This study is a prospective analysis of clinical outcome in 201 consecutive patients treated with medial patellofemoral ligament reconstruction using an autologous semitendinosus graft between October 2005 and January 2011. Patients received pre and post-operative clinical evaluation, radiological assessment and outcome scoring systems. 193 patients (92 male, 119 female) underwent 211 procedures, with mean age 26 (16–49) and follow-up 16 months (6–42 months). Indications were atraumatic recurrent patella dislocation (68%), traumatic recurrent dislocation (22.8%), instability (5%), single dislocation (2.7%) and anterior knee pain (1.4%). Trochlea dysplasia was moderate in 57% and mild in 35%. There have been no recurrent dislocations/ subluxations. 10 patients have required further surgery. The mean pre-op Kujala Scores were 55 (SE 5.21) and post-op scores improved to mean 82 (31–100) (SE 1.18)(p < 0.001). This improvement and significance is mirrored with Oxford (27 to 41), WOMAC (76 to 93), Fulkerson (53 to 83), IKDC (46 to 75), Tegner (4.1 to 5.3) and SF12 (38 to 51) scores (p < 0.005). 93% of patients were satisfied with their operation. History of prior realignment surgery was associated with significantly worse outcomes compared to patients where MPFL reconstruction was their first realignment procedure (p < 0.05). This series is the largest reported in the literature for any technique of MPFL surgery. This technique allows for objective intra-operative evaluation of the required graft tension to optimise patella tracking

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect. A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score. There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05). The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score

Introduction. LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children with Lower limb differences (LLDs). The objective is to conduct an international field test study. Materials & Methods. A mixed method multiphase approach was used to develop LIMB-Q Kids. In phase one, a systematic review was conducted to identify concepts from existing PROMs used in research with children with LLDs. A preliminary conceptual framework derived from the systematic review informed an international qualitative study. The data from qualitative interviews were used to form the LIMB-Q Kids, which was further refined through multiple rounds of cognitive debriefing interviews with children. Input was obtained from parents and healthcare professionals from Australia, Canada, Ethiopia, India, UK, and the USA. LIMB-Q Kids was translated and culturally adapted into multiple languages. Results. The final field-test version consists of 11 scales (159 items) that measure appearance, physical function, symptoms (hip, knee, ankle, foot, and leg), leg-related distress, and school, social and psychological function. This version was rigorously translated into Danish and German. Translations that are in progress include Arabic, Finnish, Hindi, Swahili, Portuguese, Spanish, and Luganda. An international field-test study is underway in nine countries (15 sites with a target recruitment of 150 participants per country). At the time of abstract submission, 190 patients from seven sites have completed LIMB-Q Kids. The UK collaborative has worked on language adaption for the UK and is currently validating the score across five paediatric limb reconstruction units. Conclusions. No internationally applicable PROM exists for children with LLDs. We present the current progress in developing and validating such a score. Data from the international field-test study will be used to reduce items and perform psychometric testing of LIMB-Q Kids. The rigorous translation and cultural adaption process will provide versions of LIMB-Q Kids in different languages. Once completed, the LIMB-Q Kids will provide a common metric for outcome assessment for children with lower limb differences internationally

Lisfranc injuries account for 0.2% of all fractures and have been linked to poorer functional outcomes, in particular resulting in post-traumatic arthritis, midfoot collapse and chronic pain. This study assesses the longitudinal functional outcomes in patients with low and high energy Lisfranc injuries treated both operatively and non-operatively. Patients above 16 years with Lisfranc injuries from January 2008 and December 2017 were identified through the Victorian Orthopaedic Trauma Outcomes (VOTOR) registry. Follow-up performed at 6, 12 and 24 months through telephone interviews with response rate of 86.1%, 84.2% and 76.2% respectively. Longitudinal functional outcome data using Global Outcome Assessment, EQ-5D-5L, numerical pain scale, Short-Form 12, the WHO Disability Assessment Schedule and return to work status were collected. Univariate analysis was performed and variables showing a significant difference between groups (p < 0.25) were analysed with multivariable mixed effects regression model. 745 patients included in this retrospective cohort study. At 24 months, both the operative and non-operative groups demonstrated similar functional outcomes trending towards an improvement. Mixed effect regression models for the EQ items for mobility (OR 1.80, CI 0.91 – 3.57), self-care (OR 1.95, 95% CI 1.09-3.49), usual activities (OR 1.10, 95% CI 0.99-1.03), pain (OR 1.07, 95% CI 0.61-1.89), anxiety (OR 1.29, 95% CI 0.72-2.34) and pain scale (OR 1.07, 95% CI 0.51 – 2.22) and return to work (OR 1.28, 95% CI 0.56-2.91) between groups were very similar and not statistically significantly different. We concluded that there was no statistically significant difference between operative and non-operative patients with low and high energy Lisfranc injuries. Current clinical practices in Lisfranc injury management are appropriate and not inadvertently causing any further harm to patients. Future research comparing fracture patterns, fixation types and corresponding functional outcomes can help determine gold standard Lisfranc injury management

