Though knee osteoarthritis (OA) is diagnosed and monitored radiographically, full thickness cartilage loss (FTCL) has rarely been correlated with radiographic classification. This study aims to analyse which classification system correlates best with FTCL and assessing their reliability.

Prospective study of 300 consecutive patients undergoing total knee arthroplasty (TKA) for OA. Two blinded examiners independently graded preoperative radiographs using 5 systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlback. Interobserver agreement was assessed using the intraclass correlation coefficient. Intraoperatively, anterior cruciate ligament (ACL) status and FTCL in 16 regions of interest were recorded. Radiographic classification and FTCL were correlated using the Spearman correlation coefficient.

On average, each knee had 6.8±3.1 regions of FTCL, most common medially. The commonest patterns of FTCL were medial with patellofemoral (48%) and tricompartmental (30%). ACL status was associated with pattern of FTCL (p=0.02). All classification systems demonstrated moderate ICC, but this was highest for IKDC: whole knee 0.68 (95%CI 0.60–0.74); medial compartment 0.84 (0.80–0.87); and lateral compartment 0.79 (0.73–0.83). Correlation with FTCL was strongest for Ahlback (Spearman rho 0.27–0.39) and KL (0.30–0.33), though all systems demonstrated medium correlation. The Ahlback was the most discriminating in severe OA. Osteophyte presence in the medial compartment had high positive predictive value for FTCL, but not in the lateral compartment.

The Ahlback and KL systems had the highest correlation with confirmed cartilage loss. However, the IKDC system displayed best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, though less discriminating in severe disease.

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy.

A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D.

There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039).

These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced.

Glenohumeral dislocation is complicated with a greater tuberosity fracture in 16% of cases. Debate regarding the safety of closed reduction in the emergency department exists, with concerns over fracture propagation during the reduction manoeuvre. The study aim was to report the results of closed reduction, identify complications and define outcome for these injuries.

188 consecutive glenohumeral dislocations with a tuberosity fracture were identified from a prospective database from 2014–2017. 182 had an attempted closed reduction under appropriate sedation using standard techniques, five were manipulated in theatre due to contra-indications to sedation. Clinical, radiographic and patient reported outcomes, in the form of the QuickDASH and Oxford Shoulder Score (OSS), were collected.

A closed reduction in the emergency department was successful in 162 (86%) patients. Two iatrogenic fractures of the proximal humerus occurred, one in the emergency department and one in theatre, representing a 1% risk. 35 (19%) of patients presented with a nerve lesion due to dislocation. Surgery was performed in 19 (10%) cases for persistent or early displacement (< 2 weeks) of the greater tuberosity fragment. Surgery resulted in QuickDASH and OSS scores comparable to those patients in whom the tuberosity healed spontaneously in an anatomical position (p=0.13). 18 patients developed adhesive capsulitis (10%).

Glenohumeral dislocation with greater tuberosity fracture can be safely treated by closed reduction within the emergency department with a low risk of humeral neck fracture. Persistent or early displacement of the tuberosity fragment will occur in 10% of cases and is an indication for surgery.

Successful return to work (RTW) is a crucial outcome after primary total knee arthroplasty (TKA) in patients under 65 years old. We aimed to determine whether TKA facilitated RTW in patients <65 years, whose intention was to return preoperatively.

We prospectively assessed 106 TKA patients under 65 years over a 1 year period both preoperatively and at 1 year following surgery. Patient demographics were collected including Oxford knee score, Oxford-APQ, VAS pain/health scores and EQ-5D. A novel questionnaire was distributed to delineate pre-operative employment status and post-operative intentions. This included questions on nature of pre and post-operative occupation, whether joint disease affected their ability to work and details of retirement plans and how this was affected by their knee.

69 patients intended to return to work following their TKA. Following arthroplasty, 57/69 patients (82.6%) returned to work at a mean of 16.4 weeks (SD 16.6). Univariate analysis showed significant factors facilitating RTW included, pre-operative oxford knee score, pre-operative Oxford-APQ score and pre-operative EQ-5D score. These were not predictive on multivariate analysis.

This study finds that TKA facilitates return to work in 83% of those who intend to return to work following their surgery. This could have significant positive and health and financial cost implications for the individual, health system and society.

To evaluate if clinical recovery following midshaft clavicle fracture is associated with nonunion and determine if this has superior predictive value compared to estimation at time of injury.

A prospective study of all patients (≥16 years) who sustained a displaced midshaft clavicle fracture was performed. We assessed patient demographics, injury factors, functional scores and radiographic predictors with a standardized protocol at six-weeks. Conditional-stepwise regression was used to assess which factors independently predicted nonunion at six-months post-injury determined by CT. The nonunion predictor six-week model (NUP6) was compared against a previously validated model based on factors available at time of injury (NUP0-smoking, comminution and fracture displacement).

200 patients completed follow-up at six months. The nonunion rate was 14% (27/200). Of the functional scores, the QuickDASH had the highest accuracy on receiver-operator-characteristic (ROC) curve analysis with a 39.8 threshold, above which was associated with nonunion (Area Under Curve (AUC) 76.8%, p<0.001).

On regression modelling QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort (n=80/200). Conversely if two or more were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%.

The NUP6 model appeared to have superior accuracy when compared to the NUP0 model on ROC curve analysis (AUC 87.3% vs 64.8% respectively).

Delayed assessment at six-weeks following displaced clavicle fracture enables a more accurate prediction of fracture healing.

There is a lack of evidence surrounding selective patella resurfacing, but patella cartilage loss at time of total knee arthroplasty (TKA) is often used as an indication in those who perform it. This study compares the outcomes of TKA without patella resurfacing in patients with and without patella cartilage loss (PFOA).

Prospective case control study of 209 consecutive patients undergoing cruciate retaining single radius TKA without patella resurfacing for KL≥3 osteoarthritis. The presence and location of full thickness patella cartilage loss was documented intra-operatively at TKA, identifying n=108 cases with PFOA (mean age 70±9.7, mean BMI 31±6.2, 72 (67%) female) Vs n=101 controls without PFOA (age 68±9.2, BMI31±5.6, 52 (51%) female). Primary outcome measure was improvement in the Oxford Knee Score (OKS) at one year.

There were more females in the PFOA group (67% Vs 51%, p=0.037), but no other preoperative differences. There was no difference in preoperative OKS between patients with patella cartilage loss (20.6±7.9) and those without (21.0±7.2, p=0.720). There was no difference in OKS improvement following TKA without patella resurfacing between those with full thickness patella cartilage loss (14.2±9.8) and those without (15.4±9.5, p=0.365). Facet involvement (number and location) did not affect OKSs. No differences were found in the individual OKS questions between groups (p>0.05).

There was no difference in one-year OKS or improvements therein between patients with and without full thickness patella cartilage loss treated with single radius cruciate retaining TKA without patella resurfacing, questioning its use an indication for selective patella resurfacing.

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion.

Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion.

Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion.

Mechanical ankle instability is elicited through examination and imaging. A subset of patients however report “functional” instability ie/ instability without objective radiological evidence. Little research compares operative outcomes between these groups. We hypothesised patients with “mechanical instability” were more likely to benefit from operative intervention than those with “functional instability”.

This was a single centre, retrospective case note review of prospectively collected data. Inclusion criteria: over six months of symptoms, failed conservative management, surgical stabilisation between 2016–2018. Data collected: demographics, operative procedure, preoperative and postoperative PROMs.

Nineteen patients were included. All had preoperative MRIs determining ligamentous involvement. Nine had radiological evidence of instability, eight had negative radiographs. Two were excluded due to no intraoperative radiographs.

There was no statistical difference in preoperative MOxFQ scores between the groups (p=0.2039). Preoperative EQ5D-TTO scores were statistically different (mean mechanical 0.58 vs functional 0.26, p=0.0162) but not EQ5D-VAS scores (mean mechanical 77 vs functional 53, p=0.0806).

Mechanical group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 57.88, 22.13, 18.5. Mean EQ5D-TTO= 0.58, 0.78, 0.84. EQ5D-VAS= 77, 82, 82.5.

Functional group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 71.87, 37.75, 23. Mean EQ5D-TTO 0.26, 0.63, 0.76. EQ5D-VAS 53, 80, 88.

This trend of improvement in PROMs was not reflected in patient satisfaction scores. 75% of respondents in the functional group reported dissatisfaction at 26 weeks versus no dissatisfaction in the mechanical group. We should consider counselling patients accordingly when offering surgery.

Gram staining is used as an initial indicator of synovial joint infection but has widely varied false negative rates in the literature. Clinical decisions are often made on the basis of gram stain results, such as whether a patient requires urgent surgery, and therefore it is important to understand the tests efficacy.

A retrospective review of synovial fluid aspirates in NHS Tayside for the years 2017 and 2018 was performed from the departmental microbiology database. Aspirates of large joints were included (hip, knee, shoulder, wrist, elbow, ankle). Any joints with prosthesis were excluded, including fixation metalwork. Any abscess overlying a joint that was not proven to penetrate the joint was also excluded. Initial gram stain results and formal culture results were reviewed. Final culture results were considered to be the gold standard to compare gram stain results to.

2167 samples were reviewed. Of these 1552 were excluded base on inclusion criteria. Of the remaining 615, 120 (19.5%) were culture positive. There were 33 positive gram stain results, 1 false positive and 32 true positive results. The sensitivity was 26.67% with a specificity of 99.80% (p=0.0001). The negative predictive value is 84.88% (CI 83.44% – 86.21%).

These results show that gram stain tests of native joints have a low sensitivity and poor negative predictive value. This is reflected in the current literature with prosthetic joints. Based on this study caution should be used when interpreting a negative gram stain result with appropriate safety netting and follow up required alongside clinical assessment.

We report a cost-effectiveness analysis of Primary Total Ankle Replacements (TAR). In addition, we looked for factors that could be predictors of increased gain in Quality-Adjusted Life Years (QALYs).

Pre-operative and six-month post-operative data for TAR was obtained over seven-and-a-half-years in NHS Lothian. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and Deprivation category. Continuous variables were assessed with Pearson correlation coefficients, Deprivation and BMI categories with Boxplots and gender with the Mann-Whitney U test.

The 74-patient cohort [Mean age 68.03 (SD 8.61), 60.8% male] had 49% classed as obese or higher. Cost per QALY gained was £3841, rising to £9202 when annual 3.5% reduction in health gains and 1.9% revision rates were included. Lower pre-operative EQ-5D-3L index correlated significantly with increased QALYs gained (p <0.01), all other predictors returned insignificant results (p >0.05).

Primary TAR has proven very cost-effective in treating end-stage ankle arthritis. Pre-operative EQ-5D-3L is the most promising predictor of QALYs gained identified.

This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions.

Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or non-operative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year using the Disabilities of the Arm, Shoulder and Hands (DASH), Oxford Shoulder Scores (OSS) and Short Form (SF-12). Reduction was evaluated using radiographs. Complications were recorded, and an economic evaluation performed.

There was no significant difference in DASH or OSS at one year between non-operative and ORTSD groups (DASH score, 4.67 versus 5.63; OSS, 45.72 versus 45.63). Patients undergoing surgery had inferior DASH scores at 6 weeks (p<0.01). Five patients who failed non-operative management subsequently received surgery. Overall cost of treatment was significantly greater after ORTSD fixation (£796.22 vs £3359.73 (p<0.01)).

ORTSD fixation confers no functional benefit over non-operative treatment at one year. While patients managed non-operatively generally recover faster, a significant group remain dissatisfied following non-operative treatment requiring delayed surgical reconstruction.