The Te Whatu Ora Southern catchment area covers the largest geographical region in New Zealand (over 62,000 km2) creating logistical challenges in providing timely access to emergency neck of femur (NOF) fracture surgery. Current Australian and New Zealand guidelines recommend that NoF surgery be performed within 48 hours of presentation. The purpose of this study was to compare the outcomes for patients with NoF fractures who present directly to a referral hospital (Southland Hospital) compared to those are transferred from rural peripheral centres. A retrospective cohort study identified 79 patients with NoF who were transferred from rural peripheral centres to a referral hospital for operative management between January 2011 to December 2020. This cohort was matched 1:1 by age and sex to patients with NoF who presently directly to the referral hospital over the same period. The primary outcome was to compare time to surgery between the groups and secondary outcomes were to compare length of hospital stay, complication rates and mortality rates at 30-days and 1-year.Introduction
Methods
Ceramic bearing fracture is a rare complication following implantation using modern day ceramic bearing materials. Revision bearing options in such cases is debated, with the choice between ceramic-on-ceramic and ceramic-on-polyethylene bearings. Revision to a hard on soft bearing raises concerns about potential catastrophic wear secondary to a third-body reaction caused by the fractured ceramic particles. Data was collected retrospectively from the NJR, electronic patient records, revision database and picture archiving and communication system. Templating software was used to determine linear wear between first post-operative radiograph and the latest available follow up. Univariate analysis was used to examine patient demographics and the wear rates for revision of ceramic bearing fractures to ceramic on polyethylene components. The intra and inter-rater reliability of wear measurements was calculated. There were twelve patients identified as meeting the inclusion criteria. The average age at revision was 62 years (54–72). There were 6 liner and 6 head fractures revised to delta ceramic heads and cross-linked polyethylene acetabular components. The most frequently used head size was 32mm. At mean follow up of 3.8 years (0.5 6.1 years), median 4.4 years, linear wear rate was calculated at 0.08± 0.06 mm/year. Both intra-rater and inter-rater reliability was excellent with ICC scores of 0.99 at all timepoints. Revision to ceramic on polyethylene (CoP) bearings following ceramic fracture does not cause early catastrophic wear at early follow up. It appears safe to use this hard on soft bearing combination, given that wear rates are comparable to what is expected in a primary hip replacement setting. Longer follow up is required to establish if this trend persists.
This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions. 132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05. There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication. Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time.
Different techniques have been described to address massive bone loss of the acetabulum in revision hip surgery. aMace has gained popularity as it provides customization aiming to restore hip centre and provide good initial stability in cases of large non-contained defects. It takes into account quality of host bone. Its porous defect filling scaffold provides an excellent surface for osteointegration. Our aim was to assess the short and mid-term outcomes of patients who underwent revision surgery using aMace system. Ethical approval was obtained. A retrospective study included all patients who had aMace between June 2013 and October 2022 allowing for a minimum of 12-months follow-up. Patients’ demographics, indication, bone-loss severity, reconstruction details, re-operation, complications, mortality, pain and function were assessed. 52 cases were performed by 13 surgeons with median 51 months follow-up. Median age was 72.7 years. 86.5% were female. Average BMI was 25.3. Average ASA grade was 3. 65% were classified as Paprosky IIIB and 32% were IIIA. 73% were found to have poor bone quality on CT. Main indication for aMace was massive bone loss/discontinuity secondary to aseptic loosening in 88.5%. 77% underwent single-stage revision. 53.8% had 2 or more previous revisions. 71% underwent stem revision in the same setting. 77% received a dual mobility bearing. Re-operation rate was 5.7% for instability and femoral PPF. LLD was reported in 9.6%. Permanent Sciatic nerve palsy occurred in 3.8% of the cases. 30-days mortality was 1.9%. Statistically significant post-op improvements in pain and mobility were reported (p<0.001). None of the acetabular components have been revised. Our study shows satisfactory surgical outcomes with a relatively low complication rate and significant pain and mobility improvements in the early to mid-term stages. We recommend these costly cases to be done in highly specialist centres adopting MDT approach.
The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome. Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score. Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001). Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively.
Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning. The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty. All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation. A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%) Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses.
The aims of this study were to determine the success of a reconstruction algorithm used in major acetabular bone loss, and to further define the indications for custom-made implants in major acetabular bone loss. We reviewed a consecutive series of Paprosky type III acetabular defects treated according to a reconstruction algorithm. IIIA defects were planned to use a superior augment and hemispherical acetabular component. IIIB defects were planned to receive either a hemispherical acetabular component plus augments, a cup-cage reconstruction, or a custom-made implant. We used national digital health records and registry reports to identify any reoperation or re-revision procedure and Oxford Hip Score (OHS) for patient-reported outcomes. Implant survival was determined via Kaplan-Meier analysis.Aims
Methods
The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity. Cite this article:
NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results.
Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in a motor impairment affecting the upper limbs more than the lower limbs, with occasional sensory impairment and urinary retention seen. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study is to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Patients ≥18 years with traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and injury, management and outcome data was collected. Statistical analysis was performed to assess mortality and between group differences.Aims
Patients and Methods
Dual mobility (DM) is an established bearing option in Total Hip Arthroplasty (THA). The traditional mono-block DM designs have limited ability for additional fixation, whereas the modular DM designs allow additional screw fixation but limit internal diameter and have the potential to generate metal debris. We report the early results of a CoCrMo alloy mono-block implant manufactured by additive technology with a highly porous ingrowth surface to enhance primary fixation and osseointegration. Prospective follow-up of the DuplexTM implant first inserted in March 2016 enrolled into Beyond Compliance (BC). Primary outcome measure was all-cause revision and secondary outcomes dislocation, peri-prosthetic fracture (PPF) and Oxford Hip Score (OHS). Patients were risk stratified and all considered to be high risk for instability. Complications were identified via hospital records, clinical coding linkage using national database and via BC website. 159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a cemented Polished taper stem (PTS) had a Type B PPF rate of 2.1% requiring revision/fixation. Compared to conventional THA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool. We believe our results demonstrate that risk stratification successfully aids implant selection to prevent dislocation in high-risk patients. This novel design has provided excellent early results in a challenging cohort where individuals are very different to the “average” THA patient. NJR data on DM has reported an increase in revision for PPF. A “perfect storm” maybe created using DM in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection.
Achilles Tendon Rupture (ATR) is a prevalent injury in Western society. Much of the recent research has focused on measuring surgical methods and strength regained, rather than practical measures such as Return to Sport (RTS). A large systematic review was published in 2016 setting a benchmark RTS as 80%. The aim of this systematic review was to provide an up-to-date RTS following ATR. PubMed and SPORTdiscuss databases were used to search for eligible studies published since 2017 that focused on closed Achilles tendon ruptures with clear definitions of return to sport and a minimum length of follow-up. The Newcastle-Ottawa grading tool was used to assess risk of bias in all included studies.Introduction
Methods
For chondral damage in younger patients, surgical best practice is microfracture, which involves drilling into the bone to liberate the bone marrow. This leads to a mechanically inferior fibrocartilage formed over the defect as opposed to the desired hyaline cartilage that properly withstands joint loading. While some devices have been developed to aid microfracture and enable its use in larger defects, fibrocartilage is still produced and there is no clear clinical improvement over microfracture alone in the long term. Our goal is to develop 3D printed devices, which surgeons can implant with a minimally invasive technique. The scaffolds should match the functional properties of cartilage and expose endogenous marrow cells to suitable mechanobiological stimuli Our novel silica/polytetrahydrofuran/polycaprolactone hybrids were prepared by sol-gel synthesis and scaffolds were 3D printed by direct ink writing. 3D printed hybrid scaffolds with pore channels of ~250 µm mimic the compressive behaviour of cartilage. Our results show that these scaffolds support human bone marrow stem/stromal cell (hMSC) differentiation towards chondrogenesis
Over the past 30 years multiple wars and embargos have reduced healthcare resources, infrastructure, and staff in Iraq. Subsequently, there are a lack of physiotherapists to provide rehabilitation after an anterior cruciate ligament reconstruction (ACLR). The implementation of home-based rehabilitation programmes may provide a potential solution to this problem. This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. This was performed arthroscopically using a hamstring autograft (2 portal technique). Patients completed a home-based rehabilitation programme of appropriate simplicity for the home setting. The programme consisted of stretching, range of motion and strengthening exercises based on criterion rehabilitation progressions. A full description of the programme is provided at: Demographics, mechanisms of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics.Introduction
Methods
To evaluate career length after surgical treatment of combined ACL + medial collateral ligament (MCL) and ACL +posterolateral corner (PLC) surgeries in all elite athletes. Secondly, in a subgroup of male professional footballers to determine career length and competition level after ACL+MCL or ACL+PLC reconstructions and compare this to a cohort who underwent isolated ACL reconstruction (ACL-R) alone. A consecutive cohort of elite athletes undergoing combined ACL+MCL surgery and combined ACL+PLC surgery between February 2001 and October 2019 were analysed. A subgroup of male footballers from this population was compared to a previously identified cohort of male, professional footballers having had primary ACL reconstruction without other ligament surgery. A minimum 2-years follow-up was required. Outcome measures were career length and competition level.Introduction
Methods
To determine if elite athletes can return to professional sport after MCL or posterolateral (PLC) reconstruction using LARS ligaments. The secondary aims are to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries, and complications. A retrospective review of all extra-articular knee ligament reconstructions, utilising a LARS synthetic ligament, by 3 sports knee surgeons between 2013 and 2020 was undertaken. All elite athletes aged over 16 years and a minimum of 2 years post reconstruction were included. No LARS were used for ACL reconstructions, and they were excluded if a LARS ligament was used for a PCL reconstruction. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport.Introduction
Methods
To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). This was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated.Aims
Methods
Ultrasound speckle tracking is a safe and non-invasive diagnostic tool to measure soft tissue deformation and strain. In orthopaedics, it could have broad application to measure how injury or surgery affects muscle, tendon or ligament biomechanics. However, its application requires custom tuning of the speckle-tracking algorithm then validation against gold-standard reference data. Implementing an experiment to acquire these data takes months and is expensive, and therefore prohibits use for new applications. Here, we present an alternative optimisation approach that automatically finds suitable machine and algorithmic settings without requiring gold-standard reference data. The optimisation routine consisted of two steps. First, convergence of the displacement field was tested to exclude the settings that would not track the underlying tissue motion (e.g. frame rates that were too low). Second, repeatability was maximised through a surrogate optimisation scheme. All settings that could influence the strain calculation were included, ranging from acquisition settings to post-processing smoothing and filtering settings, totalling >1,000,000 combinations of settings. The optimisation criterion minimised the normalised standard deviation between strain maps of repeat measures. The optimisation approach was validated for the medial collateral ligament (MCL) with quasi-static testing on porcine joints (n=3), and dynamic testing on a cadaveric human knee (n=1, female, aged 49). Porcine joints were fully dissected except for the MCL and loaded in a material-testing machine (0 to 3% strain at 0.2 Hz), which was captured using both ultrasound (>14 repeats per specimen) and optical digital image correlation (DIC). For the human cadaveric knee (undissected), 3 repeat ultrasound acquisitions were taken at 18 different anterior/posterior positions over the MCL while the knee was extended/flexed between 0° and 90° in a knee extension rig. Simultaneous optical tracking recorded the position of the ultrasound transducer, knee kinematics and the MCL attachments (which were digitised under direct visualisation post testing). Half of the data collected was used for optimisation of the speckle tracking algorithms for the porcine and human MCLs separately, with the remaining unseen data used as a validation test set.Abstract
Objectives
Methods
Biomechanics is an essential form of measurement in the understanding of the development and progression of osteoarthritis (OA). However, the number of participants in biomechanical studies are often small and there is limited ways to share or combine data from across institutions or studies. This is essential for applying modern machine learning methods, where large, complex datasets can be used to identify patterns in the data. Using these data-driven approaches, it could be possible to better predict the optimal interventions for patients at an early stage, potentially avoiding pain and inappropriate surgery or rehabilitation. In this project we developed a prototype database platform for combining and sharing biomechanics datasets. The database includes methods for importing and standardising data and associated variables, to create a seamless, searchable combined dataset of both healthy and knee OA biomechanics. Data was curated through calls to members of the OATech Network+ (Abstract
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