Aim. This is the first study to directly compare the clinical outcome of debridement, antimicrobials and implant retention (DAIR) with stabilization using new internal fixation after debridement, for patients with Fracture-related Infection (FRI). Method. Consecutive patients with FRI Consensus confirmed FRI had single-stage surgery with tissue sampling, debridement, stabilization, antimicrobial therapy and skin closure. All cases had FRIs which were unhealed at surgery. When existing implants were stable, the implant was retained but loose implants or fractures with poor reduction had implant removal and refixation with new implants. All patients had the same empiric and definitive antibiotics, the same diagnostic criteria and outcome assessment at least one year after surgery. Failure was defined as infection recurrence, reoperation or lack of fracture consolidation at one year. Results. Seventy-one patients were studied (40 DAIRs and 31 new implants, including 10 exchange nails). The two groups were well matched for age, duration of infection, BACH complexity, microbiology, bone involved and need for flap coverage. Ten patients (13.7%) died before the endpoint. Mortality was similar in both groups (DAIR 14.1% vs New Metalware 12.9%; p=0.801) but DAIR of IM nails had a higher mortality at 40% (p=0.011). Sixty-one patients were followed-up for a mean of 3.32 years (1.04-9.43). Infection was eradicated in 23/34 (67.6%) DAIR patients and 24/27 (88.9%) with new metalware (p=0.049). Overall rates of infection-free union were similar in both groups (58.8% vs 77.8%; p=0.117). DAIR of plates had significantly fewer infection-free unions compared to removal and implantation of new plates (DAIR 57.1% vs NM 91.7%; p=0.033). Conclusion. Implantation of new metalware had better eradication of infection and a strong trend towards better union rates. Treating FRI with retained or new metalware had a substantial mortality (13.7%). Choosing DAIR did not reduce this mortality and these patients more often required further surgery to treat residual infection and secure union

Abstract. Aims. Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods. Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results. 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal technique were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion. Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures

Introduction. External fixators are attached to bones with percutaneous pins and wires inserted through soft tissues and bone increasing the risk of infections. Such infections compromise patient outcomes e.g., through pin loosening or loss, failure of fixator to stabilise the fracture, additional surgery, increased pain, and delayed mobilisation. These infections also impact the healthcare system for example, increased OPD visits, hospitalisations, treatments, surgeries and costs. Nurses have a responsibility in the care and management of patients with external fixators and ultimately in the prevention of pin-site infection. Yet, evidence on best practices in the prevention of pin-site infection is limited and variation in pin-site management practices is evident. Various strategies are used for the prevention of pin-site infection including the use of different types of non-medicated and medicated wound dressings. The aim of this retrospective study was to investigate the use of dry gauze or iodine tulle dressings for the prevention of pin-site infections in patients with lower limb external fixators. Methodology. A retrospective study of patients with lower limb external fixators who attended the research site between 2015–2022. Setting & Sample: The setting was the outpatient's (OPD) orthopaedic clinic in a University Teaching Hospital in Dublin, Ireland. Eligibility Criteria:. Over the age of 16, treated with an Ilizarov, Taylor Spatial frame (TSF) or Limb Reconstruction System (LRS) external fixators on lower limbs,. Pin-sites dressed with dry gauze or iodine tulle,. Those with pre-existing infected wounds close to the pin site and/or were on long term antibiotics were excluded. Follow Up Period: From time of external fixator application to first pin-site infection or removal of external fixator. Outcome Assessment: The primary outcome was pin-site infection, secondary outcomes included but were not limited to frequency of pin-site infection according to types of bone fixation, frequency of pin/wire removal and hospitalisation due to infection. Data analysis: IBM SPSS Version 25 was used for statistical analysis. Descriptive and inferential statistics were conducted as appropriate. Categorical data were analysed by counting the frequencies (number and percentages) of participants with an event as opposed to counting the number of episodes for each event. Differences between groups were analysed using Chi-square test or Fisher's exact test, where appropriate. Continuous variables were reported using mean and standard deviations and difference analysed using a two-sample independent t-test or non-parametric test (Mann-Whitney), where appropriate. Using Kaplan-Meier, survival analysis explored time to development of infection. Ethical approval: granted by local institute Research Ethics Committee on 12th March 2018. Results. During the study period, 97 lower limb external fixators were applied with 43 patients meeting the study eligibility criteria. The mean age was 38 (SD 14.1; median 37) and the majority male (n=32, 74%). At least 50% (n=25) of participants had an IIizarov fixator, with 56% (n=24) of all fixators applied to the tibia and fibula. Pin/wire sites were dressed using iodine (n=26, 61%) or dry gauze dressings (n=15, 35%). The mean age of participants in the iodine group was significantly higher than the dry gauze group (p=.012). The only significant difference between the iodine and dry gauze dressing groups at baseline was age. A total of 30 (70%) participants developed a pin-site infection with 26% (n=11) classified as grade 2 infection. Clinical presentation included redness (n=18, 42%), discharge (n=16, 37%) and pain (n=15, 35%). Over half of participants were prescribed oral antibiotics (n=28, 65%); one required intravenous antibiotics and hospitalization due to pin-site infection. Ten (23%) participants required removal of pin/wires; two due to pin-site infection. There was no association between baseline data and pin-site infection. The median time to developing an infection was 7 weeks (95%, CI 2.7 to 11.29). Overall, there were 21 (81%, n=26) pin-site infections in the iodine group and nine (60%, n=15) in the dry gauze group, difference in proportion and relative risk between the dressing groups were not statistically significant (RR 1.35, 95% CI 0.86–2.12; p= .272). There was no association between baseline data, pin-site infection, and type of dressing. Conclusions. At the research site, patients are referred to the OPD orthopaedic clinic from internal and external clinical sites e.g., from Hospital Consultants, General Practitioners and occasionally from multidisciplinary teams, throughout Ireland. Our retrospective observation study found that 97 lower limb external fixators were applied over a seven-year period which is lower than that reported in the literature. However, the study period included the COVID pandemic years (2020 and 2021) which saw a lower number of external fixators applied due to lack of theatre availability, cancelled admissions and social/travel restrictions that resulted in fewer accidents and lower limb trauma cases requiring external fixator application. The study highlighted a high infection rate with 70% of participants developing pin-site infection which is in keeping with findings reporting in other studies. Our study showed that neither an iodine nor dry gauze dressing was successful in preventing pin-site infection. In the iodine group 81% of participants developed infection compared to 60% in the dry gauze group. Given the lack of difference between the two groups consideration needs to be given to the continued use of iodine dressings in the prevention of pin-site infection. Pin-site infections result in a high portion of participants being prescribed antibiotics and, in an era, that stresses the importance of antimicrobial stewardship there is a need to implement effective infection prevention and control strategies that minimise infection. Further research is therefore needed to investigate more innovative medicated dressings such as those that contain anti-microbial or anti-bacterial agents

