To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores. Existing UK data from 222,933 knee and 209,760 hip arthroplasty patients were used to model an individual’s probability of gaining meaningful improvement after surgery based on their preoperative Oxford Knee or Hip Score (OKS/OHS). A clinically meaningful improvement after arthroplasty was defined as ≥ 8 point improvement in OHS, and ≥ 7 in OKS.Aims
Methods
The ability to edit DNA at the nucleotide level using clustered regularly interspaced short palindromic repeats (CRISPR) systems is a relatively new investigative tool that is revolutionizing the analysis of many aspects of human health and disease, including orthopaedic disease. CRISPR, adapted for mammalian cell genome editing from a bacterial defence system, has been shown to be a flexible, programmable, scalable, and easy-to-use gene editing tool. Recent improvements increase the functionality of CRISPR through the engineering of specific elements of CRISPR systems, the discovery of new, naturally occurring CRISPR molecules, and modifications that take CRISPR beyond gene editing to the regulation of gene transcription and the manipulation of RNA. Here, the basics of CRISPR genome editing will be reviewed, including a description of how it has transformed some aspects of molecular musculoskeletal research, and will conclude by speculating what the future holds for the use of CRISPR-related treatments and therapies in clinical orthopaedic practice. Cite this article:
The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial. PROMs including the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS), EuroQol five-dimension (EQ-5D), satisfaction, net promoter score and data regarding re-rupture, and venous thromboembolic rates were collected for patients randomized to receive either operative or nonoperative treatment for acute Achilles tendon rupture in a previous study. Of the 80 patients originally randomized, 64 (33 treated surgically, 31 nonoperatively) patients were followed up at a mean of 15.7 years (13.4 to 17.7).Aims
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To systematically review the outcomes and complications of cosmetic stature lengthening. PubMed and Embase were searched on 10 November 2019 by three reviewers independently, and all relevant studies in English published up to that date were considered based on predetermined inclusion/exclusion criteria. The search was done using “cosmetic lengthening” and “stature lengthening” as key terms. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.Aims
Methods
Appropriate acetabular component placement has been proposed for prevention of postoperative dislocation in total hip arthroplasty (THA). Manual placements often cause outliers in spite of attempts to insert the component within the intended safe zone; therefore, some surgeons routinely evaluate intraoperative pelvic radiographs to exclude excessive acetabular component malposition. However, their evaluation is often ambiguous in case of the tilted or rotated pelvic position. The purpose of this study was to develop the computational analysis to digitalize the acetabular component orientation regardless of the pelvic tilt or rotation. Intraoperative pelvic radiographs of 50 patients who underwent THA were collected retrospectively. The 3D pelvic bone model and the acetabular component were image-matched to the intraoperative pelvic radiograph. The radiological anteversion (RA) and radiological inclination (RI) of the acetabular component were calculated and those measurement errors from the postoperative CT data were compared relative to those of the 2D measurements. In addition, the intra- and interobserver differences of the image-matching analysis were evaluated.Aims
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This study aimed to determine if macrophages can attach and directly affect the oxide layers of 316L stainless steel, titanium alloy (Ti6Al4V), and cobalt-chromium-molybdenum alloy (CoCrMo) by releasing components of these alloys. Murine peritoneal macrophages were cultured and placed on stainless steel, CoCrMo, and Ti6Al4V discs into a 96-well plate. Cells were activated with interferon gamma and lipopolysaccharide. Macrophages on stainless steel discs produced significantly more nitric oxide (NO) compared to their control counterparts after eight to ten days and remained elevated for the duration of the experiment.Aims
Methods
The transition from shutdown of elective orthopaedic services to the resumption of pre-COVID-19 activity presents many challenges. These include concerns about patient safety, staff safety, and the viability of health economies. Careful planning is necessary to allow patients to benefit from orthopaedic care in a safe and sustainable manner. Cite this article:
High body mass index (BMI) is associated with increased rates of complications in primary total hip arthroplasty (THA), but less is known about its impact on cost. The effects of low BMI on outcomes and cost are less understood. This study evaluated the relationship between BMI, inpatient costs, complications, readmissions, and utilization of post-acute services. A retrospective database analysis of 40,913 primary THAs performed between January 2013 and December 2017 in 29 hospitals was conducted. Operating time, length of stay (LOS), complication rate, 30-day readmission rate, inpatient cost, and utilization of post-acute services were measured and compared in relation to patient BMI.Aims
