Open lower limb fractures are resource-intensive fractures, accounting for a significant proportion of the workload and cost of orthopaedic trauma units. A recent study has evaluated that the median cost of direct inpatient treatment of open lower-limb fractures in the National Health Service (NHS) is steep, at £19189 per patient. Healthcare providers are expected to be aware of the costs of treatments, although there is very limited dissemination of this information, neither on a national or local level. Older adults (>65 years old) are at an increased risk of the types of high-energy injuries that can result in open lower limb fractures. Generally, there remains a significant lack of literature surrounding the cost of open fracture management, especially in specific patient groups that are disproportionately affected by these fractures. This study has calculated the direct inpatient care costs of older adults with open lower limb fractures. Open lower limb fractures in adult patients over 65 years old treated at Addenbrooke's Hospital of Cambridge University Hospitals NHS Trust were identified over the period of March 2014-March 2019. Isolated fractures of the femur, tibia and fibula over this time period were included. Direct inpatient care costs were calculated using information about the sustained fracture, operative time, implant(s) and theatre kit(s) used, the number of patient bed-days on the orthopaedic ward and critical care unit, and the number of hours of inpatient physiotherapy received. Direct inpatient care costs were compared with the income received by our centre for each of these cases, according to Healthcare Resource Group (HRG) cost codes. Our data was also compared with existing literature on Patient Level Costing (PLC) figures for open lower limb fractures. We extracted data from 58 patients over the age of 65 years treated for open isolated lower limb fractures at Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, between March 2014 and March 2019. The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. The absence of published primary literature and clinical audits on this topic continues to hinder the inclusion of cost-effectiveness as an important factor in clinical decision-making. This study provides valuable insight into the true cost of open lower limb fractures in a key patient population in a Major Trauma Centre in England and highlights the large losses incurred by hospitals in treating these cases. These results support the revision of the remuneration structures in the NHS for the treatment of elderly patients with these injuries

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. The purpose of this study was to determine the cost of inpatient admissions for developmental dysplasia of the hip (DDH) at a UK tertiary referral centre, and identify any association between newborn screening (NIPE) status and the cost of treatment. Methods. This was a retrospective study, using hospital episodes data from a single NHS trust. All inpatient episodes between 01/01/2014 to 30/06/2019 with an ICD-10 code stem of Q65 ‘congenital deformities of hip’ were screened to identify admissions for management of DDH. Data was subsequently obtained from electronic and paper records. Newborn screening status was recorded, and patients were divided into ‘NIPE-positive’ (diagnosed through selective screening) and ‘NIPE-negative’ (not diagnosed through screening). Children with neuromuscular conditions or concomitant musculoskeletal disease were excluded. The tariff paid for each inpatient episode was identified, and the number of individual clinic attendances, surgical procedures and radiological examinations performed (USS, XR, CT, MRI) were recorded. Results. 41 patients with DDH were admitted for inpatient management. 44% (n = 18) were NIPE-positive, diagnosed mean age 6.7 weeks. 56% (n = 23) were NIPE-negative, diagnosed mean age 26 months. The total cost of inpatient care in the NIPE-positive group was £171,471 (£9,526.18 per-patient) compared to £306,615 (£13,331.10 per-patient) for NIPE-negative. In the NIPE-positive group, there were 99 clinic attendances, 47 inpatient admissions and 160 radiological examinations performed (36 USS, 107 XR, 17 CT). This compared to 148 clinic attendances, 59 inpatient admissions and 215 radiological examinations (187 XR, 26 CT, 2 MRI) in the NIPE-negative group. Conclusion. A greater proportion of inpatient admissions for DDH are among NIPE-negative children. They incur a higher cost of treatment per patient and necessitate more inpatient resources. This study adds to the ongoing conversation around the cost-effectiveness of selective screening for DDH in the UK. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods. National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results. The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions. The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings. Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33–36. doi: 10.1302/2046-3758.52.2000506

