Reverse total shoulder arthroplasty (RTSA) is an increasingly common treatment for osteoarthritic shoulders with irreparable rotator cuff tears. Although very successful in alleviating pain and restoring some function, there is little objective information relating geometric changes imposed by the reverse shoulder and arm function, particularly the moment generating capacity of the shoulder muscles. Recent modeling studies of reverse shoulders have shown significant variation in deltoid muscle moment arms over a typical range of humeral offset locations in shoulders with RTSA. The goal of this study was to investigate the sensitivity of muscle moment arms as a function of varying the joint center and humeral offset in three representative RTSA subjects that spanned the anatomical range from our previous study cohort. We hypothesized there may exist a more beneficial joint implant placement, measured by muscle moment arms, compared to the actual surgical implant configuration. A 12 degree of freedom, subject-specific model was used to represent the shoulders of three patients with RTSA for whom fluoroscopic measurements of scapular and humeral kinematics during abduction had been obtained. The computer model used subject-specific in vivo abduction kinematics and systematically varied humeral offset locations over 1521 different perturbations from the surgical placement to determine moment arms for the anterior, lateral and posterior aspects of the deltoid muscle. The humeral offset was varied from its surgical position ±4 mm in the anterior/posterior direction, ±12mm in the medial/lateral direction, and −10 mm to 14 mm in the superior/inferior direction. The anterior deltoid moment arm varied up to 20 mm with humeral offset and center of rotation variations, primarily in the medial/lateral and superior/inferior directions. Similarly, the lateral deltoid moment arm demonstrated variations up to 20 mm, primarily with humeral offset changes in the medial/lateral and anterior/posterior directions. The posterior deltoid moment arm varied up to 15mm, primarily in early abduction, and was most sensitive to changes of the humeral offset in the superior/inferior direction. The goal of this study was to assess the sensitivity of the deltoid muscle moment arms as a function of joint configuration for existing RTSA subjects. High variations were found for all three deltoid components. Variation over the entire abduction arc was greatest in the anterior and lateral deltoid, while the posterior deltoid moment arm was mostly sensitive to humeral offset changes early in the abduction arc. Moment arm changes of 15–20 mm represent a significant amount of the total deltoid moment arm. This means there is an opportunity to dramatically change the deltoid moment arms through surgical placement of the joint center of rotation and humeral stem. Computational models of the shoulder may help surgeons optimize subject-specific placement of RTSA implants to provide the best possible muscle function, and assist implant designers to configure devices for the best overall performance

Reverse total shoulder arthroplasty (RTSA) is an increasingly common treatment for osteoarthritic shoulders with irreparable rotator cuff tears. Although very successful in alleviating pain and restoring some function there is little objective information relating geometric changes imposed by the reverse shoulder and the moment generating capacity of the shoulder muscles. Recent modeling studies of reverse shoulders have shown significant variation in deltoid muscle moment arms over varied joint centers for shoulders with RTSA. The goal of this study was to investigate the sensitivity of muscle moment arms as a function of varying the joint center in one representative RTSA subject. We hypothesized there may exist a more beneficial joint implant placement, measured by muscle moment arms, compared to the actual surgical implant placement. A 12 degree of freedom, subject-specific model was used to represent the shoulder of a patient with RTSA for whom fluoroscopic measurements of scapular and humeral kinematics during abduction had been obtained. The computer model used these abduction kinematics and systematically varied joint center locations over 1521 different perturbations from the surgical placement to determine moment arms for the anterior, lateral and posterior aspects of the deltoid muscle. The joint center was varied from its surgical position ±4 mm in the anterior/posterior direction, 0–24 mm in the medial/lateral direction, and −10 mm to 14 mm in the superior/inferior direction. The anterior deltoid moment arm varied up to 16mm with center of rotations variations, primarily in the medial/lateral and superior/inferior directions (Figure 2, Table 1(Figure 1)). Similarly, the lateral deltoid moment arm demonstrated variations up to 13 mm, primarily with joint center changes in the anterior/posterior and superior/inferior directions. The posterior deltoid moment arm varied up to 10mm, primarily in early abduction, and was most sensitive to changes of the joint center in demonstrated a sensitivity of 6 mm corresponding to variations in the superior/inferior directions (Figure 2). The goal of this study was to assess the sensitivity of the deltoid muscle moment arms as a function of joint configuration for an existing RTSA subject. High variations were found for all three deltoid components. Variation over the entire abduction arc was greatest in the anterior and lateral deltoid, while the posterior deltoid moment arm was mostly sensitive to joint center changes early in the abduction arc. Moment arm changes of 10–16mm represent a significant amount of the total deltoid moment arm. This means there is an opportunity to dramatically change the deltoid moments arms through surgical placement of the joint center of rotation. Computational models of the shoulder may help surgeons optimize subject-specific placement of RTSA implants to provide the best possible muscle function, and assist implant designers to configure devices for the best overall performance

