Aims

This Delphi study assessed the challenges of diagnosing soft-tissue knee injuries (STKIs) in acute settings among orthopaedic healthcare stakeholders.

Introduction. The recent introduction of Chatbots has provided an interactive medium to answer patient questions. The accuracy of responses with these programs in limb lengthening and reconstruction surgery has not previously been determined. Therefore, the purpose of this study was to assess the accuracy of answers from 3 free AI chatbot platforms to 23 common questions regarding treatment for limb lengthening and reconstruction. Method. We generated a list of 23 common questions asked by parents before their child's limb lengthening and reconstruction surgery. Each question was posed to three different AI chatbots (ChatGPT 3.5 [OpenAI], Google Bard, and Microsoft Copilot [Bing!]) by three different answer retrievers on separate computers between November 17 and November 18, 2023. Responses were only asked one time to each chatbot by each answer retriever. Nine answers (3 answer retrievers × 3 chatbots) were randomized and platform-blinded prior to rating by three orthopedic surgeons. The 4-point rating system reported by Mika et al. was used to grade all responses. Result. ChatGPT had the best response accuracy score (RAS) with a mean score of 1.73 ± 0.88 across all three raters (range of means for all three raters – 1.62 – 1.81) and a median score of 2. The mean response accuracy scores for Google Bard and Microsoft Copilot were 2.32 ± 0.97 and 3.14 ± 0.82, respectively. This ranged from 2.10 – 2.48 and 2.86 – 3.54 for Google Bard and Microsoft Copilot, respectively. The differences between the mean RAS scores were statistically significant (p < 0.0001). The median scores for Google Bard and Microsoft Copilot were 2 and 3, respectively. Conclusion. Using the Response Accuracy Score, the responses from ChatGPT were determined to be satisfactory, requiring minimal clarification, while the responses from Microsoft Copilot were either satisfactory, requiring moderate clarification, or unsatisfactory, requiring substantial clarification

To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3. The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures

Objectives. Acetabular fractures with quadrilateral plate involvement have been shown to have a high rate of complications. Anatomic suprapectineal plating systems have been developed to manage these injuries with good short-term outcomes, however long-term maintenance of anatomical reduction and functional outcomes is yet to be established. Efficacy of maintenance of reduction and functional outcomes at a minimum of 5-years follow-up is the aim of this study. Design and Methods. A retrospective cohort study examining patients aged over 16 years following fixation of acetabular fractures with quadrilateral plate involvement at a trauma centre in the United Kingdom. All patients had acetabular fracture fixation with an anatomically designed suprapectineal plate. Patients were admitted from March 2014 to January 2017. Primary outcomes included objective radiological outcomes such as reduction quality, maintenance of reduction, metalwork failure, complications (such as reoperation, neurological deficit and mortality) and subjective patient-related outcome measures (PROMs) using the Oxford Hip Score and EuroQol EQ5D Score at a minimum of 5-years post-operatively. Results. 16 patients met our eligibility criteria in this cohort. Post-operative mean Oxford Hip Score (OHS) at a minimum of 5-years was 40.5 (SD 11.9) with a median score of 45. Post-operative mean EuroQol EQ-5D scores at a minimum of 5-years were 0.83 (SD 0.25). Comparison of OHS and EQ5D at 1-year and 5-years showed no significant difference (OHS p = 0.27 / EQ5D p = 0.128). Radiographic outcomes were assessed with AP and Judet plain radiographs at a minimum of 5-years follow-up. Rate of conversion to total hip replacement was 6.25%. 56.3% showed some evidence of dome comminution with 18.8% demonstrating dome impaction. 93.7% showed evidence of quadrilateral plate involvement. 12.5% showed evidence of femoral head injury. Conclusion. Maintenance of reduction and functional and patient reported outcomes using anatomically contoured suprapectineal plates do not change significantly between 1 year and 5 years follow-up