A reverse total shoulder arthroplasty (RSA) is frequently performed in the revision setting. The purpose of this study was to report the clinical outcomes and complication rates following revision RSA (RRSA) stratified according to the primary shoulder procedure undergoing revision, including failed hemiarthroplasty (HA), anatomic total shoulder arthroplasty (TSA), RSA, soft tissue repair (i.e., rotator cuff repair), and open reduction internal fixation (ORIF). A systematic review of the literature was performed using four databases (EMBASE, Medline, SportDISCUS, and Cochrane Controlled Trials Register) between January 1985 and September 2017. The primary outcomes of interest included active range-of-motion (ROM), pain, and functional outcome measures including the American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), and Constant-Murley (CS) Score. Secondary outcomes included complication rates, such as infection, dislocation, perioperative fracture, base plate failure, neurovascular injury, soft tissue injury, and radiological evidence of scapular notching. Clinical outcome data was assessed for differences between preoperative and postoperative results and complication results were reported as pooled complication rates. Forty-five studies met the inclusion criteria for analysis, which included 1,016 shoulder arthroplasties with a mean follow-up of 45.2 months (range, 31.1 to 57.2 months) (Fig. 1). The mean patient age at revision was 60.2 years (range, 36 to 65.2 years). Overall, RSA as a revision procedure for failed HA revealed favorable outcomes with respect to forward elevation (FE), CS pain, ASES, SST, and CS outcome assessment scores, with mean improvements of 52.5° ± 21.8° (P = < 0 .001), 6.41 ± 4.01 SD (P = 0.031), 20.1 ± 21.5 (P = 0.02), 5.2 ± 8.7 (P = 0.008), and 30.7 ± 9.4 (P = < 0 .001), respectively. RSA performed as a revision procedure for failed TSA demonstrated an improvement in the CS outcome score (33.8 ± 12.4, P = 0.016). RSA performed as a revision procedure for failed soft tissue repair demonstrated significant improvements in FE (60.2° ± 21.2°, P = 0.031) and external rotation (20.8° ± 18°, P = 0.016), respectively. Lastly, RSA performed as a revision procedure for failed ORIF revealed favorable outcomes in FE (61° ± 20.2°, P = 0.031). There were no significant differences noted in RSA performed as a revision procedure for failed RSA, or when performed for a failed TSA, soft tissue repair, and ORIF in any other outcome of interest. Pooled complication rates were found to be highest in failed RSA (10.9%), followed by soft tissue repair (7.1%), HA (6.8%), TSA (5.4%) and ORIF (4.7%). When compared to other revision indications, RRSA for failed HA demonstrated the most favorable outcomes, with significant improvements in ROM, pain, and in several outcome assessments. Complication rates were determined and stratified as per the index procedure undergoing RRSA, patients undergoing revision of a failed RSA were found to have the highest complication rates. With this additional information, orthopaedic surgeons will be better equipped to provide preoperative education regarding the risks, benefits and complication rates to those patients undergoing a RRSA. For any figures or tables, please contact authors directly

Total joint replacement (TJR) is by far the most effective therapy for end-stage OA patients. Most of patients achieve joint pain reduction and function improvement following to TJR, however up to 22% of them either do not improve or deteriorate after surgery. The aim of this study was to identify genetic variants to be associated with poor outcome of TJR in primary OA patients by a genome-wide association approach (GWAS). Study participants were primary OA patients from the Newfoundland Osteoarthritis Study (NFOAS) that comprised total knee or hip replacement and recruited before 2016 in St. John's, NL. DNA samples were extracted from patients' blood. Study participants completed their pre-operation and 3.99±1.38 years post-surgery outcome assessment using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). DNA samples were genotyped using the genome-wide Illumina HumanOmni2.58 genotyping microarray containing 2.4 million SNPs. Pre-association quality control filtering was conducted for the raw genotyping data using PLINK 1.7 program, and genotype imputation was performed using the IMPUTE2 algorithm with multiple population reference data from 1000 Genome Project. The imputed data with ∼3.1 million variants was used to test the association with non-responders to TJR using the additive genetic model. Eighty three primary OA patients (44 responders and 39 non-responders) were included in the analysis. Association analysis detected three chromosomal regions on chr5, 7, and 8 to be significantly associated with non-responding to pain. The top SNPs at these loci are intergenic variants that include SNP (rs17118094, p=4.4×10-5) on chr5. This SNP is adjacent to SGCD gene that plays an important role in muscular strength and maintenance. Another associated SNP (rs71572810, p=4.7×10-5) is nearby IMMP2L gene on chr7. This gene is reported to be associated with behavioral abnormalities. Finally, SNP (rs6992938, p=5.8×10-5) on chr8 is located downstream of TRPA1 gene that is known to have a central role in the pain response to endogenous inflammatory mediators. Three loci were also found to be significantly associated with non-responding to function. The lead variant in the locus on chr1 is an intergenic SNP (rs9729377, p=1.7×10-5) falling between CTBS and MCOLN2 genes. CTBS gene is associated with TNF-α, a cytokine that stimulate the inflammation acute phase reaction, and MCOLN2 gene plays a role in the chemokine secretion and macrophage migration in the innate immune response. Other top SNPs in loci on chr2 and 10 harbor CCDC93, INSIG2, and KLF6 genes that are associated with heel bone mineral density, hypercholesterolemia, obesity and BMI. To our knowledge, this project is the first study that investigated the association between genetic factors and TJR non-responders. Our results demonstrated that genes related to muscle strength, behavioral trait, pain response, and inflammation play a significant role in poor outcome of TJR, warranting further investigation

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Background. Locked anterior shoulders (LAS) with static instability and anterior glenoid bone loss are challenging in the elderly population. Reverse shoulder arthroplasty (RSA) has been employed in treating these patients. No study has compared RSA for LAS to classically indicated RSA. Methods. A case-control study of patients treated with RSA for LAS with glenoid bone loss and static instability was performed using matched controls treated with primary RSA for classic indications. Twenty-four cases and 48 controls were evaluated. Average follow-up was 25.5 months and median age was 76. Motion, outcome assessments, and postoperative radiographs were compared. Results. Preoperatively, LAS had significantly less rotation and lower baseline outcome scores. Glenoid bone grafting was more common (p=0.05) in control group (26%) than LAS group (6.3%). Larger glenospheres were utilized more often (p=0.001) in LAS group (75%) than control group (29%). Both groups demonstrated significant improvements in pain, function, and outcome scores. Postoperatively, control group had significantly better elevation and functional outcome scores. With the exception of flexion and SST, effectiveness of treatment was similar between groups. Postoperative acromion stress fractures were seen in 21% of LAS and 9% of control (p=0.023) with a predominance of type 3 fractures in LAS. Two LAS patients remained dislocated. Conclusion. Treatment with RSA for LAS may anticipate improvements in pain and function using larger glenospheres often without the need for glenoid bone grafting. Worse postoperative motion, function, and a higher incidence of acromion stress fracture may be expected

Femoroacetabular impingement (FAI) is a common cause of hip pain in the young adult. Uncertainty regarding surgical indications, outcome assessment, management preferences and perceptions of the literature exist. We conducted a large international survey assessing the perceptions and demographics of orthopaedic surgeons regarding FAI. A survey was developed using previous literature, focus groups and a sample-to-redundancy strategy. The survey contained forty-six questions and was emailed to national orthopaedic associations and orthopaedic sports medicine societies for member responses. Members were contacted on multiple occasions to increase response rates. Nine hundred orthopaedic surgeons from twenty national and international organisations completed the survey. Surgeons responded across 6 continents, 58.2 % from developed nations with 35.4 % having sports fellowship training. North American and European surgeons reported significantly greater exposure to hip arthroscopy during residency and fellowships in comparison to international respondents (48.0% vs. 44.5% vs. 25.6% respectively; p<0.001). Surgeons performing a higher volume of FAI surgery (over 100 cases per year) were significantly more likely to have practiced for more than 20 years (OR 1.91; 95% CI 1.01 to 3.63), be practicing at an academic hospital (OR 2.25; 95% CI 1.22 to 4.15), and have formal arthroscopy training (OR 46.17; 95% CI 20.28 to 105.15). High volume surgeons were over two-fold more likely to practice in North America and Europe (OR 2.26; 95% CI: 1.08 to 4.72). The exponential rise in the diagnosis and surgical management for FAI appears to be driven largely by experienced surgeons in developed nations. Our analysis suggests that although FAI management is early in the innovation cycle we are at a tipping point towards wider uptake and utilisation. The results of this survey will help guide further research and study