The Stanford Upper Extremity Model (SUEM) (Holzbauer, Murray, Delp 2005, Ann Biomed Eng) includes the major muscles of the upper limb and has recently been described in scientific literature for various biomechanical purposes including modeling the muscle behavior after shoulder arthroplasty (Hoenecke, Flores-Hernandez, D'Lima 2014, J Shoulder Elbow Surg; Walker, Struk, Banks 2013, ISTA Proceedings). The initial publication of the SUEM compared the muscle moment arm predictions of the SUEM against various moment arm studies and all with the scapula fixed. A more recent study (Ackland, Pak, and Pandy 2008, J Anat) is now available that can be used to compare SUEM moment arm predictions to cadaver data for similar muscle sub-regions, during abduction and flexion motions, and with simulated scapular motion. SUEM muscle moment arm component vectors were calculated using the OpenSim Analyze Tool for an idealized abduction and an idealized flexion motion from 10° to 90° that corresponded to the motions described in Ackland for the cadaver arms. The normalized, averaged muscle moment arm data for the cadavers was manually digitized from the published figures and then resampled into uniform angles matching the SUEM data. Standard deviations of the muscle moment arms from the cadaver study were calculated from source data provided by the study authors. Python code was then used to calculate the differences, percent differences, and root-mean-square (RMS) values between the data sets. Of the 14 muscle groups in the SUEM, the smallest difference in predicted and measured moment arm was for the supraspinatus during the abduction task, with an RMS of the percent difference of 11.4%. In contrast, the middle latissimus dorsi had an RMS percent difference over 400% during the flexion task. The table presents the RMS difference and the RMS of the percent difference for the muscles with the largest abduction and adduction moment arms (during abduction) and the largest flexion and extension moment arms (during flexion). The moment arm data for the SUEM model and the cadaver data (with 1 standard deviation band) during the motion of the same muscles are provided in Figure 1 for the Abduction motion task and in Figure 2 for the Flexion motion task. It is challenging to simulate the three dimensional, time variant geometries of shoulder muscles while maintaining model fidelity and optimizing computational cost. Dividing muscles in to sub regions and using wrapping line segment approximations appears a reasonable strategy though more work could improve model accuracy especially during complex three dimensional motions