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Current treatments of prosthetic joint infection (PJI) are minimally effective against The ability of PlySs2 and vancomycin to kill biofilm and colony-forming units (CFUs) on orthopaedic implants were compared using in vitro models. An in vivo murine PJI model of DAIR was used to assess the efficacy of a combination of PlySs2 and vancomycin on periprosthetic bacterial load.Aims
Methods
Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers. All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit.Aims
Methods
It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples Aims
Methods
The aim of this study was to report the medium-term outcomes of impaction bone allograft and fibular grafting for osteonecrosis of the femoral head (ONFH) and to define the optimal indications. A total of 67 patients (77 hips) with ONFH were enrolled in a single centre retrospective review. Success of the procedure was assessed using the Harris Hip Score (HHS) and rate of revision to total hip arthroplasty (THA). Risk factors were studied, including age, aetiology, duration of hip pain, as well as two classification systems (Association Research Circulation Osseous (ARCO) and Japanese Investigation Committee (JIC) systems).Aims
Methods
To establish whether there was a consensus among the members of the Hip Society (HS) on the role of direct anterior approach (DAA) contemporary primary total hip arthroplasty (THA). An online survey was sent to all 112 active and senior members of the HS, to which 71 members responded. The survey was constructed to determine whether they believed that evidence-based medicine proves, in modern clinical practice, that the DAA has significant benefits compared to risks when contrasted with other approaches. In addition, they were asked if they currently used the DAA.Aims
Methods
The practice of overlapping surgery has been increasing in the delivery of orthopaedic surgery, aiming to provide efficient, high-quality care. However, there are concerns about the safety of this practice. The purpose of this study was to examine the safety and efficacy of a model of partially overlapping surgery that we termed ‘swing room’ in the practice of primary total hip (THA) and knee arthroplasty (TKA). A retrospective review of prospectively collected data was carried out on patients who underwent primary THA and TKA between 2006 and 2017 in two academic centres. Cases were stratified as partially overlapping (swing room), in which the surgeon is in one operating room (OR) while the next patient is being prepared in another, or nonoverlapping surgery. The demographic details of the patients which were collected included operating time, length of stay (LOS), postoperative complications within six weeks of the procedure, unplanned hospital readmissions, and unplanned reoperations. Fisher's exact, Wilcoxon rank-sum tests, chi-squared tests, and logistic regression analysis were used for statistical analysis.Aims
Methods
Earlier studies dealing with trends in the management of osteonecrosis of the femoral head (ONFH) identified an increasing rate of total hip arthroplasties (THAs) and a decreasing rate of joint-preserving procedures between 1992 and 2008. In an effort to assess new trends in the management of this condition, this study evaluated the annual trends of joint-preserving versus arthroplasties for patients aged < or > 50 years old, and the incidence of specific operative management techniques. A total of 219,371 patients with ONFH were identified from a nationwide database between 1 January 2009 and 31 December 2015. The mean age was 54 years (18 to 90) and 105,298 (48%) were female. The diagnosis was made using International Classification of Disease, Ninth revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) procedure codes. The percentage of patients managed using each procedure during each year was calculated and compared between years. The trends in the use of the types of procedure were also evaluated.Aims
Methods
Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view.Aims
Methods
The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR’s data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019. Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network’s electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019.Aims
Methods
The purpose of this study was to explore the correlation between femoral torsion and morphology of the distal femoral condyle in patients with trochlear dysplasia and lateral patellar instability. A total of 90 patients (64 female, 26 male; mean age 22.1 years (SD 7.2)) with lateral patellar dislocation and trochlear dysplasia who were awaiting surgical treatment between January 2015 and June 2019 were retrospectively analyzed. All patients underwent CT scans of the lower limb to assess the femoral torsion and morphology of the distal femur. The femoral torsion at various levels was assessed using the a) femoral anteversion angle (FAA), b) proximal and distal anteversion angle, c) angle of the proximal femoral axis-anatomical epicondylar axis (PFA-AEA), and d) angle of the AEA–posterior condylar line (AEA-PCL). Representative measurements of distal condylar length were taken and parameters using the ratios of the bianterior condyle, biposterior condyle, bicondyle, anterolateral condyle, and anteromedial condyle were calculated and correlated with reference to the AEA, using the Pearson Correlation coefficient.Aims
Methods
Patients with abnormal spinopelvic mobility are at increased risk for instability. Measuring the change in sacral slope (ΔSS) can help determine spinopelvic mobility preoperatively. Sacral slope (SS) should decrease at least 10° to demonstrate adequate posterior pelvic tilt. There is potential for different ΔSS measurements in the same patient based on sitting posture. The purpose of this study was to determine the effect of sitting posture on the ΔSS in patients undergoing total hip arthroplasty (THA). In total, 51 patients undergoing THA were reviewed to quantify the variability in preoperative spinopelvic mobility when measuring two different sitting positions using SS for planning.Aims
Methods
Dislocation is the most common indication for further surgery following total hip arthroplasty (THA) when undertaken in patients with a femoral neck fracture. This study aimed to assess the complication rates of THA with dual mobility components (THA-DMC) following a femoral neck fracture and to compare outcomes between THA-DMC, conventional THA, and hemiarthroplasty (HA). We performed a systematic review of all English language articles on THA-DMC published between 2010 and 2019 in the MEDLINE, EMBASE, and Cochrane databases. After the application of rigorous inclusion and exclusion criteria, 23 studies dealing with patients who underwent treatment for a femoral neck fracture using THA-DMC were analyzed for the rate of dislocation. Secondary outcomes included reoperation, periprosthetic fracture, infection, mortality, and functional outcome. The review included 7,189 patients with a mean age of 77.8 years (66.4 to 87.6) and a mean follow-up of 30.9 months (9.0 to 68.0).Aims
Methods
Cementless acetabular components rely on press-fit fixation for initial stability. In certain cases, initial stability is more difficult to obtain (such as during revision). No current study evaluates how a surgeon’s impaction technique (mallet mass, mallet velocity, and number of strikes) may affect component fixation. This study seeks to answer the following research questions: 1) how does impaction technique affect a) bone strain generation and deterioration (and hence implant stability) and b) seating in different density bones?; and 2) can an impaction technique be recommended to minimize risk of implant loosening while ensuring seating of the acetabular component? A custom drop tower was used to simulate surgical strikes seating acetabular components into synthetic bone. Strike velocity and drop mass were varied. Synthetic bone strain was measured using strain gauges and stability was assessed via push-out tests. Polar gap was measured using optical trackers.Aims
Methods
The worldwide COVID-19 pandemic is directly impacting the field of orthopaedic surgery and traumatology with postponed operations, changed status of planned elective surgeries and acute emergencies in patients with unknown infection status. To this point, Germany's COVID-19 infection numbers and death rate have been lower than those of many other nations. This article summarizes the current regimen used in the field of orthopaedics in Germany during the COVID-19 pandemic. Internal university clinic guidelines, latest research results, expert consensus, and clinical experiences were combined in this article guideline.Aims
Methods
Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos’ Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board’s electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status.Aims
Methods
Healthcare systems have been rapidly restructured to meet COVID-19 demand. Clinicians are working to novel clinical guidelines, treating new patient cohorts and working in unfamiliar environments. Trauma and orthopaedics (T&O) has experienced cancellation of routine clinics and operating, with redistribution of the workload and human resources. To date, no studies have evaluated the mental health impact of these changes on the T&O workforce. We report the results of a novel survey on the impact of the pandemic on the mental health of our orthopaedic workforce and the contributory factors. A 20-question survey-based cross-sectional study of orthopaedic team members was conducted during the COVID-19 pandemic. The primary objective was to identify the impact of the pandemic on mental health in the form of major depressive disorder (MDD) and general anxiety disorder (GAD). The survey incorporated the patient health questionnaire (PHQ-2), which is validated for screening of MDD, and the generalized anxiety disorder questionnaire (GAD-2), which is validated for screening of GAD.Aims
Methods
Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve. Cite this article:
The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic. A prospective cohort study was undertaken between 17 March 2020 and 30 April 2020 and compared with retrospective data from same time period in 2019. We compared the number of patients requiring acute hospital admission or orthopaedic referrals and indications of referrals from our admission sheets and obtained operative data from our theatre software.Aims
Methods
In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated. All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge.Introduction
Methods
Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics. All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison.Introduction
Methods
Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland. A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location.Aims
Methods
As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment. This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery.Aims
Methods
Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA.Aims
Methods
The use of technology to assess balance and alignment during total knee surgery can provide an overload of numerical data to the surgeon. Meanwhile, this quantification holds the potential to clarify and guide the surgeon through the surgical decision process when selecting the appropriate bone recut or soft tissue adjustment when balancing a total knee. Therefore, this paper evaluates the potential of deploying supervised machine learning (ML) models to select a surgical correction based on patient-specific intra-operative assessments. Based on a clinical series of 479 primary total knees and 1,305 associated surgical decisions, various ML models were developed. These models identified the indicated surgical decision based on available, intra-operative alignment, and tibiofemoral load data.Aims
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Describe a statistical and economic analysis plan for the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) randomized controlled trial. DRAFFT2 is a multicentre, parallel, two-arm randomized controlled trial. It compares surgical fixation with K-wires versus plaster cast in adult patients who have sustained a dorsally displaced fracture of the distal radius. The primary outcome measure is the Patient-Rated Wrist Evaluation (PRWE, a validated assessment of wrist function and pain) at 12 months post-randomization. Secondary outcomes are measured at three, six, and 12 months after randomization and include the PWRE, EuroQoL EQ-5D-5L index and EQ-VAS (visual analogue scale), complication rate, and cost-effectiveness of the treatment.Aims
Methods
Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community. We used data from a stand-alone hospital admitting and operating on 91 trauma patients. All patients were screened on admission and 100% of patients have been followed-up after discharge to assess outcome.Aims
Methods
Torus fractures of the distal radius are the most common fractures in children. The NICE non-complex fracture guidelines recently concluded that bandaging was probably the optimal treatment for these injuries. However, across the UK current treatment varies widely due to a lack of evidence underpinning the guidelines. The Forearm Fracture Recovery in Children Evaluation (FORCE) trial evaluates the effect of a soft bandage and immediate discharge compared with rigid immobilization. FORCE is a multicentre, parallel group randomized controlled equivalence trial. The primary outcome is the Wong-Baker FACES pain score at three days after randomization and the primary analysis of this outcome will use a multivariate linear regression model to compare the two groups. Secondary outcomes are measured at one and seven days, and three and six-weeks post-randomization and include the Patient Reported Outcome Measurement Information System (PROMIS) upper extremity limb score, EuroQoL EQ-5D-Y, analgesia use, school absence, complications, and healthcare resource use. The planned statistical and health economic analyses for this trial are described here. The FORCE trial protocol has been published separately.Aims
Methods
The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article:
Torus fractures are the most common childhood fracture, accounting for 500,000 UK emergency attendances per year. UK treatment varies widely due to lack of scientific evidence. This is the protocol for a randomized controlled equivalence trial of ‘the offer of a soft bandage and immediate discharge’ versus ‘rigid immobilization and follow-up as per the protocol of the treating centre’ in the treatment of torus fractures . Children aged four to 15-years-old inclusive who have sustained a torus/buckle fracture of the distal radius with/without an injury to the ulna are eligible to take part. Baseline pain as measured by the Wong Baker FACES pain scale, function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb, and quality of life (QoL) assessed with the EuroQol EQ-5D-Y will be collected. Each patient will be randomly allocated (1:1, stratified by centre and age group (four to seven years and ≥ eight years) to either a regimen of the offer of a soft bandage and immediate discharge or rigid immobilization and follow-up as per the protocol of the treating centre.Aims
Methods
It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts. Cite this article:
Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic. A vacated private elective surgical centre was repurposed to facilitate a two-site, ‘COVID’ and ‘COVID-free’, hip fracture service. Patients were screened for COVID-19 infection and either kept at our ‘COVID’ site or transferred to our ‘COVID-free’ site. We collected data for 30 days on patient demographics, Clinical Frailty Scale (CFS), Nottingham Hip Fracture Scores (NHFS), time to surgery, COVID-19 status, mortality, and length of stay (LOS).Aims
Methods
Sickle cell disease (SCD) is an autosomal recessive inherited condition that presents with a number of clinical manifestations that include musculoskeletal manifestations (MM). MM may present differently in different individuals and settings and the predictors are not well known. Herein, we aimed at determining the predictors of MM in patients with SCD at the University Teaching Hospital, Lusaka, Zambia. An unmatched case-control study was conducted between January and May 2019 in children below the age of 16 years. In all, 57 cases and 114 controls were obtained by systematic sampling method. A structured questionnaire was used to collect data. The different MM were identified, staged, and classified according to the Standard Orthopaedic Classification Systems using radiological and laboratory investigations. The data was entered in Epidata version 3.1 and exported to STATA 15 for analysis. Multiple logistic regression was used to determine predictors and predictive margins were used to determine the probability of MM.Aims
Methods
This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google.Aims
Methods
Femoral revision component subsidence has been identified as predicting early failure in revision hip surgery. This comparative cohort study assessed the potential risk factors of subsidence in two commonly used femoral implant designs. A comparative cohort study was undertaken, analyzing a consecutive series of patients following revision total hip arthroplasties using either a tapered-modular (TM) fluted titanium or a porous-coated cylindrical modular (PCM) titanium femoral component, between April 2006 and May 2018. Clinical and radiological assessment was compared for both treatment cohorts. Risk factors for subsidence were assessed and compared.Aims
Methods
Rates of readmission and reoperation following primary total knee arthroplasty (TKA) are under scrutiny due to new payment models, which penalize these negative outcomes. Some risk factors are more modifiable than others, and some conditions considered modifiable such as obesity may not be as modifiable in the setting of advanced arthritis as many propose. We sought to determine whether controlling for hypoalbuminaemia would mitigate the effect that prior authors had identified in patients with obesity. We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period of January 2008 to December 2016 to evaluate the rates of reoperation and readmission within 30 days following primary TKA. Multivariate logistic regression modelling controlled for preoperative albumin, age, sex, and comorbidity status.Aims
Methods
In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty. Patients undergoing revision hip (THA) or knee arthroplasty (TKA) for any septic or aseptic indication were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry tap (pre-lavage) followed by the injection with 20 ml of normal saline and re-aspiration (post-lavage). Pre- and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared.Aims
Methods
Short, bone-conserving femoral components are increasingly used in total hip arthroplasty (THA). They are expected to allow tissue-conserving implantation and to render future revision surgery more straightforward but the long-term data on such components is limited. One such component is the global tissue-sparing (GTS) stem. Following the model for stepwise introduction of new orthopaedic implants, we evaluated early implant fixation and clinical outcome of this novel short-stem THA and compared it to that of a component with established good long-term clinical outcome. In total, 50 consecutive patients ≤ 70 years old with end-stage symptomatic osteo-arthritis were randomized to receive THA with the GTS stem or the conventional Taperloc stem using the anterior supine intermuscular approach by two experienced hip surgeons in two hospitals in the Netherlands. Primary outcome was implant migration. Patients were followed using routine clinical examination, patient reported outcome using Harris Hip Score (HHS), Hip Disability And Osteoarthritis Outcome Score (HOOS), EuroQol five-dimension questionnaire (EQ5D), and Roentgen Stereophotogrammetric Analysis (RSA) at three, six, 12, and 24 months. This study evaluated the two-year follow-up results.Aims
Methods
Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone. A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems for 35 revision TKAs. There were two patients with follow-up of less than two years who were excluded, leaving 33 procedures in 32 patients in the study. The mean age of the patients at the time of revision TKA was 67 years (32 to 87); 20 (60%) were male. Patients had undergone a mean of four (1 to 13) previous knee arthroplasty procedures. The indications for revision were aseptic loosening (80%) and two-stage reimplantation for prosthetic joint infection (PJI; 20%). The mean follow-up was four years (2 to 11).Aims
Methods
