of a hamate facet, change in LUD, or change in LUI and pre-surgical PROS. It is unclear if our findings represent the true relationship between these radiographic parameters and PROS, or reflect our preliminary sample size. Data analysis is ongoing to add clarity to this question

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

Little guidance exists in the current literature regarding which patient recorded outcome measures (PROMs) are most clinically appropriate following anterior cruciate ligament reconstruction (ACL) surgery, and what results surgeons should expect or accept. Many PROMs have been validated, but their “ideal” results have not been published, limiting a surgeon's ability to compare their patients’ outcomes with those of their colleagues. We undertook a systematic review of PROMs for ACL to look at common usage and outcomes. After appropriate paper selection, we then undertook a pragmatic meta-analysis (i.e., including all papers that fulfilled the selection criteria, regardless of CONSORT status) and calculated weighted mean outcome scores and standard deviations for the most commonly used PROMs. A comprehensive literature search of all English articles of PubMed and other sources including search terms (‘Patient related outcome measure’ or ‘PROM’) AND ‘anterior cruciate ligament’ (limited to abstract/title) yielded 722 articles. Title review narrowed this to 268, and abstracts review to 151, of which 88 were included in our meta-analysis. Weighted mean and standard deviations were calculated for IKDC, KOOS, Lysholm, Teneger and “VAS Pain” PROMs as the most commonly reported. We identified significant, novel findings relating to selected PROMs and (i) demographics including age, gender and body mass index, (ii) surgical factors including bundle count, strand count, and graft type, and (iii) post operative complications. We clarified the most commonly used PROMs for ACL, and their weighted means and standard deviations. This will allow surgeons to compare results with colleagues, ensuring they meet international levels of quality in PROMs. We have also updated which patient and operative factors have an impact on PROMs scoring to allow for population variance

Reduced cervical spine canal AP diameter is linked to the development of spinal cord injury and myelopathy. This is of particular interest to clinicians in New Zealand, given a unique socio-ethnic make-up and prevalent participation in collision sport. Our study builds upon previous unpublished evidence, by analysing normal cervical spine CT scans to explore morphological differences in the sub-axial cervical spine canal, between New Zealand European, Māori and Paciāca individuals. 670 sub-axial cervical vertebrae (C3-C7) were analysed radiographically using high resolution CT trauma scans, showing no acute pathology with respect to the cervical spine. All measurements were made uPlising mulP-planar reconstruction software to obtain slices parallel to the superior endplate at each vertebral level. Maximal canal diameter was measured in the AP and transverse planes. Statistical analysis was performed using analysis of variance (ANOVA). We included 250 Maori, 250 NZ European and 170 Paciāca vertebrae (455 male, 215 female). Statistically and clinically signiācant differences were found in sagittal canal diameter between all ethnicities, at all spinal levels. NZ European vertebrae demonstrated the largest AP diameter and Paciāca the smallest, at all levels. Transverse canal diameter showed no signiācant difference between ethnicities, however the raatio of AP:transverse diameter was signiācantly different at all spinal levels except C3. Subjective morphological differences in the shape of the vertebral canal were noted, with Māori and Paciāca patients tending towards a flatter, curved canal shape. A previous study of 166 patients (Coldham, G. et al. 2006) found cervical canal AP diameter to be narrower in Māori and Paciāca patients than in NZ Europeans. Our study, evaluating the normal population, conārms these differences are likely reflecPve of genuine variation between these ethniciPes. Future research is required to critically evaluate the morphologic differences noted during this study

Imageless computer navigation systems have the potential to improve acetabular cup position in total hip arthroplasty (THA), thereby reducing the risk of revision surgery. This study aimed to evaluate the accuracy of three alternate registration planes in the supine surgical position generated using imageless navigation for patients undergoing THA via the direct anterior approach (DAA). Fifty-one participants who underwent a primary THA for osteoarthritis were assessed in the supine position using both optical and inertial sensor imageless navigation systems. Three registration planes were recorded: the anterior pelvic plane (APP) method, the anterior superior iliac spines (ASIS) functional method, and the Table Tilt (TT) functional method. Post-operative acetabular cup position was assessed using CT scans and converted to radiographic inclination and anteversion. Two repeated measures analysis of variance (ANOVA) and Bland-Altman plots were used to assess errors and agreement of the final cup position. For inclination, the mean absolute error was lower using the TT functional method (2.4°±1.7°) than the ASIS functional method (2.8°±1.7°, ρ = .17), and the ASIS anatomic method (3.7°±2.1, ρ < .001). For anteversion, the mean absolute error was significantly lower for the TT functional method (2.4°±1.8°) than the ASIS functional method (3.9°±3.2°, ρ = .005), and the ASIS anatomic method (9.1°±6.2°, ρ < .001). All measurements were within ± 10° for the TT method, but not the ASIS functional or APP methods. A functional registration plane is preferable to an anatomic reference plane to measure intra-operative acetabular cup inclination and anteversion accurately. Accuracy may be further improved by registering patient location using their position on the operating table rather than anatomic landmarks, particularly if a tighter target window of ± 5° is desired