Aim. To describe the histopathology of the first and last debrided bone tissue in chronic osteomyelitis and answer the following research question; is the last debrided bone tissue viable and without signs of inflammation?. Method. In total, 15 patients with chronic osteomyelitis were allocated to surgical treatment using a one stage protocol including extensive debridement. Suspected infected bone tissue eradicated early in the debridement procedure was collected as a clearly infected sample (S1). Likewise, the last eradicated bone tissue was collected as a suspected non-infected sample (S2), representing the status of the bone void. In all cases, the surgeon debrided the bone until visual confirmation of healthy bleeding bone. The samples were processed for histology, i.e. decalcification and paraffin embedding, followed by cutting and staining with Haematoxylin and Eosin. Immunohistochemistry with MAC-387 antibodies towards the calprotectin of neutrophil granulocytes (NGs) was also performed and used for estimation of a neutrophil granulocyte (NG) score (0, 1, 2 or 3), by the method described for fracture related infections (1). Results. For the S1 samples the median NG score was 3 which is considered confirmatory for infection. However, following debridement the median NG score was significantly (p = 0.032) reduced to 2. Often NGs were seen as single cells, but in seven S1 samples and in one S2 sample massive NG accumulations were observed. The S1 samples showed a mix of granulation tissue, fibrosis, viable bone, and bone necrosis. The S2 samples contained viable bone tissue and occasionally (10/15) small fragments of necrotic bone or bone debris were seen. Furthermore, a large number of erythrocytes were observed in most S2 samples. Conclusions. The present study shows that the inflammatory response still existents after debridement, although the response fades from the center of infection. Therefore, sampling of debrided bone tissue for histology must be performed initially during surgery, to avoid underestimation of the inflammatory response, i.e. the NG score. The last debrided bone tissue cannot by definition be considered completely viable and caution should be made to remove blood (rinse) before intraoperative evaluation of the viability of debrided cancellous bone. Remnant necrotic bone fragments or debris could represent low-vascular hiding places for leftover bacteria. Application of local antibiotics might have a central role in clearing of these small non-viable bone pieces at the bone void interface

Aims. Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically. Methods. This is a prospective series of 156 proximal hamstring surgical repairs, with a mean age of 48.9 years (21.5 to 78). Functional outcomes were assessed preinjury, preoperatively, and postoperatively (six months and minimum three years) using the Sydney Hamstring Origin Rupture Evaluation (SHORE) score. Operating time was recorded for every patient. Results. Overall, significant improvements in SHORE scores were seen at both six months and mid-term follow-up. Preoperatively, acute patients (median score 27.1 (interquartile range (IQR) 22.9)) reported significantly poorer SHORE scores than chronic patients (median score 42.9 (IQR 22.1); p < 0.001). However, this difference was not maintained postoperatively. For partial tears, acutely repaired patients reported significantly lower preoperative SHORE scores compared to chronically reapired partial tears (median score 24.3 (IQR 15.7) vs median score 40.0 (IQR 25.0); p < 0.001) but also significantly higher SHORE scores at six-month follow-up compared to chronically repaired partial tears (median score 92.9 (IQR 10.7) vs. median score 82.9 (IQR 14.3); p < 0.001). For complete tears, there was only a difference in preoperative SHORE scores between acute and chronic groups. Overall, acute repairs had a significantly shorter operating time (mean 64.67 minutes (standard deviation (SD) 12.99)) compared to chronic repairs (mean 74.71 minutes (SD = 12.0); t = 5.12, p < 0.001). Conclusion. Surgical repair of proximal hamstring avulsions successfully improves patient reported functional outcomes in the majority of patients, irrespective of the timing of their surgery or injury classification. However, reducing the time from injury to surgery is associated with greater improvement in patient outcomes and an increased likelihood of returning to preinjury functional status. Acute repair appears to be a technically less complex procedure, as indicated by reduced operating times, postoperative neurological symptoms and number of patients requiring bracing. Acute repair is therefore a preference among many surgeons. Cite this article: Bone Joint J 2020;102-B(10):1419–1427

Aims. The aims of this study were to validate the Forgotten Joint Score-12 (FJS-12) in the postoperative evaluation of periacetabular osteotomy (PAO), identify factors associated with joint awareness after PAO, and determine the FJS-12 threshold for patient-acceptable symptom state (PASS). Methods. Data from 686 patients (882 hips) with hip dysplasia who underwent transposition osteotomy of the acetabulum, a type of PAO, between 1998 and 2019 were reviewed. After screening the study included 442 patients (582 hips; response rate, 78%). Patients who completed a study questionnaire consisting of the visual analogue scale (VAS) for pain and satisfaction, FJS-12, and Hip disability and Osteoarthritis Outcome Score (HOOS) were included. The ceiling effects, internal consistency, convergent validity, and PASS thresholds of FJS-12 were investigated. Results. The median follow-up was 12 years (interquartile range 7 to 16). The ceiling effect of FJS-12 was 7.2%, the lowest of all the measures examined. FJS-12 correlated with all HOOS subscales (ρ = 0.72 to 0.77, p < 0.001) and pain and satisfaction-VAS (ρ = -0.63 and 0.56, p < 0.001), suggesting good convergent validity. Cronbach’s α was 0.95 for the FJS-12, which indicated excellent internal consistency. The median FJS-12 score for preoperative Tönnis grade 0 hips (60 points) was higher than that for grade 1 (51 points) or 2 (46 points). When PASS was defined as pain-VAS < 21 and satisfaction-VAS ≥ 77, the FJS-12 threshold that maximized the sensitivity and specificity for detecting PASS was 50 points (area under the curve (AUC) = 0.85). Conclusion. Our results suggest that FJS-12 is a valid and reliable assessment tool for patients undergoing PAO, and the threshold of 50 points may be useful to determine patient satisfaction following PAO in clinical settings. Further investigation of the factors influencing postoperative joint awareness may enable improved prediction of treatment efficacy and informed decision-making regarding the indication of PAO. Cite this article: Bone Joint J 2023;105-B(7):760–767

