Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries.

A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway.

570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury.

The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres.

Avulsion of the proximal hamstring tendon from the ischial tuberosity is an uncommon but significant injury. Recent literature has highlighted that functional results are superior with surgical repair over non-surgical treatment. Limited data exists regarding the optimal rehabilitation regime in post-operative patients. The aim of this study was to investigate the early interim patient outcomes following repair of proximal hamstring tendon avulsions between a traditionally conservative versus an accelerated rehabilitation regimen.

In this prospective randomised controlled trial (RCT) 50 patients underwent proximal hamstring tendon avulsion repair, and were randomised to either a braced, partial weight-bearing (PWB) rehabilitation regime (CR = 25) or an accelerated, unbraced, immediate full weight-bearing (FWB) regime (AR group; n = 25). Patients were evaluated preoperatively and at 3 months after surgery, using the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT), visual analog pain scale (VASP), Tegner score, and 12-item Short Survey Form (SF-12). Patients also filled in a diary questioning postoperative pain at rest from Day 2, until week 6 after surgery. Primary analysis was by per protocol and based on linear mixed models.

Both groups, with respect to patient and characteristics were matched at baseline. Over three months, five complications were reported (AR = 3, CR = 2). At 3 months post-surgery, significant improvements (p<0.001) were observed in both groups for all outcomes except the SF-12 MCS (P = 0.623) and the Tegner (P = 0.119). There were no significant between-group differences from baseline to 3 months for any outcomes, except for the SF-12 PCS, which showed significant effects favouring the AR regime (effect size [ES], 0.76; 95% CI, 1.2-13.2; P = .02).

Early outcomes in an accelerated rehabilitation regimen following surgical repair of proximal hamstring tendon avulsions, was comparable to a traditionally conservative rehabilitation pathway, and resulted in better physical health-related quality of life scores at 3 months post-surgery. Further long term follow up and functional assessment planned as part of this study.

Hamstring grafts have been associated with reduced strength, donor site pain and muscle strains following Anterior Cruciate Ligament Reconstruction (ACLR). Traditional graft fixation methods required both semitendinosus and gracilis tendons to achieve a graft of sufficient length and diameter, but newer techniques allow for shorter, broad single tendon grafts.

This study seeks to compare the outcomes between Single Tendon (ST) and Dual Tendon (DT) ACLR, given there is no prospective randomised controlled trial (RCT) in the literature comparing outcomes between these options.

In this ongoing RCT: (ANZ Clinical Trials Registry ACTRN126200000927921) patients were recruited and randomised into either ST or DT groups. All anaesthetic and surgical techniques were uniform aside from graft technique and tibial fixation. 13 patients were excluded at surgery as their ST graft did not achieve a minimum 8mm diameter. 70 patients (34 ST, 36DT) have been assessed at 6 months, using PROMS including IKDC2000, Lysholm and Modified Cincinnati Knee, visual analog scale for pain frequency (VAS-F) and severity (VAS-S), dedicated donor site morbidity score, KT-1000 assessment, and isokinetic strength.

Graft diameters were significantly lesser in the ST group compared to the DT group (8.44mm/9.11mm mean difference [MD],-0.67mm; P<0.001). There was a significant and moderate effect in lower donor site morbidity in the ST group compared to the DT group (effect size [ES], 0.649; P = .01). No differences between groups were observed for knee laxity in the ACLR limb (P=0.362) or any of the patient-reported outcome measures (P>0.05). Between-group differences were observed for hamstrings strength LSI favouring the ST group, though these were small-to-moderate and non-significant (ES, 0.351; P = .147).

ST (versus DT) harvest results in significantly less donor site morbidity and this is the first prospective RCT to determine this. There were no differences between ST and DT hamstring ACLR were observed in PROMs, knee laxity and hamstring strength. Younger female patients tend to have inadequate single tendon size to produce a graft of sufficient diameter, and alternative techniques should be considered. Further endpoints include radiological analysis, longer term donor site morbidity, revision rates and return to sport and will continue to be presented in the future.

Background

Conservative treatment of acute AT ruptures with functional rehabilitation has demonstrated superior results with equal reported re-rupture rates but without the added complications of surgical treatment.

There is no consensus on the duration and method of treatment using functional rehabilitation regimes.

The purpose of this paper is to define our treatment regime, the Leicester Achilles Management Protocol (LAMP), supported with patient reported outcomes and objective measures of assessment.

Acute Achilles tendon (AT) rupture management remains debatable but non-operative functional regimes are beginning to dominate current treatment algorithms. The aim of this study was to identify predictors of functional outcome in patients with AT ruptures treated non-operatively with an immediate weight bearing functional regime in an orthosis.

Analysis of prospectively gathered data from a local database of all patients treated non-operativelyat our institution with anAT rupture was performed. Inclusion criteria required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 8 months post rupture. The ATRS score was correlated against age, gender, time following rupture, duration of treatment in a functional orthoses (8- and 11-week regimes) and complications. 236 patients of average age 49.5 years were included.

The mean ATRS on completion of rehabilitation was 74 points. The mean ATRS was significantly lower in the 37 females as compared to the 199 males, 65.8 vs 75.6 (p = 0.013). Age inversely affected ATRS with a Pearsons correlation of −0.2. There was no significant difference in the ATRS score when comparing the two different treatment regime durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change significantly after 8 months of rupture.

Patients with AT ruptures treated non-operatively with a functional rehabilitation regime demonstrate good function with low re-rupture rates. Increasing age and female gender demonstrate inferior functional outcomes.

The proportion of younger patients undergoing total knee arthroplasty (TKA) is increasing and predictions state that the 45–54 age group will be the fastest growing group by 2030. We aim to collate data across studies to assess functional outcomes following total knee replacement in patients under 55 years of age. Secondary outcomes include implant survival and complications will also be reviewed.

The search identified 980 studies for title and abstract review. 43 full-texts were then assessed. 13 studies underwent quality assessment and data extraction from them. PRISMA guidelines were followed throughout. Outcomes extracted included pre- and post-operative functional scores, range of motion (ROM) and patient satisfaction. Clinical complications and survival were also recorded.

Across 13 studies we were able to demonstrate 54-point improvement in clinical Knee Society Score and a 2.9° improvement in range of motion. Satisfaction rate was 85.5%. Revision rate was 5.4% across 1323 TKAs. Risk of revision for aseptic loosening was 0.37% per year.

Total knee arthroplasty is an excellent treatment option for the young osteoarthritic knee with a >50% improvement in functional knee scores. Satisfaction is high and the revision rate remains under 1% per year.