Introduction. The impact of prior ipsilateral shoulder surgery on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) is unknown. The purpose of this study was to determine the impact of prior shoulder surgery on patients undergoing TSA and RSA compared to patients without prior shoulder surgery. The hypothesis was that patients undergoing arthroplasty after prior ipsilateral shoulder surgery would have inferior outcomes with higher complication rates compared to patients undergoing arthroplasty without having undergone prior surgery. Materials and Methods. Seven-hundred fifteen consecutive patients undergoing TSA or RSA between 1/2010 and 5/2014 with a minimum 2-year follow-up were prospectively analyzed. All patients were evaluated with the American Shoulder and Elbow Society (ASES), Simple Shoulder Test (SST), Functional Score, Visual Analog Scale (VAS) outcomes assessments, as well as with physical examination including range of motion assessments. Outcomes in patients undergoing prior ipsilateral shoulder surgery (PS group) were compared to those in patients without history of prior surgery (NPS group). Statistical analysis was performed using one-way univariate and multivariate analysis of covariates (ANCOVA/MANCOVA) adjusting for age, Whitney-Mann U tests, and Chi-square or Fisher's exact test, with P<0.05 considered significant. Results. Of the 715 patients, 506 (263 TSA, 243 RSA) were available for analysis (71% follow-up rate). A total of 144 patients (29%) underwent an average of 2.0±1.1 ipsilateral shoulder surgeries, prior to arthroplasty while 362 (71%) did not undergo prior surgery. In the PS Group, rotator cuff repair (RCR) accounted for 67% of the prior surgeries. PS group patients were significantly younger at the time of arthroplasty compared to the NPS group (61.6±10.2 vs. 68.2±8.6 years, P=0.035). At an average follow-up of 42.8±16.4 months, both groups had significant improvements in ASES, SST, and VAS outcomes scores and range of motion values (P<0.05 for all). All outcomes scores in the PS group were significantly lower compared to the NPS group (P≤0.005 for all). Within the PS group, there were no significant differences detected in outcome scores or magnitudes of change in outcomes between patients undergoing RCR or any other procedure. There were 41 total complications (8.1%) and 17 total reoperations (3.4%) following shoulder arthroplasty, and there was a significantly higher rate of complications in the PS Group (18.1%) versus the NPS Group (4.1%, P<0.001). There were no significant differences between the PS and NPS groups with respect to the number of postoperative infections (P=0.679), reoperations (P=0.553), or transfusions (P=0.220). Conclusions. While patients who have undergone prior ipsilateral shoulder surgery derive benefit from shoulder arthroplasty, these patients are significantly younger, have significantly more complications, and their magnitude of improvement and final scores are significantly lower than patients without prior surgery. This information can be used to counsel this challenging patient population on expected outcomes following shoulder arthroplasty procedures

Background. Kinesiophobia is simply defined as a fear of movement and physical activity. It can be seen in patients as a result of any injury, which results in pain or a fear of injury recurrence. It leads to decreased motion and disuse that may result in a chronic pain syndrome and decreased physical function. High levels of fear-avoidance have been found in subjects with total knee arthroplasty (TKA) and knee injuries, which predisposes them to the development of chronic pain conditions and seriously affect functional outcomes and their return to previous activity levels. However, the relationship between pain, kinesiophobia and performance-based outcomes in assessment of patients with TKA is unclear. Purpose. The aim of our study was to investigate relationship between pain, kinesiophobia and performance-based tests in assessment of patients with TKA. Methods. Twenty-eight patients (10 males, 18 females) were included in the study with mean age 63.6±9.8 years. Patients performed 2 performance tests (Timed “Up & Go” Test (TUG), 10 Meter Walk Test (10-MWT)) and one self-report measurement (TAMPA Scale) which measure the kinesiophobia were preferred to assess patients. Also the activity pain level was evaluated by The Numeric Pain Rating Scale (NPRS). Patients were evaluated preoperatively and at discharge. Results. While there was a moderate significant correlation in preoperatively between activity NPRS and 10-MWT score (r=0.432, p=0.022), there was no correlation between activity NPRS and TUG (p>0.05). Also there were no correlations between TAMPA scale and 2 performance-based tests in preoperatively (p>0.05). There were high significant correlations between TAMPA scale and 2 performance-based tests (TUG, 10-MWT) in the evaluation of patients with TKA (respectively; r=0.899, p<0.001; r=0.608, p=0.001). However, there were no correlations between activity NPRS and 2 performance-based tests in postoperatively in patients with TKA. Conclusion. While there were high significant correlations between TAMPA scale and 2 performance-based tests, there were no correlations between activity NPRS and 2 performance-based tests in postoperatively in patients with TKA. The functional level at early stage after TKA may be more related with the kinesiophobia level than the activity pain level. Given these results suggest that the rehabilitation after TKA focused on reducing kinesiophobia level could be important to enhance the potential benefits of the patients' functional outcomes at early stage after TKA