Aims. The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures. Methods. This study was a cross-sectional, questionnaire-based study conducted at a tertiary care orthopaedic centre. All cases of idiopathic paediatric trigger thumbs which underwent A1 pulley release between 2004 and 2011 and had a minimum follow-up period of ten years were included in the study. The abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH) was administered as an online survey, and ipsi- and contralateral thumb motion was assessed. Results. A total of 67 patients completed the survey, of whom 63 (94%) had full interphalangeal joint extension or hyperextension. Severe metacarpophalangeal joint hyperextension (> 40°) was documented in 15 cases (22%). The median QuickDASH score was 0 (0 to 61), indicating excellent function at a median follow-up of 15 years (10 to 19). Overall satisfaction was high, with 56 patients (84%) reporting the maximal satisfaction score of 5. Among 37 patients who underwent surgery at age ≤ two years, 34 (92%) reported the largest satisfaction, whereas this was the case for 22 of 30 patients (73%) with surgery at aged > two years (p = 0.053). Notta’s nodule resolved in 49 patients (73%) at final follow-up. No residual triggering or revision surgery was observed. Conclusion. Surgical release of A1 pulley in paediatric trigger thumb is an acceptable procedure with excellent functional long-term outcomes. There was a trend towards higher satisfaction with earlier surgery among the patients. Cite this article: Bone Jt Open 2024;5(9):736–741

Aims. The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius. Methods. We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score. Results. Long-term outcomes were available for 89 patients (72%). The mean age was 57 years (SD 15) and 68 were female (76%). The median time from injury to corrective osteotomy was nine months (interquartile range (IQR) 6 to 13). At a mean follow-up of six years (1 to 11) the median PRWE score was 22 (IQR 7 to 40), the median QuickDASH score was 11.4 (IQR 2.3 to 31.8), and the median EQ-5D-5L score was 0.84 (IQR 0.69 to 1). The NPS was 69. Multivariate regression analysis showed that the presence of an associated ulnar styloid fracture was the only significant independent factor associated with a worse PRWE score when adjusting for confounding variables (p = 0.004). Conclusion. We found that corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. However, the presence of an ulnar styloid fracture may adversely affect function. Level of Evidence: III (cohort study). Cite this article: Bone Joint J 2020;102-B(11):1542–1548

Aims. The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods. All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results. The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion. This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963

Aims. The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. Methods. This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs. Results. Overall, 712/991 (71.8%) responded at ≤ three months for THA (n = 164) and TKA (n = 199), and ≥ three years for THA (n = 88) and TKA (n = 261). The median EQ-5D-5L score in those waiting ≤ three months was 0.155 (interquartile range (IQR) -0.118 to 0.375) and 0.189 (IQR -0.130 to 0.377) for ≥ three years. Matched controls had a median EQ-5D-5L 0.837 (IQR 0.728 to 1.000). Compared to matched controls, EQ-5D-5L scores were significantly lower in both waiting cohorts (p < 0.001) with significant differences found in every domain. Negative scores, indicating a state “worse than death”, were present in 40% at ≤ three months and 38% at ≥ three years. Patients waiting ≥ three years had significantly more opioid (28.4% vs 15.2%; p < 0.001) and antidepressant prescriptions (15.2% vs 9.9%; p = 0.034) and significantly more joint-related attendances at unscheduled care (11.7% vs 0% with ≥ one ED attendance (p < 0.001) and (25.5% vs 2.5% ≥ one OOH GP attendance (p < 0.001)). Conclusion. Patients on waiting lists in Northern Ireland are severely disabled with the worst HRQoL and functional scores studied. The lack of deterioration in EQ-5D-5L and joint-specific scores between patients waiting ≤ three months and ≥ three years likely reflects floor effects of these scores. Prolonged waits were associated with increased dependence on strong opiates, depression, and attendances at unscheduled care. Cite this article: Bone Joint J 2023;105-B(7):783–794

Aims. We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. Methods. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. Results. Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a cost savings of over £13,500 per year with the new self-care model compared to the traditional model. Conclusion. Our study supports a VFC self-care pathway for patients with minimally displaced distal radius fractures. The pathway provides a good level of patient satisfaction and function. To improve the service, we will make minor amendments to our patient information sheet. Cite this article: Bone Jt Open 2022;3(9):726–732

Developmental Dysplasia of the Hip (DDH) is the most common orthopaedic disorder in newborns. Whilst the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardising teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy in DDH, we addressed this problem by scientifically obtaining international expert-based consensus on the same. An initial list of items relevant to Pavlik harness treatment was derived by systematic review of the literature according to PRISMA criteria and reviewed by two expert clinicians in DDH management. Delphi methodology was used to guide serial rounds of surveying and feedback to content matter experts from the International Hip Dysplasia Institute (IHDI), a collaborative group of paediatric orthopaedic surgeons with expertise in the management of DDH. Rounds of surveying continued in the same manner until consensus was reached. Importance ratings were derived from each round of surveying by calculating median score responses on the 5-point Likert scale for each item. Items requiring clarification or those with a median score of below 4 (“agree”) were modified as needed prior to each subsequent round. Consensus was considered reached when 90% or more of the items had an interquartile range (IQR) of ≤ 1. This value indicates low sample deviation and is accepted as having achieved consensus. This was followed by a corroboration of face validity to derive the final set of management principles. The literature search and expert review identified an initial list of 66 items in 8 categories relevant to Pavlik harness management. Four rounds of structured surveying were required to reach consensus. Following a final round of face validity, a definitive list of 33 items in 8 categories met consensus by the experts. These items were tabulated and presented as “General Principles of Pavlik Harness Treatment for DDH” and “Pavlik Harness Treatment by Severity of Hip Dysplasia”. Furthermore, highly contentious items were identified as important future areas of study and will be discussed. We have developed a comprehensive set of principles derived by expert consensus to assist clinicians, and for use as a teaching resource, in the non-operative management of DDH using the Pavlik harness. We have gained consensus on both the general principles of Pavlik harness treatment as well as the detailed treatment of hip subtypes seen across the spectrum of pathology of DDH. Furthermore, this study has also served to generate a list of the most controversial areas in the non-operative management of DDH which should be considered high priority for future study to further refine and optimise the outcomes of children with developmental hip dysplasia

Background. Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anaesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anaesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block technique (SV). Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. Methods. A single-centre prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anaesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anaesthesia along with the anaesthesia onset time. Results. A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5] vs. 3 [2, 4], respectively, P = 0.006). However, anaesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anaesthesia was more predictable in the dorsal block compared to the volar block. Conclusion. The single-injection volar subcutaneous blocks are less painful with a similar anaesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anaesthesia of the region

The aim of this study was to evaluate the long-term outcomes of patients who had sustained an unstable ankle fracture with a posterior malleolus fracture (PMF) and without (N-PMF). Adult patients presenting to a single academic trauma centre in Edinburgh, UK, between 2009 and 2012 with an unstable ankle fracture requiring surgery were identified. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary measures included Euroqol-5D-3L Index (Eq5D3L), Euroqol-5D-VAS and Manchester Oxford Foot Questionnaire (MOXFQ). There were 304 patients in the study cohort. The mean age was 49.6 years (16.3–78.3) and 33% (n=100) male and 67% (n=204) female. Of these, 67% (n=204) had a PMF and 33% did not (n=100). No patient received a computed tomography (CT) scan pre-operatively. Only 10% of PMFs (22/204) were managed with internal fixation. At a mean of 13.8 years (11.3 – 15.3) the median OMAS score was 85 (Interquartile Range 60 – 100). There was no difference in OMAS between the N-PMF and PMF groups (85 [56.25 – 100] vs 85 [61.25 – 100]; p = 0.580). There was also no difference for MOXFQ (N-PMF 7 [0 – 36.75] vs PMF 8 [0–38.75]; p = 0.643), the EQ5D Index (N-PMF 0.8 [0.7 – 1] vs PMF 0.8 [0.7 – 1]; p = 0.720) and EQ5D VAS (N-PMF 80 [70 – 90] vs PMF 80 [60 – 90]; p = 0.224). The presence of a PMF does not affect the long-term patient reported outcomes in patients with a surgically managed unstable ankle fracture

This paper presents an ongoing review of the use of a wedge-shaped porous metal augments in the shoulder to address glenoid retroversion as part of anatomical total shoulder arthroplasty (aTSA). Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42 to 85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients received either a 15º or 30º PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Standardized Shoulder Assessment Form [ASES], visual analogue scale [VAS] pain scores and forward elevation [FE]) preoperatively, at three, six, and 12 months, and yearly thereafter, with similar radiological surveillance. Forty-nine consecutive series shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24–87 months). Median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90º to 140º). Four patients died, but no others were lost to follow-up. Apart from one infection at 18 months postoperatively and one minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency or posterior re-subluxations. Radiographs showed good incorporation of the wedge augment with correction of glenoid retroversion from median 22º (13º to 46º) to 4º. All but four glenoids were corrected to within the target range (less than 10º retroversion). The porous metal wedge-shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure

Aims. The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service. Methods. All adult patients who presented with a clinically suspected scaphoid fracture that was not visible on radiographs at the time of presentation during a one-year period were eligible for inclusion in the pathway. Demographic details, findings on examination, and routine four-view radiographs at the time of presentation were collected. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year after presentation and included the abbreviated version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the EuroQol five-dimension five-level health questionnaire (EQ-5D-5L), the Net Promoter Score (NPS), and return to work. Results. A total of 221 patients were referred to the virtual pathway. Their mean age was 41 years (range 16 to 87) and there were 99 male patients (45%). A total of 189 patients (86%) were discharged with advice and 19 (9%) were recalled for clinical review: seven with an undisplaced scaphoid fracture, six with another fracture of the hand or wrist, two with a scapholunate ligament injury, and four in whom no abnormality was detected. A total of 13 patients (6%) initiated follow-up with the hand service: no fracture or ligament injury was identified in this group. PROMs were available for 179 patients (81%) at a mean follow-up of 19 months (range 13 to 33). The median QuickDASH score was 2.3 (interquartile range (IQR) 0 to 15.9), the median EQ-5D-5L was 0.85 (IQR 0.73 to 1.00), the NPS was 76, and 173 patients (97%) were satisfied with their treatment. There were no documented cases of symptomatic nonunion one year following injury. Conclusion. We describe the introduction of a virtual pathway for the management of patients with a suspected scaphoid fracture. We found high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases. Cite this article: Bone Joint J 2022;104-B(6):709–714

Introduction. Trochleoplasty is an effective surgical procedure for patients with severe trochlear dysplasia and recurrent patella instability. Previous work has suggested patients demonstrate early improvements in knee function and quality of life. However, concerns regarding longer term outcomes due to the development of stiffness and patellofemoral osteoarthritis remain a concern for these patients. Our aim was to assess mid-term patient-reported outcome and quality of life measures for trochleoplasty performed at a single centre for severe trochlear dysplasia. Methods. Retrospective review of 28 knees (23 patients) having undergone trochleoplasty for severe trochlear dysplasia were reviewed. Due to the non-parametric nature of the data, median and interquartile range (IQR) were determined for pre-operative and mid-term follow-up scores. Statistically significant differences between groups were assessed using paired Wilcoxon-signed rank test with statistical significance set at p<0.05. Data were analysed using a statistical software package (IBM® SPSS® Statistics 26.0). Results. Median time from surgery to follow-up for all patients in the series was 5.3 years (IQR 3.9 – 7.0 years). Median pre-operative Kujala score improved from 57.0 (IQR 45 – 66) to 96.3 (IQR 83 -100). Median pre-operative IKDC score improved from 42.6 (IQR 35.9 – 51.3) to 92.6 (IQR 71.6 – 98.7). Median EQ-5D score also improved from 0.691 (IQR 0.414 – 0.727) to 1.000 (IQR 0.8178 – 1.000). Improvement in Kujala scores, IKDC scores and EQ-5D were all statistically significant with p<0.001 in all domains. Discussion. Our data suggests patients experience significant improvements in knee function and quality of life following trochleoplasty surgery for severe dysplasia. We demonstrate an absolute improvement in scores at a mean of 5.3 years follow-up of 39.3 points for Kujala, 50 for IKDC and 0.309 for EQ-5D. Minimal clinically important differences (MCID) have been reported to be in the region of 10 for the Kujala score, 8.8–15.6 for IKDC and 0.085 for EQ-5D. Our data shows improvements which far exceed the published MCID, suggesting trochleoplasty confers a large treatment effect and patients benefiting from sustained improvements in knee function and overall quality of life at mid-term follow-up. Conclusion. Following trochleoplasty for severe trochlear dysplasia, patient reported outcomes demonstrate continued improvements in knee function and quality of life at mid-term (5-year) follow-up. There is a large absolute treatment effect which likely impacts on both physical and psychological wellbeing for these patients. Continued surveillance of patient reported outcomes in this clinically complex cohort is indicated