The management of maxillofacial injuries requires restoring the contours of the facial skeleton to achieve an aesthetic outcome. When fractures are simple, open reduction and rigid fixation with stock titanium osteosynthesis plates is usually sufficient. However, when the damage is more substantial (when the fracture is comminuted or in case of a bone defect) anatomical landmarks are lost and the reconstruction requires the use of titanium meshes. These meshes are usually modelled intraoperatively to restore the contours of the bone. This can be a tough and time consuming task in case of minimal invasive approach and intraoperative edema. When the injury is unilateral, printing a 3D anatomical model of the mirrored unaffected side is an easy way to accurately pre-bend the mesh preoperatively. With the emergence of “low cost” consumer 3D printers, the aim of our study was to evaluate the cost of this technique in a department of maxillofacial surgery. The first part of the study was to evaluate free software solutions available online to determine which of these could be used to create 3D virtual models from the patients' volume imaging data, mirror the model and export an STL file suitable for 3D-printing with a consumer 3D-printer. The second part was to identify the desktop 3D-printers commercially available according to the different technology used, their prices and that of consumables required. Five free software solutions were identified to create STL meshes of the patient's anatomy from thin slice CT scan DICOM data. Two more were available to repair, segment and mirror them to provide a clean STL file suitable for 3D printing with a desktop 3D printer. The prices of 2 different printers were then listed for each of the 3 additive manufacturing technologies available to date. Prices ranged from 2,299 € for the Ultimaker 2+© (Fuse Deposition Modeling, FDM), to 4,999 € for the Sintratec© printer (Selective Laser Sintering, SLS), the Formlabs 2© (stereolithography) being at an intermediate price of 3,299 €. Finally, the cost of the manufacture of a model was calculated for each of these printers. Considering a model of a supraorbital ridge printed to restore the anterior wall of the frontal sinus, the volume of the mesh is around 20 cm. 3. This represents a cost of less than 1 € with the FDM technology, 4.70 € with stereolithography and 1.50 € with the SLS printer. Since patents of additive manufacturing have become part of the public domain, the cost of 3D printing technology has fallen drastically. Desktop printers are now an investment accessible to a surgery department and the cost of the material is low. This allows the surgeons, by the mean of free software, to directly create 3D models of their patients' anatomy, mirror them if needed and manufacture a template to pre-bend titanium meshes that will be subsequently sterilized for the surgery. Having the printer in the department reduces manufacturing lead times and makes this technique possible even for urgent cases

Many orthopaedic procedures require implants to be trialled before definitive implantation. Where this is required, the trials are provided in a set with the instrumentation. The most common scenario this is seen in during elective joint replacements. In Scotland (2007) the Scottish Executive (. http://www.sehd.scot.nhs.uk/cmo/CMO(2006)13.pdf. ) recommended and implemented individually packed orthopaedic implants for all orthopaedic sets. The premise for this was to reduce the risk of CJD contamination and fatigue of implants due to constant reprocessing from corrosion. During many trauma procedures determining the correct length of plate or size of implant can be challenging. Trials of trauma implants is no longer common place. Many implants are stored in closed and sealed boxes, preventing the surgeon looking at the implant prior to opening and contaminating the device. As a result many implants are incorrectly opened and either need reprocessed or destroyed due to infection control policy, thus implicating a cost to the NHS. With even the simplest implants costing several hundreds of pounds, this cost is a very significant waste in resources that could be deployed else where. My project was to develop a method to produce in department accurate, cheap and disposable trials for implants often used in trauma, where the original manufacturer do not offer the option of a trial off the shelf. The process had to not involve contaminating or destroying the original implant in the production of a trial. Several implants which are commonly used within Glasgow Royal Infirmary and do not have trials were identified. These implants were then CT scanned within their sealed and sterile packaging without contamination. Digital 3D surface renders of the models were created using free open source software (OsiriX, MeshLab, NetFabb). These models were then processed in to a suitable format for 3D printing using laser sintering via a cloud 3D printing bureau (. Shapeways.com. ). The implants were produced in polyamide PA220 material or in 316L stainless steel. These materials could be serialized using gamma irradiation or ethylene oxide gas. The steel models were suitable for autoclaving in the local CSSU. The implants produced were accurate facsimiles of the original implant with dimensions within 0.7mm. The implants were cost effective, an example being a rim mesh was reproduced in polyamide PA220 plastic for £3.50 and in 316L stainless steel for £15. The models were produced within 10 days of scanning. The stainless steel trials were durable and suitable for reprocessing and resterilisation. The production of durable, low cost and functional implant trials all completed in department was successful. The cost of production of each implant is so low that it would be offset if just one incorrect implant was opened during a single procedure. With some of the implants tested, the trials would have paid for themselves 100 times. This is a simple and cost saving technique that would help reduce department funding and aid patient care

Objectives. To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA). Methods. This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student’s t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis. Results. There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, . sd. 39.6 versus 461.6, . sd. 61.63, p < 0.0001), days to first orthopaedic review (5.2, . sd. 0.66 versus 10.9, . sd. 1.5, p < 0.0001), discharges (33.5, . sd. 3.66 versus 129.2, . sd. 7.36, p < 0.0001) and non-attendees (14.82, . sd. 1.48 versus 60.47, . sd. 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds . sd. 106 seconds versus 13 minutes 44 seconds . sd. 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter. Conclusions. We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs. Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:–269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1

Osteoarthritis and the pain associated with it result in gait pattern alteration, in particularly gait asymmetry when the disease is unilateral [1–2]. The quantification of such asymmetry could assist with the diagnosis and follow up. Various asymmetry indices have been proposed to compare the spatiotemporal, kinematic and kinetic parameters of lower limbs during the gait cycle. One, the Continuous Relative Phase [3] compares the joints angle and its derivatives to assess the gait asymmetry during the gait cycle. However, the indices rely on marker based gait measurement systems that are costly and generally require manual examination, calibration procedures and the precise placement of sensors/markers on the body of the patient. To overcome these issues, a new asymmetry index was proposed in [4]. It uses an inexpensive, easy-to-use and markerless depth camera (Microsoft Kinect™) output. Without requiring joint localization, it directly uses depth images provided by the Kinect™. It is based on the longitudinal spatial difference between lower-limb movements averaged during several gait cycles. To evaluate the relevance of this index ILong, its sensitivity versus the position of the sensor and the sensitivity versus the number of gait cycle, fifteen healthy subjects were tested on a treadmill walking normally and with an artificially induced gait asymmetry created by placing a thick sole under one shoe. The gait movement was simultaneously recorded using two Kinects™, one placed in front of and another behind the subject, and a motion capture system. The Continuous Relative Phase computed with the Kinect™ skeleton failed to assess gait asymmetry. With the Kinect™ placed in front of and behind the patient the proposed longitudinal index distinguished the asymmetrical gait (p<0.001). Moreover, the correlation coefficient between the index measured by Kinect™ and the ground truth of this index measured by motion capture is more than .85 when using one stride and reaches .90 when using at least five strides. This gait asymmetry index measured with a Kinect™ is low cost, easy to use and is a promising development for clinical gait analysis for Osteoarthritis disease diagnostic and follow up

In the field of hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the WALANT method. We seek to investigate the degree of patient satisfaction, out of pocket cost, convenience and comfort experienced with in-office hand procedures. A ten question survey consisting of a ten-point Likert scale of agreement and questions asking for a numerical answer was administered via phone call to 33 patients treated with minor hand operations in the office setting in the United States. There were 18 male and 15 female respondents with an average age of 65.59±12.64 years. Respondents underwent procedures including trigger finger release (18), needle aponeurotomy (7), and other minor hand operations. Survey responses indicated strong agreement with questions 1-3 and 6–8, with responses averaging 9.60±0.23 in these positive metrics. Questions 4 and 5, which asked whether the surgery and recovery period were painful, respectively, averaged 2.65±0.49, indicating a mild level of disagreement that either was “painful”. Additionally, most patients responded that they did not take time off work (12) or are not currently employed (11). Other respondents (3) reported taking between one to five days off work post-operatively. 27 respondents also reported an out of pocket cost averaging $382±$976, depending on insurance coverage. Patients reported a small degree of pain in the operative and post-operative period, a high degree of comfort and convenience and a high degree of satisfaction. Likewise, the patient-reported out of pocket cost was far lower than comparable surgical costs in alternate settings. These results support the use of in-office procedures for minor hand surgeries from a patient perspective and indicate a nearly universal intent to repeat any future hand operations in the office setting

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility. IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm. We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime. IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation

Abstract. Background. Post operative radiographs following total joint arthroplasty are requested as part of routine follow up in many institutions. These studies have a significant cost to the local departments, in terms of financial and clinic resources, however, previous research has suggested they may not alter the course of the patients treatment. The purpose of this study was to assess the significance of elective post operative radiographs on changes in management of patients who underwent total joint arthroplasty. Method. All patients who underwent total knee arthroplasty and total hip arthroplasty at a District General Hospital from 2019 to 2020 were included. Data was collected retrospectively from medical records and radiograph requests. Alterations to clinical management based on radiographic findings were reviewed in clinic letters. Results. A total of 227 Total joint arthroplasty were retrieved. With 111(49%) total hip arthroplasty and 116 (51%) total knee arthroplasty. 54 were excluded due to having no clinical follow up and 173 met inclusion criteria. 56 (32%) had their post operative elective radiograph, while 93 (53.8%) patients had none. There were no abnormalities detected from the elective radiographs and none of the patients returned to the theatre. 24 patients (13%) presented with symptoms and had non-elective radiographs, 16 (67%) did not have any interventions and 8 (4.6%) required intervention and were taken to theatre. Discussion: Not performing these radiographs saves time, cost, and prevents unnecessary radiation exposure. In our institution, a 2-view joint radiograph costs £29 and takes roughly 15 minutes. This does not include indirect costs of additional clinic time and patient waiting time. In the larger context, the cost associated with elective radiographs is significant and our data suggests that routine post-operative radiographs are not beneficial as part of standard post-operative protocol for asymptomatic patients. However, performing imaging remains beneficial for patients who re-present with symptoms. Conclusion. Routine elective post-operative joint radiographs did not detect any true abnormalities. Information from elective radiographs has no clinical significance and did not change management. Therefore, this study recommends that there is no rationale requesting elective post-operative joint radiographs. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

The tendency towards using inertial sensors for remote monitoring of the patients at home is increasing. One of the most important characteristics of the sensors is sampling rate. Higher sampling rate results in higher resolution of the sampled signal and lower amount of noise. However, higher sampling frequency comes with a cost. The main aim of our study was to determine the validity of measurements performed by low sampling frequency (12.5 Hz) accelerometers (SENS) in patients with knee osteoarthritis compared to standard sensor-based motion capture system (Xsens). We also determined the test-retest reliability of SENS accelerometers. Participants were patients with unilateral knee osteoarthritis. Gait analysis was performed simultaneously by using Xsens and SENS sensors during two repetitions of over-ground walking at a self-selected speed. Gait data from Xsens were used as an input for AnyBody musculoskeletal modeling software to measure the accelerations at the exact location of two defined virtual sensors in the model (VirtualSENS). After preprocessing, the signals from SENS and VirtualSENS were compared in different coordinate axes in time and frequency domains. ICC for SENS data from first and second trials were calculated to assess the repeatability of the measurements. We included 32 patients (18 females) with median age 70.1[48.1 – 85.4]. Mean height and weight of the patients were 173.2 ± 9.6 cm and 84.2 ± 14.7 kg respectively. The correlation between accelerations in time domain measured by SENS and VirtualSENS in different axes was r = 0.94 in y-axis (anteroposterior), r = 0.91 in x-axis (vertical), r = 0.83 in z-axis (mediolateral), and r = 0.89 for the magnitude vector. In frequency domain, the value and the power of fundamental frequencies (F. 0. ) of SENS and VirtualSENS signals demonstrated strong correlation (r = 0.98 and r = 0.99 respectively). The result of test-retest evaluation showed excellent repeatability for acceleration measurement by SENS sensors. ICC was between 0.89 to 0.94 for different coordinate axes. Low sampling frequency accelerometers can provide valid and reliable measurements especially for home monitoring of the patients, in which handling big data and sensors cost and battery lifetime are among important issues

Although remnant-preserved ACL reconstruction (ACLR) restores knee joint stability and dampens the problem of acute ACL rupture-induced knee pain, an increasing number of patients still develop post-traumatic osteoarthritis (PTOA) after 10 to 15 years of ACLR. We previously found that remnant-preserved ACLR with concomitant medial and lateral meniscus repair may not prevent cartilage degeneration and weaken muscle strength, while the clinical features of PTOA are not clear. We hypothesized that remnant-preserved ACLR with concomitant medial and lateral meniscus tears is related to early cartilage damage, worse function recovery, patient-reported outcomes (PROs) and delayed duration to return to sports. The aim is to evaluate the remnant-preserved ACLR with complicated meniscal injuries in predicting which patients are at higher risk of osteoarthritic changes, worse function and limited activities after ACLR for 12 months. Human ethical issue was approved by a committee from Xi'an Jiaotong University. 26 young and active patients (24 male, 2 female) with ACL injuries (Sherman type I and II) with concomitant medial and lateral meniscus within 2 months were included from January 2014 to March 2022. The average age of the ACLR+ meniscus repair was 26.77±1.52 (8 right, 5 left) and isolated ACLR control was 31.92±2.61 years old (7 left, 6 right). Remnant-preserved ACLR with a 5- to 6-strand hamstring tendon graft was operated on by the same sports medicine specialists. MRI CUBE-T. 2. scanning with 48 channels was conducted by a professional radiologist. The volume of the ACL graft was created through 3 dimensional MRI model (Mimics 19, Ann Arbor). Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS) was applied to score visible cartilage damage. IKDC 2000 score and VAS were assessed by two blinded researchers. Results were presented as mean± SEM of each group. The cross-sectional area and 3D volume of the ACL graft were greater in the remnant-preserved ACLR+meniscus group compared with isolated ACLR (p=0.01). It showed that ACLR+ meniscus group had early signs of joint damage and delayed meniscus healing regarding ACLOAS compared to control group (p=0.045). MRI CUBE-T. 2. prediction of radiographic cartilage degeneration was not obvious in both groups post remnant-preserved ACLR over 12 months (p>0.05). However, higher VAS scores, lower IKDC scores, and long-last joint swelling were reported in the ACLR+ meniscus repair group at the end of 12 months follow-up. Although remnant-preserved ACLR+ meniscus was able to maintain the restore the knee function, it showed delayed timing (>12 months) to return to play at the pre-injury stage, while no difference between the timing of returning to the normal daily routine of their ACLR knee compared to control (p=0.30). The cost of ACLR+ meniscus (average 10,520.76$) was higher than the control group (6,452.92$, p=0.018). Remnants-preserved ACLR with concomitant injured medial and lateral meniscus repair shows a higher risk of cartilage damage, greater cost, worse functional performance, and longer time for young male patients to return to sports after 12-month follow-up compared to isolated ACLR. Further evidence and long-term follow-up are needed to better understand the association between these results and the risk of development of PTOA in this patient cohort

Introduction and Objective. Total knee arthroplasty (TKA) is a frequently and increasingly performed surgery in the treatment of disabling knee osteoarthritis. The rising number of procedures and related revisions pose an increasing economic burden on health care systems. In an attempt to lower the revision rate due to component malalignment and soft tissue imbalance in TKA, robotic assistance (RA) has been introduced in the operating theatre. The primary objective of this study is to provide the results of a theoretical, preliminary cost-effectiveness analysis of RA TKA. Materials and Methods. A Markov state-transition model was designed to model the health status of sixty-seven-year-old patients in need of TKA due to primary osteoarthritis over a twenty-year period following their knee joint replacement. Transitional probabilities and independent variables were extracted from existing literature. Patients’ state in the transition model was able to change on an annual basis. The main differences between the conventional and RA TKA were the outlier rate in the coronal plane and the cost of the procedure. In RA TKA, it was hypothesized that there were lower revision rates due to a lower outlier rate compared to conventional TKA. Results. The value attributed to the utility both for primary and revision surgery has the biggest impact on the ICER, followed by the rate of successful primary surgery and the cost of RA-technology. Only 2.18–2.34% of the samples yielded from the probabilistic sensitivity analysis proved to be cost-effective (threshold set at $50000/QALY). A calculated surgical volume of at least 191–253 cases per robot per year is needed to prove cost-effective taking the predetermined parameter values into account. Conclusions. Robot-assisted TKA might be a cost-effective procedure compared to conventional TKA if a minimum of 191 cases are performed on a yearly basis, depending on the cost of the robot. The cost-benefit of the robotic TKA surgery is mainly based on a decreased revision rate. This study is based on the assumption that alignment is a predictor of success in total knee arthroplasty. Until there is data confirming the assertion that alignment predicts success robot-assisted surgery cannot be recommended

The biological understanding for the disease progression osteoarthritis (OA) has uncovered specific biomarkers from either synovial fluid, articular chondrocytes or synoviocytes that can be used to diagnose the disease. Examples of these biomarkers include interleukin-1β (IL-1β) or collagen II fragments (1, 2). In parallel, isolation of chondrocytes or bone marrow derived mesenchymal stromal cells (MSCs) has yielded cell-based strategies that have shown long- term beneficial effects in a specific cohort of patients, specifically in traumatic cartilage lesions (2). This latter finding shows that patient stratification of OA is an important tool to both match patients for a specific treatment and to develop novel therapies, especially disease modifying drugs. In order to create disease stage specific therapies, the use of next generation analysis tools such as RNAseq and metabolomics, has the potential to decipher specific cellular and molecular endotypes. Alongside greater understanding of the clinical phenotype (e.g. imaging, pain, co- morbidities), therapies can be designed to alleviate the symptoms of OA at specific points of the disease in patients. This talk will outline the current biological understanding of OA and discuss how patient stratification could assist in the design of innovative therapies for the disease. Acknowledgements: This presentation was supported by the COST action, CA21110 – Building an open European Network on Osteoarthritis Research (NetwOArk)

Osteosarcoma is a highly malignant primary tumor of bone tissue. The 5-year survival rate of patients with metastasis is below 20% and this scenario is unchanged in the last two decades, despite great efforts in pre-clinical and clinical research. Traditional preclinical models of osteosarcoma do not consider the whole complexity of its microenvironment, leading to poor correlation between in vitro/in vivo results and clinical outcomes. Spheroids are a promising in vitro model to mimic osteosarcoma and perform drug-screening tests, as they (i) reproduce the microarchitecture of the tumor, (ii) are characterized by hypoxic regions and necrotic core as the in vivo tumor, (iii) and recapitulate the chemo-resistance phenomena. However, to date, the spheroid model is scarcely used in osteosarcoma research. Our aim is to develop a customized culture dish to grow and characterize spheroids and to perform advanced drug-screening tests. The resulting platform must be adapted to automated image acquisition systems, to overcome the drawbacks of commercial spheroids platforms. To this purpose, we designed and developed a micro-patterned culture dish by casting agarose on a 3D printed mold from a CAD design. We successfully obtained viable and reproducible homotypic osteosarcoma spheroids, with two different cells lines from osteosarcoma (i.e., 143b and MG-63). Using the platform, we performed viability assays and live fluorescent stainings (e.g., Calcein AM) with low reagent consumption. Moreover, the culture dish was validated as drug screening platform, administrating Doxorubicin at different doses, and evaluating its effect on OS spheroids, in terms of morphology and viability. This platform can be considered an attractive alternative to the highly expensive commercial spheroid platforms to obtain homogeneous and reproducible spheroids in a high-throughput and cost effective mode