As treatments of knee osteoarthrosis are continually refined, increasingly sophisticated methods of evaluating their biomechanical function are required. Whilst TKA shows good preoperative pain relief and survivorship, functional outcomes are sub-optimal, and research focus has shifted towards their improvement. Restoration of physiological function is a common design goal that relies on clear, detailed descriptions of native biomechanics. Historical simplifications of true biomechanisms, for example sagittal plane approximation of knee kinematics, are becoming progressively less suitable for evaluation of new technologies. The patellar tendon moment arm (PTMA) is an example of such a metric of knee function that usefully informs design of knee arthroplasty but is not fully understood, in part due to limitations in its measurement. This research optimized PTMA measurement and identified the influence of knee size and sex on its variation. The PTMA about the instantaneous helical axis was calculated from optical tracked positional data. A fabricated knee model facilitated calculation optimization, comparing four data smoothing techniques (raw, Butterworth filtering, generalized cross-validated cubic spline-interpolation and combined filtering/interpolation). The PTMA was then measured for 24 fresh-frozen cadaveric knees, under physiologically based loading and extension rates. Sex differences in PTMA were assessed before and after size scaling. Large errors were measured for raw and interpolated-only techniques in the mid-range of extension, whilst both raw and filtered-only methods saw large inaccuracies at terminal extension and flexion. Combined filtering/interpolation enabled sub-mm PTMA calculation accuracy throughout the range of knee flexion, including at terminal extension/flexion (root-mean-squared error 0.2mm, max error 0.5mm) (Figure 1). Before scaling, mean PTMA throughout flexion was 46mm; mean, peak, and minimum PTMA values were larger in males, as was the PTMA at terminal flexion, the change in PTMA from terminal flexion to peak, and the change from peak to terminal extension (mean differences ranging from 5 to 10mm, p<0.05). Knee size was highly correlated with PTMA magnitude (r>0.8, p<0.001) (Figure 2). Scaling eliminated sex differences in PTMA magnitude, but peak PTMA occurred closer to terminal extension in females (female 15°, male 29°, p=0.01) (Figure 3). Improved measurement of the PTMA reveals previously undocumented characteristics that may help to improve the functional outcomes of knee arthroplasty. Knee size accounted for two-thirds of the variation in PTMA magnitude, but not the flexion angle at which peak PTMA occurred, which has implications for morphotype-specific arthroplasty and musculoskeletal models. The developed calculation framework is applicable both in vivo and vitro for accurate PTMA measurement and might be used to evaluate the relative performance of emerging technologies. For any figures or tables, please contact the authors directly

Introduction. Total knee arthroplasty (TKA) using conventional instrumentation has been shown to be a safe and effective way of treating end stage osteoarthritis by restoring function and alleviating pain. As robotic technology is developed to assist surgeons with intra-operative decision making such as joint balancing and component positioning, the safety of these advancements must be established. Furthermore, functional recovery and clinical outcomes should achieve comparable results to the gold standard of conventional instrumentation TKA. Methods. Eighty-seven subjects (89 knees) underwent robotic arm assisted TKA by one of three investigators as part of an FDA and IRB approved Investigational Device Exemption (IDE). To achieve the primary endpoint of intra-operative patient safety using a robotic arm assisted cutting tool, the investigators completed questionnaires to assess a series of complications related to soft tissue damage associated with conventional TKA. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Knee Scores (KSS) were collected pre-operatively and at three month follow-up. Results. The average subject age was 65.8 ± 8.5 and the average BMI was 31.4 ± 5.7. 55% of the subjects were female. No subject experienced any of the rare intra-operative complications that comprise the primary safety endpoint. The average WOMAC score improvement from pre-operative to three months was 33.1 ± 20.04 (p<0.0001). The average KSS Knee score improvement was 46.1 ± 19.7 (p<0.0001). Subjects recovered their pre-operative range of motion by three months post-operative. Conclusion. Results from this prospective robotic arm assisted trial indicated greater intra-operative safety in blood loss and ligamentous damage when compared to conventional TKA. Subjects had excellent return to function and pain relief by three months as indicated by the KSS and WOMAC scores. Robotic technologies should be considered a safe and effective method in total joint restoration

Introduction. One of the disadvantages of lateral decubitus position during arthroscopic rotator cuff repair is the difficulty to control arm rotation intraoperatively making it necessary to create additional portals for anchor placement or an additional scrubbed assistant to control arm rotation. Methods & Technique. We describe the use of commercially available TRIMANO® support arm from Arthrex as an easy device for secure positioning during arthroscopic rotator cuff repair in lateral decubitus position. Though initially marketed to be used for shoulder arthroplasties performed in beach chair position, the senior author has used TRIMANO® to perform arthroscopic rotator cuff repair in lateral decubitus position. The device is easily connected to the operating table side rail while the affected side forearm of the patient is placed in a disposable sterile foam arm holder and attached to the TRIMANO® arm. The “Click and Move” system of the TRIMANO® allows freedom to move the arm in any direction and also provides traction to distract the joint if needed. Conclusion. To conclude TRIMANO® arm is an easy to use flexible device for use in arthroscopic rotator cuff repair in lateral decubitus position decreasing the need for additional portals or an additional scrub assistant thereby decreasing the manpower required and cost of surgery

