Prolonged waits for hip and knee arthroplasty have raised questions about the equity of current approaches to waiting list prioritization for those awaiting surgery. We therefore set out to understand key stakeholder (patient and surgeon) preferences for the prioritization of patients awaiting such surgery, in order to guide future waiting list redesign. A combined qualitative/quantitative approach was used. This comprised a Delphi study to first inform which factors patients and surgeons designate as important for prioritization of patients on hip and knee arthroplasty waiting lists, followed by a discrete choice experiment (DCE) to determine how the factors should be weighed against each other. Coefficient values for each included DCE attribute were used to construct a ‘priority score’ (weighted benefit score) that could be used to rank individual patients waiting for surgery based on their respective characteristics.Aims
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Traditionally, patients with a fracture of the distal radius are treated in a cast if they do not require surgery. If the fracture requires manipulation, the cast is moulded to hold the reduction and maintain normal anatomical alignment during healing. However, is a cast necessary for patients whose fracture does not require manipulation? Removable splints are an alternative treatment option. Such splints have the advantage that they can be adjusted to improve fit around the wrist as swelling reduces, and can be removed and reapplied for the purpose of washing or, in some cases, exercise. However, evidence for their safety and effectiveness in the management of distal radius fractures is lacking. DRAFT3 is a multicentre randomized non-inferiority trial and economic analysis designed to determine the safety and effectiveness of removable splints as an alternative to casts in the treatment of distal radius fractures that do not require manipulation. Cite this article:
The “2 to 10% strain rule” for fracture healing has been widely interpreted to mean that interfragmentary strain greater than 10% predisposes a fracture to nonunion. This interpretation focuses on the gap-closing strain (axial micromotion divided by gap size), ignoring the region around the gap where osteogenesis typically initiates. The aim of this study was to measure gap-closing and 3D interfragmentary strains in plated ovine osteotomies and associate local strain conditions with callus mineralization. MicroCT scans of eight female sheep with plated mid-shaft tibial osteotomies were used to create image-based finite element models. Virtual mechanical testing was used to compute postoperative gap-closing and 3D continuum strains representing compression (volumetric strain) and shear deformation (distortional strain). Callus mineralization was measured in zones in and around the osteotomy gap.Aims
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The aim of this study was 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 medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). Ten-year follow-up of patients who were randomized to rUKA (n = 64) or mUKA (n = 65) was performed. Patients completed the EuroQol five-dimension health questionnaire preoperatively, at three months, and one, two, five, and ten years postoperatively, which was used to calculate quality-adjusted life years (QALY) gained and the incremental cost-effectiveness ratio (ICER). Costs for the index and additional surgery and healthcare costs were calculated.Aims
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Unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) have both been shown to be effective treatments for osteoarthritis (OA) of the knee. Many studies have compared the outcomes of the two treatments, but less so with the use of robotics, or individualized TKA alignment techniques. Functional alignment (FA) is a novel technique for performing a TKA and shares many principles with UKA. Our aim was to compare outcomes from a case-matched series of robotic-assisted UKAs and robotic-assisted TKAs performed using FA. From a prospectively collected database between April 2015 and December 2019, patients who underwent a robotic-assisted medial UKA (RA-UKA) were case-matched with patients who had undergone a FA robotic-assisted TKA (RA-TKA) during the same time period. Patients were matched for preoperative BMI, sex, age, and Forgotten Joint Score (FJS). A total of 101 matched pairs were eligible for final review. Postoperatively the groups were then compared for differences in patient-reported outcome measures (PROMs), range of motion (ROM), ability to ascend and descend stairs, and ability to kneel.Aims
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Objective. We aimed to analyse the clinical outcomes and survivorship of anatomic total shoulder arthroplasty using a stemless humeral component with cemented pegged polyethylene glenoid performed with the technique of eccentric reaming to partially correct retroversion. These results were then compared with TSA using the same implant for end-stage shoulder arthritis with a normal version of the native glenoid. Design and methods. A retrospective case series was performed using a prospectively collected database of anatomic TSA patients operated at Woodend General Hospital, Aberdeen, UK. Between 2010 and 2019, 107 total shoulder arthroplasties (TSA) were done using standard anatomic stemless TSA implants (Affinis Short, Mathys Ltd, Bettlach, Switzerland) in 98 patients. Standardized preoperative and postoperative shoulder radiological imaging for glenoid retroversion was collected. Depending on the angle of native glenoid version, patients were divided into retroverted and non-retroverted glenoid as per the Walch Classification. To assess the radiological outcome at the final follow-up, radiolucency was assessed on the glenoid and humeral side using the Lazarus grading. The final clinical and radiologic outcome from the retroverted group was compared with the population with a non-retroverted glenoid. Five TSAs were excluded from the analysis as they did not have satisfactory postoperative radiographs. Hence, a total of 102 shoulders were available for analysis. Results. The mean follow-up was 3.48 years (2-10.2 years) in the retroverted group (n=44) and 3.9 years (2-8.9 years) in the non-retroverted group (n=58). The mean pre-operative retroversion of the glenoid in the retroverted group was 20.18, and the post-operative retroversion was 15.87, with a mean correction of 4.31. There was no significant difference between the two groups in the percentage of radiological loosening. The mean Oxford shoulder score was 41.4 (16-48) in the retroverted group, while it was 42.1 (20-48) in the non-retroverted group. Three patients in the retroverted group required revision surgery for rotator cuff failure. There were no revisions for aseptic loosening or instability. Conclusion. The degree of severity of retroversion of the glenoid was not associated with poor clinical outcomes, revisions, or failure in stemless TSA. At medium-term follow-up,
This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation. A total of 16 subjects with CAI (eight without OLT and eight with OLT) and eight healthy subjects underwent gait analysis in a stair descent setting. Inverse dynamic analysis was applied to ground reaction forces and marker trajectories using the AnyBody Modeling System. One-dimensional statistical parametric mapping was performed to compare ankle joint reaction force and joint moment curve among groups.Aims
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The December 2024 Knee Roundup360 looks at: Unicompartmental knee arthroplasty and total knee arthroplasty in the same patient?; Lateral unicompartmental knee arthroplasty: is it a good option?; The fate of the unresurfaced patellae in contemporary total knee arthroplasty: early- to mid-term results; Tibial baseplate migration is not associated with change in PROMs and clinical scores after total knee arthroplasty; Unexpected positive intraoperative cultures in aseptic revision knee arthroplasty: what effect does this have?; Kinematic or mechanical alignment in total knee arthroplasty surgery?; Revision total knee arthroplasty achieves minimal clinically important difference faster than primary total knee arthroplasty; Outcomes after successful DAIR for periprosthetic joint infection in total knee arthroplasty.
Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR). Between May 2022 and March 2024, we enrolled 45 dissatisfied knee arthroplasty patients who lacked any clear indication for revision to this prospective cohort study. All patients were at least six months post-surgery and had undergone conventional physiotherapy previously. The patients participated in a supervised LL-RT combined with BFR in 18 sessions. Primary assessments included the following patient-reported outcome measures (PROMs): Knee injury and Osteoarthritis Outcome Score (KOOS); Knee Society Score: satisfaction (KSSs); the EuroQol five-dimension five-level questionnaire (EQ-5D-5L); and the pain catastrophizing scale (PCS). Functionality was assessed using the six-minute walk Test (6MWT) and the 30-second chair stand test (30CST). Follow-up timepoints were at baseline, six weeks, three months, and six months after the start.Aims
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This study aimed to determine clinical outcomes; relationships between postoperative anterior, lateral, and posterior acetabular coverage and joint survival; and prognostic factors for joint survival after transposition osteotomy of the acetabulum (TOA). Data from 616 patients (800 hips) with hip dysplasia who underwent TOA between November 1998 and December 2019 were reviewed. The median follow-up period was 8.9 years (IQR 5 to 14). A medical notes review was conducted to collect demographic data, complications, and modified Harris Hip Score (mHHS). Radiological indicators of acetabular coverage included lateral centre-edge angle (LCEA), anterior wall index (AWI), and posterior wall index (PWI). The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors for failure.Aims
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A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness. Clinical data from a multicentre database identified patients who underwent primary aTSA from November 2004 to January 2023. A total of 390 patients (mean follow-up 48.1 months (SD 42.0)) were included: 97 (24.9%) were classified as appropriate, 218 (55.9%) inconclusive, and 75 (19.2%) inappropriate. Patients were classified as “appropriate”, “inconclusive”, or “inappropriate”, using a modified version of an appropriateness algorithm, which accounted for age, rotator cuff status, mobility, symptomatology, and Walch classification. Multiple pre- and postoperative scores were analyzed using Pearson’s chi-squared test and one-way analysis of variance (ANOVA). Postoperative complications were also analyzed.Aims
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The December 2024 Foot & Ankle Roundup360 looks at: Tibiotalar sector and lateral ankle instability; Isolated subtalar fusion and correction of progressive collapsing foot deformity; Diabetic control and postoperative complications following ankle fracture fixation; Are insoles of any benefit for plantar fasciitis?; Postoperative foot shape and patient-reported outcome following surgery for progressing collapsing foot deformity; Calcaneo-stop procedure for symptomatic flexible flatfoot in children.
Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects. A retrospective review was performed of all patients who underwent combined single-stage orthoplastic treatment of calcaneal osteomyelitis (01/2008 to 12/2022). Primary outcome measures were osteomyelitis recurrence and below-knee amputation (BKA). Secondary outcome measures included flap failure, operating time, complications, and length of stay.Aims
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Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes. Cite this article:
The December 2024 Shoulder & Elbow Roundup360 looks at: Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation; Predictors of surgery and long-term outcomes in nonoperative management of full-thickness rotator cuff tears; Reverse shoulder arthroplasty viable despite acquired acromial compromise, but higher infection risk noted; LP-PRP reduces retear rates in rotator cuff repair but shows no functional outcome advantage; Long-term clinical outcomes of arthroscopic supraspinatus tendon repair using the single anchor tension band technique – minimum five-year follow-up; Arthroscopic stabilization for anterior shoulder dislocation shows low recurrence rates regardless of prior dislocations; ORIF outperforms arthroplasty for complex radial head fractures: mid-term outcomes; Routine use of surgical helmet systems may not reduce infection risk in shoulder arthroplasty.
Aim. There is limited data on the frequency and impact of untoward events such as glove perforation, contamination of the surgical field (drape perforation, laceration, detachment), the unsterile object in the surgical field (hair, sweat droplet…), defecation, elevated air temperature…that may happen in the operating theatre. These events should influence the surgical site infection rate but it is not clear to what extent. We wanted to calculate the frequency and measure the impact of these events on the infection and general revision rate. Method. In our institution, scrub nurses prospectively and diligently record untoward events in the theatres. We have an institutional implant registry with close to 100% data completion since 2001, and surgeons register complications before discharge. We analysed the respective databases and compared the revision and infection rate in the group with untoward events with the outcome of all arthroplasty patients within the same period. Two-tailed Z statistical test was used for analysis. Results. Between 1.1.2012 and 31.12.2018 we operated 13574 prosthetic joints: 6232 primary THR (total hip replacement) and 5466 primary KR (total and
Aim. Periprosthetic joint infection (PJI) is one of the most devastating complications after joint replacement. It is associated with high morbidity and economic burden when misdiagnosed as an aseptic failure. Among all cases of PJI, up to 25% could yield negative cultures. Conversely, among cases of aseptic failures, up to 30% may actually be undiagnosed PJIs. In PJIs microbiological diagnosis is a key step for successful treatment. Sonication of the removed prosthesis is more sensitive than conventional periprosthetic-tissue culture, especially in patients who received antimicrobial therapy before surgery. This study aimed to compare the diagnostic value of classic sonication fluid cultures (SF-C) and sonication fluid incubation in blood culture bottle (SF-BCB). Method. Between 2016 and 2018 we analysed 160 revision procedures of joint arthroplasties. For each procedure, at least 5 microbiological and multiple histopathological samples were harvested, and explant sonication was performed which was further analysed by SF-C and SF-BCB. For SF-C classical cultivation of sonication fluid was performed. While for SF-BCB, 10 mL of sonication fluid was inoculated into aerobic and anaerobic lytic blood culture bottles. The definite diagnosis of PJI was based on the EBJIS definition. Results. Among 160 revisions, 59 PJIs were identified, 15 patients were treated with the debridement and implant retention, 7 patients with the one-stage and 35 with the two-stage exchange, remaining 2 were
The Bankart and Latarjet procedures are two of the most common surgical techniques to treat anterior shoulder instability with satisfactory clinical and functional outcomes. However, the outcomes in the adolescent population remain unclear, and there is no information regarding the arthroscopic Latarjet in this population. The purpose of this study was to evaluate the outcomes of the arthroscopic Bankart and arthroscopic Latarjet procedures in the management of anterior shoulder instability in adolescents. We present a retrospective, matched-pair study of teenagers with anterior glenohumeral instability treated with an arthroscopic Bankart repair (ABR) or an arthroscopic Latarjet (AL) procedure with a minimum two-year follow-up. Preoperative demographic and clinical features, factors associated with dislocation, and complications were collected. Recurrence, defined as dislocation or subluxation, was established as the primary outcome. Clinical and functional outcomes were analyzed using objective (Rowe), and subjective (Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE)) scores. Additionally, the rate of return to sport was assessed.Aims
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Introduction. The human wrist is a highly complex joint, offering extensive motion across various planes. This study investigates scapholunate ligament (SLL) injuries’ impact on wrist stability and arthritis risks using cadaveric experiments and the finite element (FE) method. It aims to validate experimental findings with FE analysis results. Method. The study utilized eight wrist specimens on a custom rig to investigate Scapho-Lunate dissociation. Contact pressure and flexion were measured using sensors. A CT-based 3D geometry reconstruction approach was used to create the geometries needed for the FE analysis. The study used the Friedman test with pairwise comparisons to assess if differences between testing conditions were statistically significant. Result. The study found significant variations in scaphoid and lunate bone movement based on ligament condition. Full tears increased scapholunate distance in the distal-proximal direction and decreased in the medial-lateral direction. Lunate angles shifted from flexion to extension with fully torn ligaments. Conversely, the scaphoid shifted significantly from extension to flexion with full tears. A proximal movement was observed in the distal-proximal direction in all groups, with significant differences in the
For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis. We reviewed 15 patients over a five-year period (January 2017 to December 2022) who had undergone extra-articular resection of the hip joint due to malignant tumour using a custom-made osteotomy guide and 3D-printed endoprosthesis. Each of the 15 patients had a single lesion, with six originating from the acetabulum side and nine from the proximal femur. All patients had their posterior column preserved according to the surgical plan.Aims
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