Introduction. The goal of total hip arthroplasty (THA) is to reduce pain, restore function but also activity levels for general health benefits or social participation. Thus evaluating THA patient activity can be important for diagnosis, indication, outcome assessment or biofeedback. Methods. Physical activity (PA) of n=100 primary THA patients (age at surgery 63 ±8yrs; 49M/51F; 170 ±8cm, 79.8 ±14.0kg) was measured at 8 ±3yrs follow-up. A small 3D accelerometer was worn for 4 successive days during waking hours at the non-affected lateral upper leg. Data was analyzed using validated algorithms (Matlab) producing quantitative (e.g. #steps, #transfers, #walking bouts) and qualitative (e.g. cadence, temporal distribution of events) activity parameters. An age matched healthy control group (n=40, 69 ±8yrs, 22M/18F) served as reference. Results. Daily steps were only 13% lower (n.s) for patients (avg. ±SD: 5989 ±3127) than controls (6890 ±2803). However, the Nr. of walking bouts (187 ±85 vs 223 ±78, −16%) and sit-stand transfers (35 ±14 vs 48 ±15, −27%) were sign. less in patients (p<0.05, Mann-Whitney). Patients showed equal amounts of walking bouts in medium duration (30–60s, 1–5min) but sign. less (−25%) short (<10s, 10–30s) and less (−43%) long events (>5min). This corresponds with sign. less (−32%) short sitting periods (>10min) in patients. Also cadence was sign. lower in patients (93.8 ±11.7 vs 98.9 ±7.3 steps/min). Conclusions. PA varies widely in patients with a substantial proportion (35%) being more active than average controls. Thus, THA must not per se reduce or limit PA. Only 17% of controls and 11% of patients reached the WHO target (10,000 steps/day) suggesting that the THA related drop in activity may inflate the risks for cardiovascular, metabolic or mental disease associated with low activity. Patients avoided short and long activities, both associated with effort (transfers, fatigue) and walked more slowly. Targeted interventions may address this behaviour. Objective clinical outcome assessment must focus on these parameters and not, as commercial fitness trackers may imply, total step counts alone

To propose a national specification for hospitals which offer treatment of complex bone and joint infections to adults. Patients with bone and joint infections are treated in a wide variety of hospitals in the UK. A few have developed services with infection physicians, microbiology laboratory support and dedicated orthopaedic and plastic surgeons working together to deliver a multidisciplinary care pathway. However, many patients are treated in non-specialist units leading to multiple, often unsuccessful procedures with long hospital stays, high costs and additional pain and disability. Inappropriate antibiotic therapy without adequate surgery risks antibiotic resistance. A draft specification was written defining the types of patients who should be referred to a specialist unit for treatment. A description of the components which must be available to treat these cases (staffing, expertise, diagnostic support, outcome assessment and governance structure) was proposed. This draft was circulated to infection units in the UK for consideration and agreed with the Health Department in England. Complex bone and joint infections would be best served nationally by 3–6 networks, each with a single specialist centre. This is similar to national arrangements for bone sarcoma treatment. Patients to be referred will include those with:. Chronic osteomyelitis (long bone, pelvis, spine). Chronic destructive septic arthritis. Complex prosthetic joint infections (multiple co-morbidities, difficult/multi-resistant organisms, multiply operated or failed revision surgery). Infected fractures and non-unions. Specialist units should have:. Orthopaedic surgeons who specialise in infection (joint revision, Ilizarov techniques, etc). Infection physicians who can treat medically unwell patients with complex co-mordidities and multi-resistant infections. Plastic surgeons with experience in difficult microsurgical reconstruction techniques. Scheduled (at least weekly) meetings of all of the above, with a radiologist to discuss new referrals and complex cases. A home IV therapy service. Dedicated in-patient beds staffed by infection trained staff. Multi-disciplinary (one-stop) out-patient clinics. Quality measures assessed, including PROMS, clinical success rates, and functional outcome. Education and research programmes. This service specification is a tool for developing regional units. It facilitates the creation of designated centres in a national network (hub and spoke model). This service specification has been agreed and published by NHS England