Lumbar fusion surgery is an established procedure for the treatment of several spinal pathologies. Despite numerous techniques and existing devices, common surgical trends in lumbar fusion surgery are scarcely investigated. The purpose of this Canada-based study was to provide a descriptive portrait of current surgeons’ practice and implant preferences in lumbar fusion surgery while comparing findings to similar investigations performed in the United Kingdom. Canadian Spine Society (CSS) members were sampled using an online questionnaire which was based on previous investigations performed in the United Kingdom. Fifteen questions addressed the various aspects of surgeons’ practice: fusion techniques, implant preferences, and bone grafting procedures. Responses were analyzed by means of descriptive statistics. Of 139 eligible CSS members, 41 spinal surgeons completed the survey (29.5%). The most common fusion approach was via transforaminal lumber interbody fusion (TLIF) with 87.8% performing at least one procedure in the previous year. In keeping with this, 24 surgeons (58.5%) had performed 11 to 50 cases in that time frame. Eighty-six percent had performed no lumbar artificial disc replacements over their last year of practice. There was clear consistency on the relevance of a patient specific management (73.2%) on the preferred fusion approach. The most preferred method was pedicle screw fixation (78%). The use of stand-alone cages was not supported by any respondents. With regards to the cage material, titanium cages were the most used (41.5%). Published clinical outcome data was the most important variable in dictating implant choice (87.8%). Cage thickness was considered the most important aspect of cage geometry and hyperlordotic cages were preferred at the lower lumbar levels. Autograft bone graft was most commonly preferred (61.0%). Amongst the synthetic options, DBX/DBM graft (64.1%) in injectable paste form (47.5%) was preferred. In conclusion, findings from this study are in partial agreement with previous work from the United Kingdom, but highlight the variance of practice within Canada and the need for large-scale clinical studies aimed to set specific guidelines for certain pathologies or patient categories

There are numerous patient satisfaction questionnaires by none specific for an Independent Medical Examination (IME). The aim of this study was to develop and evaluate a questionnaire suitable for an IME. The questionnaire (IMESQ) consisted of five process domains (“Interpersonal manner”, “Communication”, “Technical ability”, “Information exchange”, “Time allocation”) and an outcome domain (“Satisfaction”), each with a five-scale Likert response. An 11-point numerical satisfaction scale (NSS) and a 3-point scale question on the “willing to undergo another examination with the doctor if required” were alternative measures of validation. The questionnaire was tested against numerous independent variables. Statistical analysis included Spearman correlation ((r. S. ) between the items in the questionnaire and the total score with the NSS, and “willing to undergo another examination with the doctor if required” with point-biserial correlation (r. pb. ). Internal consistent reliability was tested using split-half correlation coefficient (r. SB. ) and Cronbach's alpha coefficient (α). The construct was subjected to Factor Analysis. The results from 53 respondents were analysed. There was moderate to strong inter-item correlation (r. s. range 0.57 to 0.83, median 0.67, p < 0.01) and good correlation with the NSS (r. s. = 0.79, p < 0.01) and dichotomous question (r. pb. = 0.45, p < 0.01). Five respondents were “neither satisfied or dissatisfied” (Item 6) and 12 recorded “maybe” to further examination. The split-half correlation was strong (r. SB. = 0.76, p < 0.01). There was good internal consistency reliability (α = 0.92). “Interpersonal manner” (ψ = 4.3) was the only item to have an eigenvalue greater than one, accounting to 72% of the variance across the scale. Eigenvector analysis confirmed the questionnaire was unidimentional. The IMESQ is a brief questionnaire to assess satisfaction with an IME. It is validated and has good internal consistency reliability. The five process domains can identify areas of suboptimal performance: useful for a 360° audit

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 t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test. A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals. On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity

The Adams-Berger reconstruction is an effective technique for treating distal radioulnar joint (DRUJ) instability. Graft preparation techniques vary amongst surgeons with insufficient evidence to support one technique over another. Our study evaluated the biomechanical properties of four graft preparation techniques. Extensor tendons were harvested from fresh frozen porcine trotters obtained from a local butcher shop and prepared in one of three configurations (n=5 per group): tendon only; tendon prepared with non-locking, running suture (2-0 FiberLoop, Arthrex, Naples, FL) spaced at 6 mm intervals; and tendon prepared with suture spaced at 12 mm intervals. A fourth configuration of suture alone was also tested. Tendons were allocated in a manner to ensure comparable average diameters amongst groups. Biomechanical testing occurred using custom jigs simulating radial and ulnar tunnels attached to a Bose Electroforce 3510 mechanical testing machine (TA Instruments). After being woven through the jigs, all tendons were sutured end-to-end with 2-0 PROLENE suture (Ethicon). Tendons then underwent a staircase cyclic loading protocol (5-25 Newtons [N] at 1 hertz [Hz] for 1000 cycles, then 5-50 N at 1 Hz for 1000 cycles, then 5-75 N at 1 Hz for 1000 cycles) until graft failure; if samples did not fail during the protocol, they were then loaded to failure. Samples were visually inspected for mode of failure after the protocol. A one-way analysis of variance was used to compare average tendon diameter; post-hac Tuhey tests were used to compare elongation and elongation rate. Survival to cyclic loading was analyzed using Kaplan-Meier survival curves with log rank. Statistical significance was set at a = 0.05. The average tendon diameter of each group was not statistically different [4.17 mm (tendon only), 4.33 mm (FiberLoop spaced 6 mm), and 4.30 mm (FiberLoop spaced 12 mm)]. The average survival of tendon augmented with FiberLoop was significantly higher than tendon only, and all groups had significantly improved survival compared to suture only. There was no difference in survival between FiberLoop spaced 6 mm and 12 mm. Elongation was significantly lower with suture compared to tendon augmented with FiberLoop spaced 6 mm. Elongation rate was significantly lower with suture compared to all groups. Modes of failure included rupture of the tendon, suture, or both at the simulated bone and suture and/or tendon interface, and elongation of the entire construct without rupture. In this biomechanical study, augmentation of porcine tendons with FiberLoop suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol, as suture material was significantly stiffer than any of the tendon graft configurations

Introduction. Innovations in orthopaedic technology and infrastructure growth often require significant funding. Although an increasing trend has been observed for third-party investments into medical startups and physician practices, no study has examined the role of this funding in orthopaedics, including the influence of venture capital (VC). Therefore, this study analyzed trends in VC investments related to the field of orthopaedic surgery, as well as the characteristics of companies receiving said investments. Methods. Venture capital investments into orthopaedic-related businesses were reviewed from 2000–2019 using Capital IQ, a proprietary market intelligence platform documenting financial transactions. The dataset was initially filtered to include healthcare-related venture capital transactions pertaining to the field of orthopaedic surgery. The final list of VC investments and their corresponding businesses were categorized by transaction year, amount (in USD), and orthopaedic subspecialty. The number and sum of VC investments was calculated both annually and cumulatively across the entire study period. Linear regression was used for trend analysis within two distinct, decade-long timeframes (2000–2009 and 2010–2019) and one-way analysis of variance was used to assess differences across orthopaedic subspecialties. Results. Over the course of two decades, 672 VC investments were made into orthopaedic-related businesses, representing a total of $3.5 billion. Both the number and dollar value of transactions were greater in the second decade (2010–19) (233, $1.9 billion), compared to the first decade (439, $1.6 billion). Linear regression revealed significant trends in both the quantity and dollar amount of VC transactions within the decade from 2000–09 (p = 0.0002 and p = 0.0143, respectively) but no such trend in the latter decade (Figure 1A-B, Figure 2A-B). Throughout both decades studied, the largest and most frequent VC investments took place within Spine and Adult Reconstruction (Figure 3). One-way analysis of variance revealed significant differences in the annual frequency and amount of investment across orthopaedic subspecialties (p < 0.001 and p < 0.001, respectively). Discussion and Conclusion. The present data suggest that an initially rising trend in VC investment in orthopaedic-related businesses may have plateaued over the past decade. These findings may have important implications for continued investment into orthopaedic innovations and collaboration between the surgical community and private sector, as well as the perceived profitability of orthopaedic industries by third-party interests. For any figures or tables, please contact the authors directly

Introduction. Acquired chronic radial head (RH) dislocations present a significant surgical challenge. Co-existing deformity, length discrepancy and RH dysplasia, in multiply operated patients often preclude acute correction. This study reports the clinical and radiological outcomes in children, treated with circular frames for gradual RH reduction. Materials and Methods. Patient cohort from a prospective database was reviewed to identity all circular frames for RH dislocations between 2000–2021. Patient demographics, clinical range and radiographic parameters were recorded. Results. From a cohort of 127 UL frames, 30 chronic RH dislocations (14 anterior, 16 posterior) were identified. Mean age at surgery was 10yrs (5–17). Six pathologies were reported (14 post-traumatic, 11 HME, 2 Nail-Patella, 1 Olliers, OI, Rickets). 70% had a congruent RH reduction at final follow-up. Three cases re-dislocated and 6 had some mild persistent incongruency. Average follow up duration was 4.1yrs (9mnths-11.5yrs). Mean radiographic correction achieved in coronal plane 9. o. , sagittal plane 7. o. and carrying angle 12. o. Mean ulna length gained was 7mm and final ulnar variance was 7mm negative (congenital). All cases achieved bony union with 2 requiring bone grafting. Mean frame duration was 166 days. Mean final range of motion was 64. o. supination, 54 . o. pronation, 2. o. to 138. o. flexion. 5 complications and 7 further operations were reported. Conclusions. The majority of children having frame correction achieve complete correction or minor subluxation, which is well tolerated clinically. Frame assisted reduction is an effective tool for selective complex cases irrespective of the pathology driving the RH dislocation

While controversy remains as to the relative benefit of operative (OM) versus non-operative management (NOM) of Achilles tendon ruptures (ATR), few studies have examined the effect on high impact maneuvers such as jumping and hopping. The purpose of this study is to compare functional performance and musculotendinous morphology in patients following OM or NOM for acute ATR. Eligible patients were aged 18-65 years old with an ATR who underwent OM or NOM within three weeks of injury and were at least one-year post injury. Gastrocnemius muscle thickness and Achilles tendon length and thickness were assessed with ultrasound. Functional performance was examined with single-leg hop tests and isokinetic plantar strength at 60o/s and 120o/s. 24 participants completed testing (12/ group). Medial (OM: 2.2 ± 0.4 cm vs 1.9 ± 0.3 cm, NOM 2.15 ± 0.5 cm vs 1.7 ± 0.5 cm; p = 0.002) and lateral (OM 1.8 ± 0.3 cm vs 1.5 ± 0.4 cm, NOM 1.6 ± 0.4 cm vs 1.3 ± 0.5 cm; p = 0.008) gastrocnemius thickness were reduced on the affected limb. The Achilles tendon was longer (OM: 19.9 ± 2.2 cm vs 21.9 ± 1.6 cm; NOM: 19.0 ± 3.7 cm vs 21.4 ± 2.9 cm; p = 0.009) and thicker (OM: 0.48 ± 0.16 cm vs 1.24 ± 0.20 cm; NOM: 0.54 ± 0.08 cm vs 1.13 ± 0.23 cm; p < 0.001) on the affected limb with no differences between groups. Affected limb plantar flexion torque at 20o plantar flexion was reduced at 60o/s (OM: 55.6 ± 20.2 nm vs 47.8 ± 18.3 nm; NOM: 59.5 ± 27.5 nm vs 44.7 ± 21.0 nm; p = 0.06) and 120o/s (OM: 44.6 ± 17.9 nm vs 36.6 ± 15.0 nm; NOM: 48.6 ± 16.9 nm vs 35.8 ± 10.7 nm; p = 0.028) with no group effect. There was no difference in single leg hop performance. Achilles tendon length explained 31.6% (p = 0.003) and 18.0% (p = 0.025) of the variance in plantar flexion peak torque limb symmetry index (LSI) at 60o/s and 120o/s respectively. Tendon length explained 28.6% (p=0.006) and 9.5% (p = 0.087) of LSI when torque was measured at 20o plantar flexion at 60o/s and 120o/s respectively. Conversely, tendon length did not predict affected limb plantar flexion peak torque (nm), angle-specific torque at 20o plantar flexion (nm) and affected limb single leg hop distance (cm) or LSI (%). There was no difference in tendon length between treatment groups and deficits in gastrocnemius thickness and strength are persistent. Deficits in the plantar flexion strength LSI are partially explained by increased tendon length following Achilles tendon rupture, regardless of treatment strategy. Hop test performance is maintained and may be the result of compensatory movements at other joints despite persistent plantarflexion weakness

Aims. Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care. Methods. This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance. Results. Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits. Conclusion. These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity. Cite this article: Bone Jt Open 2021;2(7):493–502