Aim. To describe the management of PJI due to S. aureus in CRIOAcs in 2019 and to particularly focus on the evaluation of the efficacy of DAIR regarding control of infection and risk factors for failure up to 12 months. Method. Thirteen CRIOAcs were selected to participate to the study. Data concerning the management of all the PJI in the year 2019 were retrospectively collected and registered in eCRFs. Inclusion criteria were: ≥ 18 years old patients with S. aureus ± other bacteria (in per surgical procedure sample); knee or hip PJI and with clinical signs of infection. Patients treated with bacteriophages were excluded. All eligible patients were notified by an information letter. Patients treated by the DAIR procedure were selected, and rate of control of infection (no inflammatory local signs or no new surgical procedure or no S. aureus in case of puncture) was analyzed using Kaplan Meier method and risk factors for failure at 12 months were assessed using Cox regression model. Results. A total of 978 PJI were managed in the 9 CRIOAcs, including 238 hip and knee PJI due to S. aureus and 79 to S. aureus plus another bacteria. Among all of them, 154 were managed with DAIR, and 100 fulfilled inclusion criteria, notifying no opposition to their data collection. The median age was 73.0 years; 57% were male, the median Charlson score was 4.0; 66% had hip PJI. A total of 45 failure were observed during the period studied. At 12 months, the control rate was 58. 7% [36.5–75.4], 49.3% [34.3–62.7] in in early and late PJI respectively according to Tsukuyama classification and 49.6% [30.5–66.1], 54.1% [37.7 – 68.0] in early and delayed/late PJI respectively according to Zimmerli classification, 56.6% [39.5–70.5] in case of mobile part exchange, 53.4% [35.3–68.5] for MRSA PJI and 63.4% [50.5–73. 8] in patients treated with rifampicin. No rifampicin intake was the only significative risk factor for failure in univariate analysis (HR=0.31 (0.17–0.57), p=0.0002), and remained significant after adjustment on Charlson score (aHR=0.34 (0.18–0.64), p=0.0008). Conclusions. The DAIR procedure is frequently performed in patients with acute and late PJI, and is associated with a high rate of failure, especially for patients who cannot receive rifampin. There is a strong rational to assess the use of bacteriophages during the DAIR, as bacteriophages have antibiofilm activity in vitro, and could improve the efficacy of the DAIR to control the disease

This study describes the introduction of a virtual pathway for the management of suspected scaphoid fractures and reports patient-reported outcome measures (PROMs) and satisfaction following treatment with this service. All adult patients that presented with a clinically suspected scaphoid fracture that was not visible on presentation radiographs over a one-year period were eligible for inclusion in the pathway. Demographics, examination findings, clinical scaphoid score (CSS) and standard four view radiographs were collected at presentation. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year post presentation and included the QuickDASH, EQ-5D-5L, the Net Promoter Score (NPS) and return to work. There were 221 patients referred to the virtual pathway. The mean age was 41 (range 16–87; SD 18.4 years) and there were 99 men (45%). There were 189 (86%) patients discharged with advice and 19 (9%) patients were recalled for clinical review (seven undisplaced scaphoid fractures, six other acute fractures of the hand or wrist, two scapholunate ligament injuries, and four cases where no abnormality was detected). Thirteen patients (6%) initiated follow-up with the hand service; no fracture or ligament injury was identified within this group. PROMs were available for 179 (81%) patients at a mean of 19 months follow-up (range: 13 – 33 months). The median QuickDASH score was 2.3 (IQR, 0–15.9), the median EQ-5D-5L was 0.85 (IQR, 0.73–1.00), the NPS was 76, and 173 (97%) patients were satisfied with their treatment. There were no documented cases of symptomatic non-union one year following injury. This study reports the introduction of a virtual pathway for suspected scaphoid fractures, demonstrating high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases