Introduction

Diabetic foot disease is a major public health problem with an annual NHS expenditure in excess of £1 billion. Infection increases risk of major amputation fivefold. Due to the polymicrobial nature of diabetic foot infections, it is often difficult to isolate the correct organism with conventional culture techniques, to deliver appropriate narrow spectrum antibiotics. Rapid DNA-based technology using multi-channel arrays presents a quicker alternative and has previously been used effectively in intensive care and respiratory medicine.

Aims

During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon’s decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing.

Introduction

Flexor sheath infections require prompt diagnosis, and management with intravenous antibiotics and/or surgical washout followed by physiotherapy. Complication rates as high as 38% have been reported.

Aims

In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA).

In 2021 the bone grafting market was worth €2.72 billion globally. As allograft bone has a limited supply and risk of disease transmission, the demand for synthetic grafting substitutes (BGS) continues to grow while allograft bone grafts steadily decrease. Synthetic BGS are low in mechanical strength and bioactivity, inspiring the development of novel grafting materials, a traditionally laborious and expensive process. Here a novel BGS derived from sustainably grown coral was evaluated. Coral-derived scaffolds are a natural calcium carbonate bio-ceramic, which induces osteogenesis in bone marrow mesenchymal stem cells (MSCs), the cells responsible for maintaining bone homeostasis and orchestrating fracture repair. By 3D printing MSCs in coral-laden bioinks we utilise high throughput (HT) fabrication and evaluation of osteogenesis, overcoming the limitations of traditional screening methods.

MSC and coral-laden GelXA (CELLINK) bioinks were 3D printed in square bottom 96 well plates using a CELLINK BIO X printer with pneumatic adapter Samples were non-destructively monitored during the culture period, evaluating both the sample and the culture media for metabolism (PrestoBlue), cytotoxicity (lactose dehydrogenase (LDH)) and osteogenic differentiation (alkaline phosphatase (ALP)). Endpoint, destructive assays used included qRT-PCR and SEM imaging.

The inclusion of coral in the printed bioink was biocompatable with the MSCs, as reflected by maintained metabolism and low LDH release. The inclusion of coral induced osteogenic differentiation in the MSCs as seen by ALP secretion and increased RUNX2, collagen I and osteocalcin transcription.

Sustainably grown coral was successfully incorporated into bioinks, reproducibly 3D printed, non-destructively monitored throughout culture and induced osteogenic differentiation in MSCs. This HT fabrication and monitoring workflow offers a faster, less labour-intensive system for the translation of bone substitute materials to clinic.

Acknowledgements: This work was co-funded by Enterprise Ireland and Zoan Biomed through Innovation Partnership IP20221024.

Aims

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

Aims

There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method.

Abstract

Abstract

The Montgomery ruling advocates patients be informed of ‘material risks’ of a procedure. With no guidelines for patients wishing to return to high activity levels after knee arthroplasty, we explore patient and surgeon perceptions in climbers.

Ethical approval was granted by the University of Central Lancashire. Anonymous questionnaires were sent via email and social media to consultant knee arthroplasty surgeons and to climbers/mountaineers across the UK. Consultants were asked about advice given for patients who participate in climbing. Climbers were asked about their experiences of knee arthroplasty and return to activity.

Of 33 knee arthroplasty surgeons, 11(33%) were firmly against any return to climbing, 10(30%) counselled against it, and 12(36%) were open to return to previous activity. Of 11(33%) surgeons who do not gather information about levels of climbing, 8 would not provide specific advice regarding risks of returning to sport. Of 28 climbers, only 5(18%) were informed to cease completely, with 11(39%) cautioned against and 12(43%) permitted to return. There was no correlation between the advice received and climbing ability post-operatively, (kappa=0.143,p=0.058), with a substantial agreement between ability 1-year post-operatively and currently, (kappa=0.689,p<0.001).

There is a discrepancy between the advice given and received by climbers/mountaineers prior to knee arthroplasty, with ability post-operatively having no relationship to advice given. Climbing is possible at high level with no reported complications following knee arthroplasty. The 1-year time point is predictive of longer-term outcome. This information should help surgeons better inform their patients preoperatively.

Aims

Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme.

Climbers and mountaineers will present to arthroplasty surgeons in need of hip replacement surgeries. There is a lack of guidance for both parties with a paucity in the literature. Climbing is often considered a high-risk activity to perform with a total hip replacement, due to the positions the hip is weighted in, and the potential austere environment in which an injury may occur.

The aim was to assess levels of climbing and mountaineering possible following hip arthroplasty, and any factors affecting these levels.

Ethical approval was obtained from the University of Central Lancashire. An anonymous online questionnaire was disseminated via email, social media and word-of-mouth to include all climbers, hill-walkers or mountaineers across the UK. This was used to collect climbing and mountaineering ability at various timepoints, along with scores such as the Oxford Hip Score and UCLA Score. The Kappa statistic was used to assess for correlations.

Of the responders, 28 had undergone right hip arthroplasty surgery, with 11 having left hips and 22 receiving bilateral hips. A total of 67 of the replaced hips were total hip replacements, with 16 having undergone hip resurfacing. There is a fair agreement in level of climbing ability 3 months pre- and 3 months post-operatively (kappa=0.287, p<0.001), and a substantial agreement between 1 year post-operatively and currently for both climbing (kappa=0.730, p<0.001) and mountaineering (kappa=0.684, p<0.001). Impressively, 17 participants are climbing at more than E1 trad or 6c sport at one or more time points post operatively, which is regarded as an advanced level within the climbing community. Out of those 17 participants, 8 were climbing at this level within 3 months post-operatively.

The level of climbing possible following hip arthroplasty surgery is above what is expected and perhaps desired by the operating surgeon. It is essential to take the individual patient into account when planning an operative intervention such as arthroplasty. The one year post-operative time point is highly predictive of longer term outcomes for both climbing and mountaineering.

Introduction

LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children with Lower limb differences (LLDs). The objective is to conduct an international field test study.

A hip fracture represents the extreme end of osteoporosis, placing a significant burden on secondary care, society, and the individual patient. The National Hip Fracture Database (NHFD) reports each hospital's attainment of the BPT with other measures, along with reporting outcomes. There is clearly wide variability in provision of orthogerriatrician (OG) services across the dataset. Unfortunately, despite overwhelming evidence that provision of an OG service is of benefit, it is presently challenging to recruit to this important specialty within the UK.

Publicly available reports from the NHFD were obtained for each of the 177 participating hospitals for 2017. This was matched with information held within the annual NHFD Facilities Audit for the same period, which include hours of OG support for each hospital. This information was combined with a Freedom of Information request made by email to each hospital for further details concerning OG support. The outcome measures used were Length of Stay (LoS), mortality, and return to usual residence. Comparison was made with provision of OG services by use of Pearson's correlation coefficient. In addition, differences in services were compared between the 25% (44) hospitals delivering outcomes at the extremes for each measure.

Attainment of BPT correlated fairly with LoS (−0.48) and to less of a degree with mortality (−0.1) and return home (0.05). Perioperative medical assessment contributed very strongly with BPT attainment (0.75). In turn perioperative medical assessment correlated fairly with LoS (−0.40) and mortality (−0.23) but not return home (0.02). Provision of perioperative medical assessment attainment was correlated fairly with total OG minutes available per new patient (0.22), total OG minutes available per patient per day (0.29) and number of days per week of OG cover (0.34); with no link for number of patients per orthogeriatrician (0.01). Mortality for the best units were associated with 30% more consultant OG time available per patient per day, and 51% more OG time available per patient. Units returning the most patients to their usual residence had little association with OG time, although had 59% fewer patients per OG, the best units had a 19% longer LoS. For all three measures results for the best had on average 0.5 days per week better routine OG access.

There is no doubt that good quality care gives better results for this challenging group of patients. However, the interaction of BPT, other care metrics, level of OG support and patient factors with outcomes is complex. We have found OG time available per patient per day appears to influence particularly LoS and mortality. Options to increase OG time per patient include reducing patient numbers (ensuring community osteoporosis/falls prevention in place, including reducing in-patient falls); increasing OG time across the week (employing greater numbers/spreading availability over 7 days per week); and reducing LoS. A reduction in LoS has the largest effect of increasing OG time, and although it is dependent on OG support, it is only fairly correlated with this and many other factors play a part, which could be addressed in units under pressure.

Aims

The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA).

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 t-tests for continuous variables.

A total of 206 patients were included in this study (105 patients not crossing the CTJ and 101 crossing the CTJ). Patients who underwent a construct extending through the CTJ were more likely to be female and had worse baseline EQ5D and NDI scores (p> 0.05). When adjusted for baseline difference, there was no statistically significant difference between the two groups for the PROs and mJOA at 3 and 12 months. Surgical duration was longer (p 0.05). Satisfaction with the surgery was high in both groups but significantly different at 12 months (80% versus 72%, p= 0.042 for the group not crossing the CTJ and the group crossing the CTJ, respectively). The percentage of patients reaching MCID for the NDI score was 55% in the non-crossing group versus 69% in the group extending through the CTJ (p= 0.06).

Up to 12 months after the surgery, there was no statistically significant differences in PROs between posterior construct extended to or not extended to the upper thoracic spine. The adverse event profile did not differ significantly, but longer surgical time and blood loss were associated with construct extending across the CTJ.

Knowledge of the premorbid glenoid shape and the morphological changes the bone undergoes in patients with glenohumeral arthritis can improve surgical outcomes in total and reverse shoulder arthroplasty. Several studies have previously used scapular statistical shape models (SSMs) to predict premorbid glenoid shape and evaluate glenoid erosion properties. However, current literature suggests no studies have used scapular SSMs to examine the changes in glenoid surface area in patients with glenohumeral arthritis. Therefore, the purpose of this study was to compare the glenoid articular surface area between pathologic glenoid cavities from patients with glenohumeral arthritis and their predicted premorbid shape using a scapular SSM. Furthermore, this study compared pathologic glenoid surface area with that from virtually eroded glenoid models created without influence from internal bone remodelling activity and osteophyte formation. It was hypothesized that the pathologic glenoid cavities would exhibit the greatest glenoid surface area despite the eroded nature of the glenoid and the medialization, which in a vault shape, should logically result in less surface area.

Computer tomography (CT) scans from 20 patients exhibiting type A2 glenoid erosion according to the Walch classification [Walch et al., 1999] were obtained. A scapular SSM was used to predict the premorbid glenoid shape for each scapula. The scapula and humerus from each patient were automatically segmented and exported as 3D object files along with the scapular SSM from a pre-operative planning software. Each scapula and a copy of its corresponding SSM were aligned using the coracoid, lateral edge of the acromion, inferior glenoid tubercule, scapular notch, and the trigonum spinae. Points were then digitized on both the pathologic humeral and glenoid surfaces and were used in an iterative closest point (ICP) algorithm in MATLAB (MathWorks, Natick, MA, USA) to align the humerus with the glenoid surface. A Boolean subtraction was then performed between the scapular SSM and the humerus to create a virtual erosion in the scapular SSM that matched the erosion orientation of the pathologic glenoid. This led to the development of three distinct glenoid models for each patient: premorbid, pathologic, and virtually eroded (Fig. 1). The glenoid surface area from each model was then determined using 3-Matic (Materialise, Leuven, Belgium).

Figure 1. (A) Premorbid glenoid model, (B) pathologic glenoid model, and (C) virtually eroded glenoid model.

The average glenoid surface area for the pathologic scapular models was 70% greater compared to the premorbid glenoid models (P < 0 .001). Furthermore, the surface area of the virtual glenoid erosions was 6.4% lower on average compared to the premorbid glenoid surface area (P=0.361).

The larger surface area values observed in the pathologic glenoid cavities suggests that sufficient bone remodelling exists at the periphery of the glenoid bone in patients exhibiting A2 type glenohumeral arthritis. This is further supported by the large difference in glenoid surface area between the pathologic and virtually eroded glenoid cavities as the virtually eroded models only considered humeral anatomy when creating the erosion.

For any figures or tables, please contact the authors directly.

Patients receiving reverse total shoulder arthroplasty (RTSA) often have osseous erosions because of glenohumeral arthritis, leading to increased surgical complexity. Glenoid implant fixation is a primary predictor of the success of RTSA and affects micromotion at the bone-implant interface. Augmented implants which incorporate specific geometry to address superior erosion are currently available, but the clinical outcomes of these implants are still considered short-term. The objective of this study was to investigate micromotion at the glenoid-baseplate interface for a standard, 3 mm and 6 mm lateralized baseplates, half-wedge, and full-wedge baseplates. It was hypothesized that the mechanism of load distribution from the baseplate to the glenoid will differ between implants, and these varying mechanisms will affect overall baseplate micromotion.

Clinical CT scans of seven shoulders (mean age 69 years, 10°-19° glenoid inclinations) that were classified as having E2-type glenoid erosions were used to generate 3D scapula models using MIMICS image processing software (Materialise, Belgium) with a 0.75 mm mesh size. Each scapula was then repeatedly virtually reconstructed with the five implant types (standard,3mm,6mm lateralized, and half/full wedge; Fig.1) positioned in neutral version and inclination with full backside contact. The reconstructed scapulae were then imported into ABAQUS (SIMULIA, U.S.) finite element software and loads were applied simulating 15°,30°,45°,60°,75°, and 90° of abduction based on published instrumented in-vivo implant data. The micromotion normal and tangential to the bone surface, and effective load transfer area were recorded for each implant and abduction angle. A repeated measures ANOVA was used to perform statistical analysis.

Maximum normal micromotion was found to be significantly less when using the standard baseplate (5±4 μm), as opposed to the full-wedge (16±7 μm, p=0.004), 3 mm lateralized (10±6 μm, p=0.017), and 6 mm lateralized (16±8 μm, p=0.007) baseplates (Fig.2). The half-wedge baseplate (11±7 μm) also produced significantly less micromotion than the full-wedge (p=0.003), and the 3 mm lateralized produced less micromotion than the full wedge (p=0.026) and 6 mm lateralized (p=0.003). Similarly, maximum tangential micromotion was found to be significantly less when using the standard baseplate (7±4 μm), as opposed to the half-wedge (12±5 μm, p=0.014), 3 mm lateralized (10±5 μm, p=0.003), and 6 mm lateralized (13±6 μm, p=0.003) baseplates (Fig.2). The full wedge (11±3 μm), half-wedge, and 3 mm lateralized baseplate also produced significantly less micromotion than the 6 mm lateralized (p=0.027, p=012, p=0.02, respectively). Both normal and tangential micromotion were highest at the 30° and 45° abduction angles (Fig.2). The effective load transfer area (ELTA) was lowest for the full wedge, followed by the half wedge, 6mm, 3mm, and standard baseplates (Fig.3) and increased with abduction angle.

Glenoid baseplates with reduced lateralization and flat backside geometries resulted in the best outcomes with regards to normal and tangential micromotion. However, these types of implants are not always feasible due to the required amount of bone removal, and medialization of the bone-implant interface. Future work should study the acceptable levels of bone removal for patients with E-type glenoid erosion and the corresponding best implant selections for such cases.

For any figures or tables, please contact the authors directly.

Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position.

A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions.

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers.

This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median.

A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS.

In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS.

Aims

Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre.