The prevalence of gluteal tendinopathy (GT) associated with osteoarthritis of the hip is difficult to determine as it is frequently undiagnosed or misdiagnosed as trochanteric bursitis. Its relationship to total hip arthroplasty (THA) outcomes is currently unknown. The aim of this study was to determine the incidence of GT at the time of hip arthroplasty and examine the relationship between GT and patient reported outcomes (PROMS) before and after THA.

Patients undergoing THA for primary osteoarthritis between August 2017 and August 2020 were recruited. Tendinopathy was assessed and graded at time of surgery. PROMS included the Oxford Hip Score (OHS), HOOS JR, EQ-5D, and were collected preoperatively and at one year after THA. Satisfaction with surgery was also assessed at 1 year.

797 patients met eligibility criteria and were graded as Grade 1: normal tendons (n =496, 62%), Grade 2: gluteal tendinopathy but no tear (n=222, 28%), Grade 3: partial/full thickness tears or bare trochanter (n=79, 10%). Patients with abnormal gluteal tendons were older (p=0.001), had a higher mean BMI (p=0.01), and were predominately female (p=0.001). Patients with higher grade tendinopathy had statistically significant inferior PROMS at one year, OHS score (44.1 v 42.9 v 41.3, p 0.001) HOOS JR (89.3 V 86.3 V 85.6 p 0.005). Increasing gluteal tendon grade was associated with a greater incidence of problems with mobility (p=0.001), usual activities (p=0.001) and pain (p=0.021) on EQ5D. There was a 3 times relative risk of overall dissatisfaction with THA in the presence of gluteal tears.

This study demonstrated that gluteal tendinopathy was commonly observed and associated with inferior 1-year PROMS in patients undergoing THA for OA. Increasing degree of tendinopathy was a negative prognostic factor for worse functional outcomes and patient satisfaction.

Obesity is a common in individuals undergoing arthroplasty, and the potential for weight loss with improved mobility may be expected by some. The aim of this study was 1. determine the proportion that achieved weight loss after hip or knee arthroplasty, and 2. examine the effect of obesity on patient reported outcomes (PROMS) and satisfaction with surgery.

Participants underwent primary TKA or THA between July 2015 and December 2020 and consented to participation in a research database with baseline PROMS, including weight, BMI, Oxford Knee, or Hip Score, and EQ5D. Participants repeated PROMS at 12 months after surgery with additional questions regarding satisfaction with surgery.

3449 patients completed PROMS 1 year after arthroplasty with weight and BMI. There were 1810 THA and 1639 TKA procedures. The mean baseline BMI was higher in TKA (29.8, SD 5.2) compared to THA (27.7, SD 5.0), p=0.001. A higher proportion of TKA were classified as obese class 1 (29% TKA, 19% THA), obese class 2 (11% TKA and 6% THA), and obese class 3 (5% TKA and 2% THA), p=0.001. The mean weight loss after 1 year was 0.4kg and 0.9kg in obese THA subjects and TKA subjects respectively. In the obese >5kg weight loss was achieved in 13% of TKA and 7% of THA (p=0.001). Obese experienced equivalent improvement in Oxford scores, compared to non-obese subjects. Satisfaction with surgery was reported by 95% of THA and 91% of TKA subjects with no significant differences between BMI group grades (p=0.491 THA and p=0.473 TKA).

Preoperative obesity was observed in 44% of TKA and 27% of THA subjects. In the obese only 1 in 10 subjects lost 5kg or more over 12 months. Obese patients experienced equivalent improvements in outcome after arthroplasty and rates of satisfaction with surgery to the non-obese.

Total Knee Arthroplasty (TKA) is a successful treatment for end stage osteoarthritis of the knee joint. However, post-operative pain can lead to patient dissatisfaction and poorer outcomes. Cooled radiofrequency nerve ablation (CRNA) has reportedly been effective at treating pain osteoarthritic knee pain by targeting the periarticular nerves of the knee. We undertook a prospective, controlled pilot study to determine if CRNA provides effective post-operative analgesia when utilised intra-operatively during total knee arthroplasty.

Participants were recruited from January 2019 to February 2020. Those meeting inclusion criteria underwent TKA with intraoperative CRNA to 6 target sites prior to the cementing of implants. The primary outcomes were pain scores and opiate usage in the first 4 days post-operatively, then weekly up to 6 weeks. A total of 62 patients were screened and allocated sequentially; 18 were recruited to the control group and 12 recruited to the study group. The two groups did not have any significant difference in demographics.

There were no clinically significant differences between the two groups in terms of pain scores nor opiate usage. There were complications as a result of the intervention.

This study demonstrated no benefit of using intraoperative CRNA for improving post-operative pain scores or reducing opiate use after TKA.

The aim of this study was to determine Anterior Cruciate Ligament (ACL) graft and contralateral ACL (CACL) survival in patients who have undergone ACL reconstruction (ACLR) with hamstring autograft following netball injuries, and determine factors associated with repeat ACL injury and return to netball.

From a prospectively collected database, a consecutive series of 332 female netballers who underwent primary ACLRs using hamstring autografts were identified. Subjects were surveyed at a minimum of five years following reconstruction, including details of further ACL injuries to either knee, return to netball or other sports and psychological readiness with the ACL-RSI score.

264 participants (80%) were reviewed at the mean follow up of 9 years (60-180 months). There were 12 ACL graft ruptures (5%) and 35 contralateral ACL ruptures (13%). ACL graft survival was 97% and 97%, 96% at 2, 5 and 7 years respectively. CACL survival was 99%, 94%, and 90% at 2, 5 and 7 years respectively. The 7-year ACL graft survival was 97% in those 25 or more and 93% in those under 25 years (p=0.126). The 7-year CACL survival was 93% in those 25 or more and 85% in those under 25 years (HR 2.6, 95%CI 1.3-5.0, p=0.007). A family history of ACL injury was reported by 32% of participants. A return to netball was reported by 61% of participants. The mean ACL-RSI score was 65 in those who returned to netball and 37 in those who did not (p=0.001).

ACLR with hamstring autografts is a reliable procedure for netballers with a survival rate of 96% at 7 years, allowing 63% of participants to return to netball. A successful return to sport was associated with greater psychological readiness. CACL injury occurred with more than double the frequency of ACL graft rupture and was increased by 2.6x in those <25 years.

The aim of this study was to determine the long term 20 year survival and outcomes of high tibial osteotomy (HTO).

100 consecutive subjects underwent HTO under the care of a single surgeon between 2000 and 2002, consented to participation in a prospective study and completed preoperative WOMAC scores. Subjects were reviewed at 10 years, and again at a minimum of 20 years after surgery. PROMS included further surgery, WOMAC scores, Oxford Knee Score (OHS), KOOS, and EQ-5D, and satisfaction with surgery. 20 year survival was assessed with Kaplan-Meir analysis, and failure defined as proceeding to subsequent knee arthroplasty.

The mean age at HTO was 50 years (range 26-66), and 72% were males. The 5, 10, and 20 year survival of the HTO was 88%, 76%, 43% respectively. On multiple regression analysis HTO failure was associated with poor preoperative WOMAC score of 45 or less (HR 3.2, 95% CI 1.7-6.0, p=0.001), age at surgery of 55 or more (HR 2.3, 95% CI 1.3-4.0, p=0.004), and obesity (HR 1.9, 95% CI 1.1-3.4, p=0.023). In patients who met all criteria of preoperative WOMAC score of 45 or less, age <55 years and body mass index of <30 HTO survival was 100%, 94%, and 59% at 5, 10 and 20 years respectively. Of those who had not proceeded to TKA the mean Oxford Score was 40, KOOS Pain score was 91 and KOOS function score was 97. 97% reported they were satisfied with the surgery and 88% would have the same surgery again under the same circumstances.

At 20 years after HTO 43% had not proceeded to knee arthroplasty, and were continuing to demonstrate high subjective scores and satisfaction with surgery. HTO survival was higher in those under 55 years, with BMI <30 and baseline WOMAC score of >45 at 59% HTO survival over 20 years. HTO may be considered a viable procedure to delay premature knee arthroplasty in carefully selected subjects.

Total hip arthroplasty (THA) has high rates of patient satisfaction; however patient expectations for recreational and sporting activities are not always met. Our study aimed to identify preoperative factors that predict whether patient expectations for sporting or recreational activity are met 12 months following THA.

Patient reported outcome measures (PROMs) were collected prospectively from 2015-2018 at one private hospital in Sydney. Age, gender, postcode, weight, and height were recorded preoperatively. Included participants underwent primary THA by one of the investigating surgeons. Univariable and multivariable analyses were performed with an expectation fulfilment score used as the primary outcome variable. Preoperative predictor variables included: age, gender, BMI, Socio-economic Indexes for Areas (SEIFA), Oxford Hip Score, Hip Osteoarthritis Outcome Score, EQ-5D-5L and EQ Visual Analogue Scale (EQ VAS).

1019 participants were eligible and included. 13% reported that preoperative expectations of sport or recreation were not met at 12 months. Younger age, lower preoperative EQ VAS, and higher BMI were associated with failed expectations on multivariable analysis. Odds of failed expectations increased by 2% for every one year younger in age (OR= 0.98, 95% CI = 0.96 to 1.00, p=.048), by 2% for every one point lower on EQ VAS (OR=0.98, 95% CI = 0.98 to 0.99, p=.002), and by 4% for every one-point increase in BMI (OR = 1.04, 95% CI = 1.00 to 1.09, p=.042).

Failure to have expectations met for sporting or recreational activity was associated with younger age, poorer general health, and high BMI. With a rise in younger patients who likely have higher physical demands, a tailored preoperative education is preferable to generic models to better manage patient expectations.

Younger age, higher BMI, and poorer health may predict unmet expectations for sport and recreation after THA. Tailored education in these groups should be considered.

The emergence of patient specific instrumentation has seen an expansion from simple radiographs to plan total knee arthroplasty (TKA) with modern systems using computed tomography (CT) or magnetic resonance imaging scans. Concerns have emerged regarding accuracy of these non-weight bearing modalities to assess true mechanical axis. The aim of our study was to compare coronal alignment on full length standing AP imaging generated by the EOS acquisition system with the CT coronal scout image.

Eligible patients underwent unilateral or bilateral primary TKA for osteoarthritis under the care of investigating surgeon between 2017 and 2022, with both EOS X-Ray Imaging Acquisition System and CT scans performed preoperatively. Coronal mechanical alignment was measured on the supine coronal scout CT scan and the standing HKA EOS.

Pre-operative lower limb coronal alignment was assessed on 96 knees prior to TKA on the supine coronal scout CT scan and the standing HKA EOS. There were 56 males (56%), and 44 right knees (44%). The mean age was 68 years (range 53-90). The mean coronal alignment was 4.7 degrees (SD 5.3) on CT scan and 4.6 degrees (SD 6.2) on EOS (p=0.70). There was a strong positive correlation of coronal alignment on CT scan and EOS (pearson

0.927, p=0.001). The mean difference between EOS and CT scan was 0.9 degrees (SD 2.4). Less than 3 degrees variation between measures was observed in 87% of knees. On linear regression for every 1° varus increase in CT HKA alignment, the EOS HKA alignment increased by 0.93° in varus orientation. The model explained 86% of the variability.

CT demonstrates excellent reliability for assessing coronal lower limb alignment compared to EOS in osteoarthritic knees. This supports the routine use of CT to plan TKA without further weight bearing imaging in routine cases.

Introduction

Ambulation in the postoperative period following TKR is a marker of speed of recovery and, potentally, longer term outcomes. However, patient lifestyle factors are a major confounder. This study sought to develop a model of expected patient step count taking into account preoperative condition and demographics in order to benchmark recovery at a patient specific level.

Aim

Computer assisted total knee arthroplasty may have advantages over conventional surgery with respect to component positioning. Femoral component mal-rotation has been shown to be associated with poor outcomes, and may be related to posterior referencing jigs. We aimed to determine the variation between the transepicondylar axis (TEA) and posterior condylar axis (PCA) in a series of knees undergoing navigated total knee arthroplasty (TKA), and to determine the correlation between final intra-operative and post-operative coronal alignment.

Bioabsorbable screws for anterior cruciate ligament reconstruction (ACLR) have been shown to be associated with femoral tunnel widening and cyst formation.

To compare a poly-L-lactide–hydroxyapatite screw (PLLA-HA) with a titanium screw with respect to clinical and radiological outcomes over a 5 year period.

40 patients were equally randomized into 2 groups (PLLA-HA vs titanium) and ACLR performed with a 4 strand hamstring graft with femoral tunnel drilling via the anteromedial portal. Evaluation at 2 and 5 years was performed using the International Knee Documentation Committee assessment (IKDC), Lysholm knee score, KT 1000 arthrometer, single-legged hop test. Magnetic resonance imaging was used to evaluate tunnel and screw volume, ossification around the screws, graft integration and cyst formation.

There was no difference in any clinical outcome measure at 2 or 5 years between the 2 groups. At 2 years, the PLLA-HA femoral tunnel was significantly smaller than the titanium screw tunnel (p=0.015) and at 5 years, there was no difference. At 2 years the femoral PLLA-HA screw was a mean 76% of its original volume and by 5 years, 36%. At 2 years the tibial PLLA-HA screw mean volume was 68% of its original volume and by 5 years, 46%. At 5 years, 88% of femoral tunnels and 56% of tibial tunnels demonstrated a significant ossification response. There was no increase in cyst formation in the PLLA-HA group and no screw breakages.

The PLLA-HA screw provides adequate aperture fixation in ACLR with excellent functional outcomes. It was not associated with femoral tunnel widening or increased cyst formation when compared with the titanium screw. The resorbtion characteristics appear favourable and the hydroxyapatite component of the screw may stimulate osteoconduction, contributing to these results. The PLLA-HA screw is a good alternative to a titanium screw in ACLR, which may aid revision procedures and allow for imaging without artifact.

Anterior cruciate ligament (ACL) injuries are being seen with increasing frequency in children. Treatment of the ACL deficient knee in skeletally immature patients is controversial.

To determine the outcome of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years after surgery.

Between 2007–2008, 16 prepubescent skeletally immature patients underwent anatomic transphyseal ACL reconstruction using soft tissue grafts. All patients were tanner stage 1 and 2 and all had open growth plates. Outcomes were assessed at a minimum of 2 years after surgery and included: limb alignment, limb length, instrumented testing with KT-1000 and International Knee Documentation Committee (IKDC) score.

Mean age at the time of surgery was 12 years (8–14). Graft choices included: living-related donor hamstring tendon allograft (n=14), hamstring tendon autograft (n=1) and fresh frozen allograft (n=1). Mean IKDC subjective score was 96 (84–100). Sixty-two percent of patients had <3mm side-to-side difference on instrumented KT-1000 testing and 88% had a negative pivot shift. At 2 years after surgery, all patients had returned to strenuous activities and normal or nearly normal overall IKDC score was documented in 94% of patients. There were no cases of limb malalignment or growth arrest.

We present a large series of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years following surgery. Excellent clinical outcomes were obtained with high levels of return to desired activities. Importantly, no growth disturbances were seen in this series of patients.

This prospective longitudinal study compares the results of isolated endoscopic ACL reconstruction utilizing 4-strand hamstring tendon (HT) or patellar tendon (PT) autograft over a 15-year period with respect to re-injury, clinical outcomes and the development of osteoarthritis.

90 consecutive patients with isolated ACL rupture were reconstructed with a PT autograft and 90 patients received HT autograft, with an identical surgical technique. Patients were assessed at 2, 5, 7, 10 and 15 years. Assessment included the IKDC Knee Ligament Evaluation including radiographic evaluation, KT1000, Lysholm Knee Score, kneeling pain, and clinical outcomes.

Subjects who received the PT graft had significantly worse outcomes compared to those who received the HT graft at 15 years for the variables of radiologically detectable osteoarthritis (p=0.03), motion loss (p=0.01), single leg hop test (p=0.002), participation in strenuous activity (p=0.05), and kneeling pain (p=0.04). There was no significant difference between the HT and PT groups in overall IKDC grade (p=0.31). ACL graft rupture occurred in 16% of HT group and 8% of the PT group (p=0.07). ACL graft rupture was associated with non-ideal tunnel position (odds ratio 5.0) and males (odds ratio 3.2). Contralateral ACL rupture occurred in significantly more PT patients (24%) than HT patients (12%) (p=0.03), and was associated with age < 18 years (odds ratio 4.1) and the patellar tendon graft (odds ratio 2.6). Radiologically detectable osteoarthritis at 15 years was associated with the PT graft (odds ratio 2.3).

Significant differences have developed in the groups at 15 years after surgery which were not seen at earlier reviews. Compared to the HT Group, the PT group had significantly worse outcomes with respect to radiological osteoarthritis, extension loss and functional tests but no significant difference in laxity was identified. There was a high incidence of ACL injury after reconstruction, to both the reconstructed and the contralateral knee.

To determine the relationship between advancing months from ACL rupture and the incidence of intra-articular meniscal and chondral damage.

From a prospectively collected database 5086 patients undergoing primary ACL reconstruction, using hamstring graft, carried out between January 2000 and August 2010 were identified. Data collected included the interval between injury and surgery, type and location of meniscal tears (requiring meniscectomy) and location and severity of chondral damage (ICRS grading system). Patients were grouped according to time interval and age.

The median time from ACL injury to ACL reconstruction was 3 months (range 0.25 to 480). Overall, an increasing incidence of medial meniscal injury and chondral damage occurred with advancing chronicity of ACL deficiency. The incidence of medial meniscal injury requiring meniscectomy increased from 18% of patients undergoing ACL reconstruction within 4 months of injury to 59% of patients if ACL reconstruction was delayed more than 12 months (p<0.001). The incidence of lateral meniscal tears did not increase significantly over time.

The increasing incidence of secondary pathology with advancing chronicity was more pronounced in the younger age groups. The risk of a medial meniscal tear requiring resection was significantly less if surgery was performed before 5 months in the <17 years group (Odds Ratio 2) and 17–30 years group (OR 1.9), but less so in the 31–50 years group (OR 1.5) and >50 years group (OR 1.5). Advancing age was associated with a greater incidence of chondral damage and medial meniscal injury, but not lateral meniscal injury. Males had a greater incidence of lateral meniscal tears (34% vs. 20%), but not medial (28% vs. 25%) or chondral damage (35% vs. 36%), compared to females.

The incidence of chondral damage and medial meniscal tears increases with advancing time after ACL injury. Particularly in younger patients, ACL reconstruction should be performed within 4 months of ACL injury in order to minimise the risk of irreversible damage to meniscal and chondral structures.

The results of PLLA screws for ACL reconstruction have demonstrated no significant clinical differences when compared to metallic screws up to two years. However, studies examining PLLA-HA screws are lacking, as are medium term outcomes of bioresorbable screws. This study aims to compare the clinical outcome of ACL reconstruction with a PLLA-HA to a titanium screw, and to assess the extent of resorption of the PLLA-HA screw at two and five years after ACL reconstruction.

Forty patients were randomised to receive either a PLLA-HA or titanium RCI interference screw for ACL reconstruction. Both examiners and patients were blinded to screw type. Patients were prospectively reviewed at 24 and 60 months after surgery with full IKDC assessment, Instrumented Ligament Testing, Lysholm knee score. MRI scans were performed at two and five years following surgery.

Five years after surgery, one patient with a titanium screw had an ACL graft rupture and had undergone revision surgery. Of the remaining 39 patients, 38 (97%) were reviewed at five years. There was no significant difference between the two groups in the volume of the tibial (p=0.89) or femoral (p=0.22) tunnels at five years. Significant screw resorbtion at five years was seen in 77% on the tibial side and 88% on the femoral side in the PLLA group. Good ossification was evident on five year MRI in 94% of the tibial screws and 56% of the femoral screws. In the PLLA-HA group peri tunnel bone marrow oedema was present in 35% of patients on the tibial side and 53% of patients on the femoral side at five years. There was no peri-tunnel bone marrow oedema evident in the titanium group. Peri-graft ganglion cyst was evident on MRI scan on the tibial side in 24% of patients from the PLLA-HA group and 18% of the titanium group (p=0.67). There was no significant difference between the PLLA-HA group and the titanium group on any of the other clinical parameters including IKDC subjective knee score (mean 93), symptoms, range of motion, instrumented ligament laxity (mean 1.8 mm) or overall IKDC grade (90% normal or nearly normal).

ACL reconstruction with PLLA-HA bioabsorbable screws affords comparable clinical and subjective results to titanium screws at five years after surgery. Significant progression of PLLA HA screw resorption occurs between two and five years, with over 75% of screws demonstrating some resorption by five years. However, complete resorption was only evident in a small number of patients. ACL reconstruction with a PLLA HA screw has excellent clinical outcomes and progressive screw resorption and ossification is evident at five years.

The aim of this study was to compare the outcome of cemented TKR using either oxidized zirconium (oxinium) or cobalt chrome (CoCr) femoral components in patients undergoing simultaneous bilateral TKR. Patients involved in the study received one of each prosthesis, thereby acting as their own control. The hypothesis was that there would be no difference in the clinical and radiographic outcome between the two prosthetic materials.

Forty consecutive patients who were undergoing bilateral Genesis ll TKR consented to participate in the study. Patients were assessed preoperatively, at five days, six weeks and one, two and five years, postoperatively. The outcome measures included the KOOS, Knee Society Score, BOA Patient Satisfaction Scale, and radiographs at six weeks and one, two and five years. In two patients polyethlylene exchange was performed at 56 months from surgery during patellofemoral resurfacing. The four retrieved polyethylene liners were studied for wear with the aid of a stereo zoom microscope and an environmental scanning electron microscope (ESEM). Both the patients and the all examiners were blinded as to the prosthesis type throughout the study.

Forty patients (80 knees) were included in the study. At five years, three patients were deceased and two had developed senile dementia. No patients were lost to follow up. At five years from surgery the CoCr knee was preferred by 41% of patients compared to 13% who preferred the Oxinium knee (p=0.009). There was no significant difference in range of motion between the two prosthesis at five days, six weeks or one, two and five years. There were also no significant differences between the two prostheses in any of the other variables assessed. The four retrieved polyethylene inserts showed similar patterns of wear in terms of both wear types and patterns under examination with both the stereo zoom and scanning electron microscope with no clear differences between CoCr and Oxinium bearing against the polyethlylene. There was no difference in the grade or incidence of radiographic lucencies between the two prosthesis at five years.

At five years after surgery the only significant difference between the Genesis II Oxinium prosthesis and the CoCr prosthesis was a subjective preference for the CoCr prosthesis by a higher proportion of patients. There were no unexpected complications associated with the use the Oxinium femoral implants. In the four retrieved polyethylene liners, no significant differences were identified between the two prosthesis materials in terms of detectable wear type and patterns. Continued follow up of this cohort is planned to establish whether Oxinium femoral implants have an improved survivorship compared to CoCr femoral component in total knee replacement to warrant the additional cost.