The aim of this paper is to evaluate the Linvatec SE graft tensioner system in obtaining predictable initial tension during ACL reconstruction using hamstring grafts. The gracilis and semitendinosus grafts were tensioned individually prior to fixation distally to a combined tension of 80N. The knees were then cycled through full range of motion and the tension recorded at 90 degrees and in full flexion and extension. Experience on the first 22 patients indicated that 41% required 10 cycles of the knee to remove pre-conditioning and equalise tension at 80N combined, while the remaining 50% required 15 cycles. 90% reached stable tension after 15 cycles. In 54% the tension increased at full extension and graft tension was adjusted to 80N in extension to avoid overconstraining the graft. Twenty-two patients studied following this initial protocol underwent outcome assessment after minimum 6 months. Mean KT1000 arthrometry manual maximum side to side difference was 1.5mm. Femoral fixation was achieved using the Endobutton (Smith and Nephew) and Tibial fixation using the Extralok bioabsorbable screw (Linvatec). A subsequent shortened protocol of initial over-tensioning to 60N and 40N for the semitendinosus and gracilis double bundles respectively, followed by 15 cycles of the knee resulted in stable 80N combined tension with no further drop with more cycling. We conclude that the new tensioner system allows for accurate and predictable initial tension of hamstring reconstructed ACL grafts and that its use can be simplified by using the second technique protocol

Introduction. Many journals require outcome data at 2 years post-operative for the assessment of operative procedures in spinal surgery. This study seeks to clarify the timescale of improvement after surgery to see if a shorter period of assessment will indicate the final outcome. Methods. Outcome data for 185 consecutive patients who underwent spinal surgery was analysed. All were given a global outcome assessment questionnaire (as used in the Swedish Spinal Fusion study) at 6 months, 1 year and 2 years following surgery. Results were analysed according to the type of spinal surgery undertaken. Results. Six patients had incomplete data and were excluded. 124 of 179 patients were ‘much better’ or ‘better’ at 6 months. There was no significant change in the outcome of this group at 2 years (p<0.05). Only 18 showed any deterioration at 1 year and 2 years post surgery. Conclusion. Of the 55 patients who were ‘same’ or ‘worse’ at 6 months, most had no significant improvement in outcome at 2 years. Only 6 showed any significant improvement. Sixty four patients underwent disc replacement or spinal fusion. Of these, 19 patients improved between 6 months and 2 years follow-up. Eight patients got worse during the same period. Fifty eight patients underwent decompressive surgery. Of these 12 had a better outcome at 2 years than 6 months, and 17 had a worse outcome. Data from the remaining 57 patients was too heterogenous to analyse by subgroup

Methods. There were 106 men and 94 women (mean age 65 years; 22 - 85). 69 patients had inflammatory arthritis and 131 osteo-arthritis. 27 patients (13 B-P, 14 STAR) had a pre-operative varus/valgus deformity greater than or equal to 20 degrees. Mean follow-up was 48 months (36-72). Results. Ten patients had died from unrelated cause with satisfactory final outcome assessment. Thirteen ankles (4 STAR, 9 B-P) required revision surgery. The causes of failure were: early deep infection (1 STAR), recurrent deformity (1 STAR, 4BP) aseptic loosening (1STAR, 4 BP), implant failure (1STAR, 1 BP). Six revised ankles (5BP, 1STAR) had pre-operative varus/valgus deformity of 20 degrees or more. AOFAS score for pain improved from 0 to 35 and for function from 30 to 43. There was no difference between the two groups. Pre-operative range of movement was predictive of the final range of movement. Radiographic assessment showed that 30 patients (17BP, 13 STAR) had recurrent deformity (edge loading) as shown by the UHMWPE insert no longer articulating congruently with the metallic components. 14 ankles (8BP, 6 STAR) from this group had pre-operative deformity of 20 degrees or more. Conclusion. Patients with severe pre-operative deformity had a significant evidence of edge loading and failure resulting in revision surgery. BP replacements failed more frequently than STAR replacements but most BP failures were in ankles with severe pre-operative deformity

Aims

Bone demonstrates good healing capacity, with a variety of strategies being utilized to enhance this healing. One potential strategy that has been suggested is the use of stem cells to accelerate healing.