INTRODUCTION. Total hip arthroplasty (THA) is regarded as one of the most successful surgeries in medicine. However, recent studies have revealed that ideal acetabular cup implantation is achieved less frequently than previously thought, as little as 50% of the time. It is well known that malalignment of the acetabular component in THA may result in dislocation, reduced range of motion, or accelerated wear. This study reports accuracy of a tactile robotic arm system to ream the acetabulum and impact an acetabulur cup compared to manual instrumentation. METHODS. 12 fresh frozen cadaveric acetabulae were pre-operatively CT scanned and 3D templating was used to plan the center of rotation, and anteversion and inclination of the cup. Each specimen received THA, six prepared manually and six prepared with robotic arm guidance. Tactile, visual, and auditory feedback was provided through robotic guidance as well as navigated guided reaming and cup impaction. The robotic guidance constrained orientation of instruments thus constraining anteversion, inclination, and center of rotation for reaming, trialing, and final cup impaction. Post-operative CT scans were taken of each specimen to determine final cup placement for comparison to the pre-operative plans. RESULTS. In all cases, robotic arm guidance resulted in ±4° of anteversion and ±5° of inclination each relative to the pre-operative plan. Absolute RMS errors were 2.16 ± 1.35° for anteversion and 1.91 ± 1.55° for inclination. Cup placement with robotic guidance was significantly more accurate and precise than placement with manual instruments. With manual instrumentation the errors were, on average, 4.0 times higher in anteversion and 5.9 times higher in inclination compared to robotic instrumentation. CONCLUSION. This tactile robotic system substantially improved the accuracy of acetabular reaming and placement of the final cup compared to traditional manual techniques. With greater knowledge of ideal acetabular cup position, highly accurate techniques may allow surgeons to decrease the risk of dislocation, promote durability and improve the ability to restore appropriate leg length and offset. Tactile robotics has proven to be safe and effective in both knee and hip surgery and provides the potential to redefine the “instrument set” used for orthopedic procedures

Accurate and reproducible measurement of three-dimensional shoulder kinematics would contribute to better understanding shoulder mechanics, and therefore to better diagnosing and treating shoulder pathologies. Current techniques of 3D kinematics analysis use external markers (acromial cluster or scapula locator) or medical imaging (MRI or CT-Scan). However those methods present some drawbacks such as skin movements for external markers or cost and irradiation for imaging techniques. The EOS low dose biplanar X-Rays system can be used to track the scapula, humerus and thorax for different arm elevation positions. The aim of this study is to propose a novel method to study scapulo-thoracic kinematics from biplanar X-rays and to assess its reliability during abduction in the scapular plane. This study is based on the EOS™ system (EOS Imaging, Paris, France), which allows acquisition of 2 calibrated, low dose, orthogonal radiographs with the subject standing at 30 to 40° angle of coronal rotation to the plane of one of the X-ray beams, in order to limit superimposition with the ribcage and spine. Seven abduction positions in the scapular plane were maintained by the subjects for 10 seconds, during X-ray acquisition. Between two positions, the subjects returned at rest position. Arm elevations were approximately 0, 10, 20, 30, 60, 90 and 150° (position 1 to 7). Six subjects were enrolled to perform a reproducibility study based on the 3D reconstructions of 2 experienced observers three times each. For each subject, a personalised 3D reconstruction of the scapula was created. The observer digitises clearly visible anatomical landmarks on both stereoradiographs for each arm position. These landmarks are used to make a first adjustment of a parameterised 3D model of the scapula. This provides a pre-personalised model of the subject's scapula which is then rigidly registered on each pair of X-rays until its retroprojection fits best on the contours that are visible on the X-rays. The thorax coordinate system (CS) was built following the ISB (International Society of Biomechanics) recommendations. The CS associated to the scapula was a glenoid centred CS based on the ellipse which fit on the glenoid rim on the 3D model of scapula. Scapular CS orientation and translation in the thorax CS was calculated following a Y,X,Z angle sequence for each position. Each 3D reconstruction of the scapula was performed in approximately 30 minutes. The most reproducible rotation was upward/downward rotation (along X axis) with a 95% confidence interval (95% CI) from 2.71° to 3.61°. Internal/external rotation and anterior/posterior tilting were comprised respectively between 5.18° to 8.01° and 5.50° to 7.23° (CI 95%). The most reproducible translation was superior-inferior translation (along Y axis) with a 95% CI from 1.22mm to 2.46mm. Translation along X axis (antero-posterior) and Z axis (medio-lateral) were comprised respectively between 2.49mm to 4.26mm and 2.47mm to 3.30mm (CI 95%). We presented a new technique for 3D functional quantitative analysis of the scapulo-thoracic joint. This technique can be used with confidence; uncertainty of the measures seems acceptable compared to the literature. Main advantages of this technique are the very low dose irradiation compared to the CT-Scan and the possibility to study arm elevation above 120°

The introduction of robotics for total knee arthroplasty (TKA) into the operating theatre is often associated with a learning curve and is potentially associated with additional complications. The purpose of this study was to determine the learning curve of robotic-assisted (RA) TKA within a multi-surgeon team.

This prospective cohort study included 83 consecutive conventional jig-based TKAs compared with 53 RA TKAs using the Robotic Surgical Assistant (ROSA) system (Zimmer Biomet, Warsaw, Indiana, USA) for knee osteoarthritis performed by three high-volume (> 100 TKA per year) orthopaedic surgeons. Baseline characteristics including age, BMI, sex and pre-operative Kellgren-Lawrence grade were well-matched between the conventional and RA TKA groups. Cumulative summation (CUSUM) analysis was used to assess learning curves for operative times for each surgeon. Peri-operative and delayed complications were reviewed.

The CUSUM analysis for operative time demonstrated an inflexion point after 5, 6 and 15 cases for each of the three surgeons, or 8.7 cases on average. There were no significant differences (p = 0.53) in operative times between the RA TKA learning (before inflexion point) and proficiency (after inflexion point) phases. Similarly, the operative times of the RA TKA group did not differ significantly (p = 0.92) from the conventional TKA group. There was no discernible learning curve for the accuracy of component planning using the RA TKA system. The average length of post-operative follow-up was 21.3 ± 9.0 months. There was no significant difference (p > 0.99) in post-operative complication rates between the groups.

The introduction of the RA TKA system was associated with a learning curve for operative time of 8.7 cases. Operative times between the RA TKA and conventional TKA group were similar. The short learning curve implies this RA TKA system can be adopted relatively quickly into a surgical team with minimal risks to patients.

An understanding of forces that act on the shoulder joint is important for designing, testing, and evaluating shoulder arthroplasty products. Last year, we presented data describing upper arm motion during eight in-situ hours of occupational and recreational tasks. Using that data the associated humeral head joint forces were calculated with an upper extremity model in OpenSim. Five subjects from a nonrandom sampling of occupations wore the Inertial Measurment Units during a four hour period while at their work place performing their normal work duties and then during the four hour period of non-work activities immediately following. An unscented Kalman filter (UKF) was used to produce the 3D humeral – thoracic angles at 128 Hz from the IMU data. Because of the very large number of data points collected with the IMUs, ninety samples of twenty second duration were randomly selected from each four hour collection period. Using the sampled files, the time scales of the sampled files were scaled by a factor of five and then analyzed with the SUEM static optimization and joint reaction features. Not every sample file could be modeled resulting in an average number of sampled files of 66.7 per subject and condition (work/recreation). The humeral – thoracic angles were then used as input to the Stanford Upper Extremity Model (SUEM) in the OpenSim environment. The SUEM model allowed 2 rotation degree of freedom (rdof) for the forearm (flexion twist), 3 rdof at the humeral – scapular joint, and predicted scapular motion based on the humeral – thoracic elevation angle. All models were run for an assumed 80 kg body weight and included the bone mass of the scapula, clavical, humerus, radius, and ulna, but none of the soft tissue mass. Shoulder muscles were represented by 15 actuators: three heads for each of the deltoid, latissimus dorsi, and pectoralis, and 1 head each for the coracobrachialis, infraspinatous, subscapularis, supraspinatous, termes major, and teres minor. The 5. th. , 50. th. , and 95. th. percentile values of each force component acting on the humeral head from each sampled file for each subject and condition were calculated and the distribution of forces was plotted as a histogram. The overall mean and standard deviation for the 5. th. , 50. th. , and 95. th. percentile values were also determined. Of the A-P and S-I force components, anterior and inferior directed force components were larger than the posterior and superior directed force components. For the M-L force component, the forces were nearly exclusively directed in the medial direction. The 5. th. and 95. th. percentile forces during these subjects' ADL were generally lower than those described by Westerhoff 2009, suggesting that within the limitations of the modeling assumptions, loading experienced during in-situ ADL may be different than loading during laboratory simulation of representative motions