Knee pain is common, representing a significant socioeconomic burden. Caused by a variety of pathologies, its evaluation in primary-care is challenging. Subsequently, an over-reliance on magnetic resonance imaging (MRI) exists. Prior to orthopaedic surgeon referral, many patients receive no, or incorrect, imaging. Electronic-triage (e-triage) tools represent an innovative solution to address this problem. The primary aim of this study was to ascertain whether an e-triage tool is capable of outperforming existing clinical pathways to determine the correct pre-hospital imaging based on knee pain diagnosis. Patients ≥18 years with a new presentation of knee pain were retrospectively identified. The timing and appropriateness of imaging was assessed. A symptom-based e-triage tool was developed, using the Amazon LEXbotplatform, and piloted to predict five common knee pathologies and suggest appropriate imaging. 1462 patients were identified. 17% of arthroplasty patients received an ‘unnecessary MRI’, whilst 28% of arthroscopy patients did not have a ‘necessary MRI’, thus requiring a follow-up appointment, with a mean delay of three months (SD 2.6, range 0.2-20.2). Using NHS tariffs, a wasted cost through unnecessary/necessary MRIs and subsequent follow-up appointments was estimated at £45,816. The e-triage pilot was trialled with 41 patients (mean age:58.4 years, 58.5% female). Preliminary diagnoses were available for 34 patients. Using the highest proportion of reported symptoms in the corresponding group, the e-triage tool correctly identified three of the four knee pathologies. The e-triage tool did not correctly identify anterior cruciate ligament injuries (n=3). 79.2% of participants would use the tool again. A significant number of knee pathology patients received incorrect imaging prior to their initial hospital appointment, incurring delays and unnecessary costs. A symptom-based e-triage tool was developed, with promising pilot data and user feedback. With refinement, this tool has the potential to improve wait-times and referral quality, whilst reducing costs

Gait analysis is an indispensable tool for scientific assessment and treatment of individuals whose ability to walk is impaired. The high cost of installation and operation are a major limitation for wide-spread use in clinical routine. Advances in Artificial Intelligence (AI) could significantly reduce the required instrumentation. A mobile phone could be all equipment necessary for 3D gait analysis. MediaPipe Pose provided by Google Research is such a Machine Learning approach for human body tracking from monocular RGB video frames that is detecting 3D-landmarks of the human body. Aim of this study was to analyze the accuracy of gait phase detection based on the joint landmarks identified by the AI system. Motion data from 10 healthy volunteers walking on a treadmill with a fixed speed of 4.5km/h (Callis, Sprintex, Germany) was sampled with a mobile phone (iPhone SE 2nd Generation, Apple). The video was processed with Mediapipe Pose (Version 0.9.1.0) using custom python software. Gait phases (Initial Contact - IC and Toe Off - TO) were detected from the angular velocities of the lower legs. For the determination of ground truth, the movement was simultaneously recorded with the AS-200 System (LaiTronic GmbH, Innsbruck, Austria). The number of detected strides, the error in IC detection and stance phase duration was calculated. In total, 1692 strides were detected from the reference system during the trials from which the AI-system identified 679 strides. The absolute mean error (AME) in IC detection was 39.3 ± 36.6 ms while the AME for stance duration was 187.6 ± 140 ms. Landmark detection is a challenging task for the AI-system as can clearly be seen be the rate of only 40% detected strides. As mentioned by Fadillioglu et al., error in TO-detection is higher than in IC-detection

Pre-operative anaemia can present in up to 30% of elective arthroplasty patients. The presence of anaemia increases the risk of requiring blood transfusion post-operatively as well as acts as an independent risk factor for poor outcome such as prosthetic joint infection. Recent international consensus on this topic has recommended a specific care pathway for screening patients with pre-operative anaemia using a simple bedside Heaemacue finger-prick test to detect in a simple and cost-effective manner, and then allow treatment of preoperative anaemia. This pathway was therefore incorporated in our trust. This was a retrospective study done at a single tertiary-referral arthroplasty centre. Our data collection included the Heamacue test results and formal haemoglobin levels if they were performed as well as compliance and costs of each of the tests for patients listed for an elective shoulder, hip and knee arthroplasty between September and December 2018. Medical records and demographics were also collected for these patients for subgroup analysis. Our exclusion criteria comprised patients listed for revision arthroplasty surgery. 87 patients were included in this study. Our compliance rate was 15%. The mean difference between a Haemacue test and a formal FBC result was only 17.6g/L suggesting that it has a reasonably high accuracy. With regards to costs, we found that a Haemacue test costs £2, compared to £7.50 for a full blood count and Haematinics combined. This gave an overall cost saving of £5.50 per patient. Extrapolation of this date locally for 2017 at our hospital, where 1575 primary joint arthroplasties were done, a cost saving of £8,662.5 could have been achieved. Within the UK using data extrapolated from the National Joint Registry a total of £1,102,205.5 (1,221,894 Euros) could have been saved. The use of a single, Haemacue test to screen for pre-operative anaemia in elective arthroplasty patients is more cost effective compared to a formal full count and haematinics tests. However, we found that compliance with the care pathway is variable due to system limitations. This may be addressed through implementing changes to our electronic system in which patients are booked for surgery. We also noted a significant cost reduction if this pathway were to be used Nation-wide. Thus, we encourage other centres to consider the use of the Haemacue test pre-operatively in elective arthroplasty instead of formal full blood counts at the time of decision to treat with arthroplasty; this allows sufficient time for correction of pre-operative anaemia thus improving patient outcomes from arthroplasty

Introduction. Patients (2.7M in EU) with positive cancer prognosis frequently develop metastases (≈1M) in their remaining lifetime. In 30-70% cases, metastases affect the spine, reducing the strength of the affected vertebrae. Fractures occur in ≈30% patients. Clinicians must choose between leaving the patient exposed to a high fracture risk (with dramatic consequences) and operating to stabilise the spine (exposing patients to unnecessary surgeries). Currently, surgeons rely on their sole experience. This often results in to under- or over-treatment. The standard-of-care are scoring systems (e.g. Spine Instability Neoplastic Score) based on medical images, with little consideration of the spine biomechanics, and of the structure of the vertebrae involved. Such scoring systems fail to provide clear indications in ≈60% patients. Method. The HEU-funded METASTRA project is implemented by biomechanicians, modellers, clinicians, experts in verification, validation, uncertainty quantification and certification from 15 partners across Europe. METASTRA aims to improve the stratification of patients with vertebral metastases evaluating their risk of fracture by developing dedicated reliable computational models based on Explainable Artificial Intelligence (AI) and on personalised Physiology-based biomechanical (VPH) models. Result. The METASTRA-AI model is expected to be able to stratify most patients with limited effort end cost, based on parameters extracted semi-automatically from the medical files and images. The cases which are not reliably stratified through the AI model, are examined through a more detailed and personalised biomechanical VPH model. These METASTRA numerical tools are trained through an unprecedentedly large multicentric retrospective study (2000 cases) and validated against biomechanical ex vivo experiments (120 specimens). Conclusion. The METASTRA decision support system is tested in a multicentric prospective observational study (200 patients). The METASTRA approach is expected to cut down the indeterminate diagnoses from the current 60% down to 20% of cases. METASTRA project funded by the European Union, HEU topic HLTH-2022-12-01, grant 101080135