Introduction:

Isolated lateral compartment osteoarthritis (OA) occurs in 5–10% of knees with unicompartmental OA. Lateral unicompartmental knee arthroplasty has been limited in its prevalence due to challenging surgical technique issues. A robotic-arm assisted surgical technique has emerged as a way to achieve precise implant positioning which can potentially improve surgical outcomes.

Introduction

Isolated lateral compartment osteoarthritis (OA) occurs in 5–10% of knees with OA [1, 2]. Lateral unicompartmental knee arthroplasty (LUKA) emerged as a treatment to this disease in the early 80s but challenging surgical technique has limited the prevalence of this treatment option [1–3]. A robotic-arm assisted surgical technique (MAKO Surgical Corp.) has emerged as a way to achieve precise implant positioning which can potentially improve surgical outcomes.

This study looks at the dynamic tendon-to-bone contact properties of rotator cuff (RC) repairs—comparing single row repairs (SRR) with double row transosseous- equivalent (TOE) repairs. It was postulated that relaxation during, and movement following, the repair would significantly compromise contact properties and therefore, the ability of the tendon healing. Simulated tears were created in the supraspinatus tendon of six cadaveric human shoulders. A SRR was then performed using the OPUS System, creating two horizontal mattress sutures. An I-Scan electronic pressure-sensor (Tekscan, Boston, MA) was placed between the supraspinatus tendon and bone. The arm was then rested for 300secs (relaxation) before being passively moved twice through a range-of-motion (0-90 degrees abduction, 0-45 external and 0-45 internal rotation) and finally returned to neutral. The contact properties were recorded throughout each movement. The procedure was then repeated using two TOE techniques: parallel sutures (TOE-P) and a cross over suture pattern (TOE-C). While peak pressures during the repair were higher in the two TOE repairs, all three methods demonstrated relaxation over 300s such that there was no significant diference in contact pressures at the end of this time. TOE parallel and cross-over repairs demonstrated no significant change in mean TTB contact pressure, force and area during abduction, external rotation and return to neutral, when compared to the 300sec relaxation state. TOE-C demonstrated a higher contact force on internal rotation (+53%). The SRR demonstrated a significant drop in contact force on abduction (−63%), and return to neutral (−43%) and a trend on external rotation (−34%). SRR exhibited no change on internal rotation. There have been very few biomechanical studies with which observe RC repair contact properties dynamically. Relaxation of the repair can be partially reversed. Significant decrease in contact area with SRR during movement occurred, compared to the TOE repairs, which remains unaltered. This is an important consideration when determining postoperative rehabilitation

Introduction:

UKA allows replacement of a single compartment in patients who have isolated osteoarthritis. However, limited visualization of the surgical site and lack of patient-specific planning provides challenges in ensuring accurate alignment and placement of the prostheses. Robotic technology provides three-dimensional pre-op planning, intra-operative ligament balancing and haptic guidance of bone preparation to mitigate the risks inherent with current manual instrumentation. The aim of this study is to examine the clinical outcomes of a large series of robot-assisted UKA patients.

Aims

To establish if COVID-19 has worsened outcomes in patients with AO 31 A or B type hip fractures.

Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery. Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery. Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41). Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings

Introduction. The purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration. Materials & Methods. Sixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents

The Disability of Arm Shoulder and Hand (DASH) score questionnaire is a common self-administered tool to assess symptom severity and function in patients with injuries or pathology of the upper limb. However, having such a pertinent tool only in English is limiting in multi-cultural and multilingual populations where English is not always the first language, such as our South African context. IsiZulu is the most widely spoken language in South Africa (approximately 25% of the population). There are certain instances in research, particularly in international studies, where non-English speaking individuals need to be excluded based on translator reliability. This puts our institutions at a disadvantage by not being able to contribute to research. As per the international Institute of Work and Health (IWH), we followed the 5 stage guidelines to achieve the most appropriate linguistic and cultural adapted translation for our setting. (1) Two independent translations from English to isiZulu. (2) A synthesis of the 2 initial translations. (3) Two independent back-translations from the synthesized isiZulu version into English. (4) Expert panel (consisting of university lecturers and official translators) to review all versions and re-create an optimized synthesized version. (5) Pre-testing of the final optimized synthesized version in a pilot study. This rigorous process allowed for a concise and more culturally relevant translation for use in our population. The fourth stage in the process was integral in synthesizing the tool while considering the colloquial and semantic differences and resolving them with appropriate equivalents. The IWH guidelines aids in the cross-cultural adaptation of the DASH score while remaining valid and comparable to the original English version. This is beneficial in multi-national research projects and allows for the standardization of health outcome measures

The trapeziometacarpal joint (TMCJ) is the most common hand joint affected by osteoarthritis (OA), and trapezium implant arthroplasty is a potential treatment for recalcitrant OA. This meta-analysis aimed to investigate the efficacy and safety of various trapezium implants as an interventional option for TMCJ OA. Web of Science, PubMed, Scopus, Google Scholar, and Cochrane library databases were searched for relevant studies up to May 2022. Preferred Reported Items for Systematic Review and Meta-Analysis guidelines were adhered to and registered on PROSPERO. The methodological quality was assessed by National Heart, Lung, and Blood Institute tools for observational studies and the Cochrane risk of bias tool. Subgroup analyses were performed on different replacement implants, the analysis was done via Open Meta-Analyst software and P values < 0.05 were considered statistically significant. A total of 123 studies comprising 5752 patients were included. Total joint replacement (TJR) implants demonstrate greater significant improvements in visual analogue scale pain scores postoperatively. Interposition with partial trapezial resection implants was associated with the highest grip strength and highest reduction in the Disabilities of the Arm, Shoulder, and Hand score. Revision rates were highest in TJR (12.3%), and lowest in interposition with partial trapezial resection (6.2%). Total joint replacement and interposition with partial trapezial resection implants improve pain, grip strength, and DASH scores more than other implant options. Future studies should focus on high-quality randomized clinical trials comparing different implants to accumulate higher quality evidence and more reliable conclusions

Thumb carpometacarpal joint (CMCJ) arthritis is a common and debilitating condition. The mainstay of surgical management is Trapeziectomy. Concerns about possible functional implications of collapse of the metacarpal into the arthroplasty space as well as the potential for scaphometacarpal led to the development of techniques to try and prevent this. The purpose of this study was to investigate if there were any significant differences in the long-term outcomes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy with ligament reconstruction and tendon interposition (LRTI). Sixty-five patients participated in our original trial, the 1 year findings of which were published in 2007. These patients were invited for a follow-up visit at a mean of 17 years (range 15–20) postoperatively. Twenty-eight patients attended, who had 34 operations, 14 trapeziectomy alone and 20 with LRTI. Patients were asked to complete a visual analogue scale (VAS) for satisfaction with the outcome of their procedure, rated on a scale from 0 (most dissatisfied) to 100 (most satisfied). They also completed the short version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) at their appointment. They underwent a functional assessment with a hand therapist and had a radiograph of the thumb. There were no statistically significant differences between the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements showing minimal or no differences in means between the two groups. There was no difference in the space between the metacarpal and scaphoid on radiograph. Radial abduction was the only parameter that was significantly greater in the patients with simple trapeziectomy (median 79°) compared with trapeziectomy with LRTI (median 71°) (p = 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for thumb carpometacarpal joint osteoarthritis