Abstracts - 2021

90 - Does hip dislocation increase with the cessation of hip precautions following elective primary total hip arthroplasty?

Rene Gray, Trudie Lewis

James Paget University Hospital, Great Yarmouth, United Kingdom

Background: There is limited evidence to support the case for continuing the use of hip precautions following primary total hip arthroplasty. There is increasing evidence to suggest that allowing patients to move as they feel comfortable with no restriction improves patient function and satisfaction. We investigated the impact of stopping hip precautions on dislocation rates in the first six-weeks and first year post surgery.

Methods: A retrospective cohort study looking at patients who underwent primary total hip arthroplasty was completed looking at one year prior to and one year following the change in protocol. 

There were 329 patients in the “with precautions” group and 261 patients in the “no precautions” group. Patients with restricted weight bearing post-operatively were excluded from the “with precautions” group (n = 1), and patients with limited weight bearing and any hip precautions were excluded from the “no precautions” group (n = 5).

Operative records were used to identify key demographic and operative data. Incidence of primary dislocation were extracted from the Trust patient electronic database. 

Results: The rate of dislocation at 6 weeks in those following standard hip precautions and those not following hip precautions was 0.61% and 0.77% respectively. At 1 year this rose to 0.91% and 1.15% respectively.

The two cohorts were evenly matched for gender, surgical approach, use of cement and operated leg, although the no hip precaution group were slightly older (74 vs 70) with a lower BMI (28 vs 30). 

Conclusions: Cessation of routine hip precautions following elective primary total hip arthroplasty does not appear to increase the rate of hip dislocation in the first year following surgery. 

These findings will hopefully add to the growing evidence finding no negative affect from stopping hip precautions following elective total hip arthroplasty and increase confidence to change practice at other UK sites.

413 - Is the deep squat test a valid and reliable test for the diagnosis of femoral acetabular impingement? A systematic review

Simon Wood^1,2, Meredith Newman^1,2, Martha Batting², Karen Barker^1,2

¹Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom. ²Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom

Background: Femoral acetabular impingement syndrome (FAIS) is a painful hip condition impacting on activities that that involve large range of hip movements such as squatting. The deep squat test (DST) is a functional, weight-bearing test used by physiotherapists to assist in the diagnosis of FAIS. Laboratory based DST kinematics studies have demonstrated reduced squat range and abnormal pelvic biomechanics in people with FAIS.  However, the psychometric properties of the DST in a clinical environment are unclear. 

Objective: To examine the evidence for the validity and reliability of the DST to determine its clinical utility diagnosing FAIS.

Method: A Systematic Review following the (PRISMA) guidelines and registered with PROSPERO (CRD42020199249). 

Two reviewers searched eight databases up until April 2021. Medical Subject Headings, synonyms, key words, free text key words and wild cards tailored to individual databases were used to search for peer-reviewed studies in any language.

Data was extracted independently and the QUADAS-2 tool was used to evaluate the risk of bias and applicability of primary diagnostic accuracy studies.

Result: The search netted 1138 abstracts. Screening excluded 1119 articles and 1 met the criteria. Synthesis was not possible. No studies investigated reliability. One study (n=78 hips) investigated criterion-based validity. QUADAS demonstrated low risk-of-bias. The DST likelihood ratio for a positive test was 1.3 (95% CI 0.9–1.7) and a negative test 0.6 (95% CI 0.3–1.2). The pre-test probability improved to 20% with a negative squat test and a 30% pre-test probability improved to 36% following a positive test.

Conclusion: Physiotherapists should use the DST with caution.  

Impact: Further studies are needed to assess inter-rater and test-retest reliability of the DST in patients with FAIS and to determine if laboratory-based observations of abnormal pelvic biomechanics and squat depth in FAIS can be identified by physiotherapists in a clinical setting.

433 - Physiotherapy Process Benchmarking: Analysis of Current Practice

Katherine Hodson¹, Dolina Birchall², Bibhas Roy²

¹St Helens and Knowsley Hospitals NHS Trust, Liverpool, United Kingdom; ²Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom

Background: There is no data to suggest how many physiotherapy sessions a patient will require following shoulder surgery, nor is there literature addressing attempts to standardise this. To inform the development of such treatment norms, a study was undertaken to observe existing practice. The aim was to analyse post-operative physiotherapy provision in order to benchmark average number of treatments required for different shoulder surgeries.

Methods: A five hospital, single trust, multi-surgeon retrospective review of all elective shoulder surgery patients between January 2018-March 2020 who were referred onto the physiotherapy service, was performed. Outcome metrics included duration and number of treatments, and number of appointments cancelled or unattended (DNA), with subgroup analysis for each procedure. Multivariate analysis of variance (MANOVA) was used for analysis. 

Results: 807 patients (mean age 55 years, range 14-89) were included. Age had no significant impact on any of the metrics. Duration of treatment was strongly positively correlated with number of treatments (Pearson correlation coefficient 0.77). 385 (47.7%) of patients completed their treatment within 100 days, but outliers were seen, including in the reverse total shoulder arthroplasty subgroup (range 1-649 days of treatment, IQR 118.5). Significant differences were seen in number and duration of treatments when grouped according to procedure. There was no correlation between duration of treatment and number of DNAs, but there was a weak correlation between duration and number of cancellations by patients. 

Conclusion: Analysis shows significant differences in metrics between subgroups. This provides practice-based evidence with which to benchmark recovery timeframes. A standardised physiotherapy management pathway incorporating realistic patient target setting and prompt outlier identification, will enhance the therapy pathway. This will enable early intervention for those who require escalation. This model could be replicated across different orthopaedic subspecialties.

1088 - Survey: Are Hip Precautions Necessary on Discharge Following Hemiarthroplasty for Neck of Femur Fractures?

Sundas Butt, Kishore Dasari, Prateek Gupta, Faizan Hussain, Ravindra Mahajan, Gurbhinder Nandhara, Emad Mallick, Eyaz Lakdawala

George Eliot Hospital NHS Trust, Nuneaton, United Kingdom

Introduction: The British Orthopaedic Association’s (BOA) ‘Blue Book’ does not recommend the routine practice of hip precautions following hemiarthroplasty for neck of femur fractures. It states: ‘hemiarthroplasty introduced via an anteror-lateral approach should no longer be used’. Valuable therapist time is utilised alongside the need for specialised equipment, which can potentially delay discharge. Our aim was to explore the current practice of hip precautions on discharge following hemiarthroplasty for hip fractures across trauma and orthopaedic departments in the UK. In addition, to assess the necessity of hip precautions and identify any areas for improvement.

Methods: An online survey was distributed to trauma and orthopaedic trainees from CT to Consultant level across 26 different UK trusts. The survey included both closed and open questions. Overall, 55 responses were collected over a four-month period.

Results: 72.7% of respondents were aware of the ‘Blue Book’ recommendations, but 22.6% did not follow hip precautions for post-hemiarthroplasty patients. 90.6% used the anteror-lateral approach, consistent with the approach mentioned in the ‘Blue Book’. In addition, 84.9% did not notice any increased risk for dislocations in the absence of hip precautions. 76.4% felt hip precautions should not be practiced and 85.5% agreed that patients failed to comply with hip precautions.

Conclusion: Hip precautions are not widely regarded as a useful practice for post-hip hemiarthroplasty. They are viewed as increasing costs and resources when they are being implemented as mandatory practice. Thus, this potentially delays discharge overall and increases the risk of patient’s acquiring hospital-acquired infections. A consistent approach should be followed across all trusts and in collaboration with both physiotherapists and clinicians.

Implications: Changing the practice to follow the BOA guidance is recommended. For hip precautions to instead be included as post-operative advice, such as with information leaflets given to patients on discharge.

1096 - Do baseline scores or comorbidities affect patient-reported outcome measures following first metatarsophalangeal joint arthrodesis?

Martin Hughes, Linzy Houchen, Vidhi Adukia, Vaarun Burgula, Jitendra Mangwani

University Hospitals of Leicester, Leicester, United Kingdom

Background: First metatarsophalangeal joint (MTPJ) arthrodesis is the gold standard treatment for patients with end-stage arthritis. The Manchester – Oxford foot questionnaire (MOxFQ) and EuroQol-5D (EQ-5D) are patient reported outcome measures (PROMs) commonly used following MTPJ arthrodesis. However, the impact of baseline scores and patient comorbidities on these PROMs is unknown.

Aim: The aim of this study was to identify the change in PROMs measured by MOxFQ and EQ-5D following first MTPJ arthrodesis, and to determine if the baseline score, and/or the presence of comorbidities affected this change seen.

Methods: Data was collected prospectively from patients who had undergone first MTPJ arthrodesis. This included comorbidities, baseline PROMs and PROMs following surgery.

Results: A total of 90 patients were identified, of which 52 had complete PROMs data. Mean age was 56.9 +/- 17.8 years, and male to female ratio was 11:39. Comorbidities included diabetes (2%), hypertension (21%), rheumatoid arthritis (RA) (43%) and current smokers (10%). Majority of cases were unilateral (94%) and 37% of patients had other foot procedures carried out concurrently.

A significant change was seen in all domains of the MOxFQ as well as in the MOxFQ and EQ-5D total (p<0.01). Baseline scores of both PROMs were significantly correlated with the change seen (r=0.5 and 0.6 respectively, p<0.001). Presence of RA was found to significantly reduce the change in the EQ-5D total (p<0.05).

Conclusion: Following first MTPJ arthrodesis, statistically significant changes were observed in EQ-5D and MOxFQ total, and all the MOxFQ sub-domains. Baseline scores in both PROMs were correlated with the change seen in scores following surgery, suggesting that we may be able to identify a baseline score which could predict outcomes. Presence of RA dampened the change seen in EQ-5D total which is useful to know when having pre-operative discussions with patients.

1143 - Therapy contributions to a systemic rapid recovery change programme in elective orthopaedics

Alexa Coyle¹, Rebecca Fox¹, Ashley McClean¹, Penny Palmer¹, Ruth Griffiths², Luke Brunton¹

¹Northern Devon, Barnstaple, United Kingdom; ²Zimmer Biomet UK Ltd, Swindon, United Kingdom

Rising length of stay (LoS) and increased demand for elective hip and knee surgery in 2018 triggered a multidisciplinary change programme at Northern Devon Healthcare NHS Trust. With external project support from Zimmer Biomet the entire patient pathway was reviewed from preoperative through theatres and in-patient care to discharge, aiming to identify sustainable opportunities for improvement. 

Therapy interventions included trial of a Taurus^TM walking frame enabling early regain of a step-through gait pattern, maintaining and promoting joint range and muscle group co-contractions. The Taurus frames, alongside training and education of nursing colleagues, gave confidence to embrace early mobilization on day of surgery and a cultural shift in expectations and roles across staff and patients. This removed dependence on availability of therapy staff to initiate mobility with 97% patients now mobilized within 8 hours of surgery (57% within 4 hours). 

The preoperative ‘joint school’ was re-organised, now providing a personalised discharge planning process and education more timely in the patient pathway. Clinical criteria for discharge and equipment needs are identified and ‘owned by’ the patient. The initial therapy interview is streamlined and waste work by therapy staff preparing patients who swap providers or lost equipment prescriptions is reduced. There is added value in patients having a greater lead in their own care needs. Currently average LoS for those attending joint school is 1.3 days compared to 1.5 days not attending. 

Evaluation of the project has been systemic and multidisciplinary interventions have been concurrent therefore attribution of specific changes to the overall improvements is difficult. However, LOS for THR and TKR reduced dramatically over 2 years (4.2 to 1.36 days and 3.8 to 1.18 days respectively). There has been an associated increase in operational capacity of 61% and reduction in cost of per patient of greater than £1000 (THR £1136; TKR £1048).

253 - Real time measurement of intramuscular pH during routine knee arthroscopy and arthroplasty using a tourniquet: A preliminary study

David MacDonald¹, David Neilly², Kirsten Elliott³, Alan Johnstone⁴

¹Aberdeen Royal Infirmary, Aberdeen, United Kingdom; ²Royal Adelaide Hospital, Adelaide, Australia. ³University Hospital Southampton, Southampton, United Kingdom; ⁴Aberdeen, Aberdeen, United Kingdom

Aims: Tourniquets have potential adverse effects including postoperative thigh pain, likely caused by their ischaemic and compressive effects. The aims of this preliminary study were to determine if it is possible to directly measure intramuscular pH in human subjects over time, and to measure intramuscular pH changes resulting from tourniquet ischaemia in patients undergoing routine knee arthroscopy and knee arthroplasty (TKR).

Methods: For patients undergoing knee arthroscopy and TKR, a sterile calibrated pH probe was inserted into the anterior fascial compartment of the leg after skin preparation, but before tourniquet inflation. The limb was elevated for 3 minutes prior to tourniquet inflation to 250 or 300mmHg. Intramuscular pH was recorded at one second intervals throughout the procedure and for 20 minutes following tourniquet deflation. Probe-related adverse events were recorded.

Results: 39 patients were recruited (27 arthroscopy and 12 TKR). Mean tourniquet time was 21 minutes for arthroscopy and 74 minutes for TKR. Mean muscle pH prior to tourniquet inflation was 6.80 in the arthroscopy group and 6.74 in the TKR group (p=0.37). In both groups muscle pH decreased upon inflation, with a steeper fall in the first 10 minutes than for the rest of the procedure. Change in muscle pH was significant after 5 minutes of tourniquet ischaemia (p<0.001). In the arthroscopy group mean muscle pH prior to tourniquet release was 6.58 and recovered to 6.75 within 20 minutes following release. In the TKR group the mean muscle pH prior tourniquet release was significantly lower (6.35 p=0.002) and recovered to 6.54 within 20 minutes following release. No probe-related adverse events were recorded.

Conclusion: It is possible to directly measure skeletal muscle pH in human subjects over time. Tourniquet ischaemia results in a decrease in human skeletal muscle pH over time, with a greater decrease seen in TKR than knee arthroscopy. 

270 - Use of a Blast Wave Represents a Novel Therapy for Enhancing the Osteogenic Capacity of Mesenchymal Stem Cells

Sarah Stewart^1,2, Alastair Darwood¹, Spyros Masouros¹, Claire Higgins³, Arul Ramasamy^1,2

¹Centre for Blast Injury Studies, Imperial College London, London, United Kingdom; ²Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom; ³Department of Bioengineering, Imperial College London, London, United Kingdom

Background: Combat related fractures have a high non-union rate. With limited treatment options, mesenchymal stem cells (MSCs) are emerging as a possible therapy. Blast victims present with a high incidence of Heterotopic Ossification, with the mechanism of action postulated as being transfer of energy from the blast wave stimulating osteoblastic transformation of MSCs.

The aim of this study was to investigate whether a blast wave can induce osteoblastic transformation in MSCs and therefore offer a novel therapy to aid fracture healing. 

Methods: Human bone marrow-derived MSCs were exposed to four blast wave pressures (15, 30, 45 and 60psi) generated by a custom-made shock tube. The expression of three osteogenic genes (RUNX2, ITGAV, DLX5) was assessed at 24h. Calcium mineralisation (an endpoint marker of osteoblast formation) was assessed at day 7 and 14.

Results: Analysis of osteogenic gene expression at 24 hours demonstrated a statistically significant upregulation of RUNX2 expression by 3 fold (3.03±0.89, p<0.05) and ITGAV expression by almost 2.5 fold (2.41±0.17, p<0.05) in the 45 psi test group compared to control samples (1.00±0.35). 

Calcium mineralisation assays at day 7 demonstrated a statistically significant rise in the 45 psi (4.05±0.41mg/dl, p<0.05) and 60 psi test groups (4.37±0.30mg/dl, p<0.01) compared to control samples (2.93±0.75mg/dl). At day 14, a statistically significant rise in calcium mineralisation was observed in the 60 psi test group compared to control samples (10.44±2.18mg/dl vs. 6.51±2.03mg/dl, p<0.05). 

Conclusion: This study is the first to demonstrate the osteogenic potential of blast waves. Exposure of MSCs to a blast wave before implantation into a non-union can increase osteogenesis, and should be considered as a novel therapy for improving the chances of fracture union.  

161 - Outcomes after peri-operative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

COVIDSurg Collaborative

University of Warwick, Coventry, United Kingdom

Background: Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with peri-operative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multi-variate analysis.

Methods: This prospective, international, multicentre cohort study included patients undergoing any operation for a proximal femoral fracture from 1^st February to 30^th April 2020 and with perioperative SARS-CoV-2 infection (either 7-days prior, or 30-days post-operative). The primary outcome was 30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.  

Results: This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68-3.13, p=0.000), age >80 years (OR 1.60, 95% CI 1.1-2.31, p=0.013), pre-operative diagnosis of dementia (OR 1.57, 95% CI 1.15-2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18-2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06-2.48, p=0.025). 30-day mortality was lower in patients with a pre-operative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42-0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220), or type of anaesthetic given (p=0.787).

Conclusion: Patients undergoing surgery for a proximal femoral fracture with a peri-operative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful pre-operative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

296 - IMPACT-Global: Prevalence, Clinical Predictors and Mortality Associated with COVID-19 in Hip Fracture Patients. An international multicentre study of 7,090 patients

Andrew Hall^1,2,3,4, Nick Clement^1,2,3,4, IMPACT-Global Group^4,3, Cristina Ojeda-Thies⁵, Alastair MacLullich^3,6, Giuseppe Toro⁷, Antony Johansen⁸, Timothy White^1,2,4, Andrew Duckworth^1,2,4

¹Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²Scottish Orthopaedic Research Trust into Trauma (SORT-IT), Edinburgh, United Kingdom; ³Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, Edinburgh, United Kingdom; ⁴Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; ⁵Department of Traumatology and Orthopaedic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain; ⁶Department of Geriatric Medicine & Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; ⁷Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy; ⁸University Hospital of Wales; Cardiff University; National Hip Fracture Database, Royal College of Physicians, Cardiff, United Kingdom

This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.

A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1^st March-31^st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.

A total of 7090 patients were included, with a mean age of 82.2 (range 50-104) years and 4959 (70%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) became positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p=0.001), residential care (OR 2.15, p<0.001), inpatient fall (OR 2.23, p=0.003), cancer (OR 0.63, p=0.009), ASA grade 4-5 (OR 1.59, p=0.008; OR 8.28, p<0.001), and longer admission (OR 1.06 for each increasing day, p<0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p<0.001).  COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p<0.001). Increasing age (HR 1.03, p=0.028), male sex (HR 2.35, p<0.001), renal disease (HR 1.53, p=0.017), and pulmonary disease (HR 1.45, p=0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.

The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher mortality risk.

832 - The Safe Resumption of Elective Orthopaedic Services following the first wave of the SARS-CoV-2 pandemic: a review of 2316 consecutive cases and implications for recovery following the current wave

Vipin Asopa, Amit Sagi, Habeeb Bishi, Fanuelle Getachew, Yiannis Vyrides, Irrum Afzal, David Sochart, Vipul Patel, Deiary Kader

South West London Elective Orthopaedic Centre, London, United Kingdom

There is little published on the outcomes after re-starting elective orthopaedic procedures following cessation of surgery due to the SARS-CoV-2 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection whilst undergoing elective orthopaedic surgery was 18-20%.

The aim of this study is to report the surgical outcomes, complications and the risk of developing SARS-CoV-2 in 2316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographics, ASA, BMI, 30-day re-admission rates, mortality and complications at one and six-weeks intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019.

2316 patients underwent surgery in 2020 compared to 2552 in the same period in 2019. There was no statistical difference in gender distribution, BMI or ASA grade found. The 30-day readmission rate and 6-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p<0·05).  No deaths were reported at 30-days in the 2020 group as opposed to three in the 2019 group (p<0·05). 

In 2020, one patient developed SARS-CoV-2 symptoms 5 days following foot and ankle surgery with no evidence that this was a direct result of undergoing surgery.

Elective surgery was safely resumed following the cessation of operating during the SARS-CoV-2 pandemic in 2020. Strict adherence to protocols resulted in elective surgical procedures being performed with lower complications, readmissions and mortality compared to 2019. Furthermore, only one patient developed Covid-19 with no evidence that this was a direct result of undergoing surgery.

1160 - The Global Impact of COVID-19 on Surgeons and Team Members (Global COST) Study

Zahra Jaffry¹, Siddarth Raj², Antony Yiu³, Anshul Sobti³, Ahmed Negida⁴, Bijayendra Singh⁵, Peter Brennan⁶, Mohamed Imam³, OrthoGlobe Collaborative³

¹The Royal London Hospital, London, United Kingdom; ²King's College London, London, United Kingdom; ³Ashford and St Peter's Hospitals, Surrey, United Kingdom; ⁴University of Portsmouth, Portsmouth, United Kingdom; ⁵Medway Hospital, Kent, United Kingdom; ⁶Portsmouth Hospital, Portsmouth, United Kingdom

Background: Healthcare workers have had to make rapid and drastic adjustments to their practice in response to the COVID-19 pandemic. This work describes the effect on their physical, mental, financial and family well-being and assesses the support provided by their institutions.

Methods: An online survey was distributed through medical organisations, social media platforms and collaborators to staff based in an operating theatre environment. 

Results: 1590 responses were received from 54 countries from the 15^th of July to the 15^th of December 2020. The average age of participants was between 30 and 40 years old, 64.9% were male, 79.5% were surgeons, 6.2% nurses, 5.4% assistants, 4.2% anaesthetists, 1.7% operating department practitioners and 3.0% classed as other.  Of the total, 32.0% had become physically ill since the start of the pandemic. Physical illness was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82-7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18-2.06; p=0.002). Those with a decrease in salary (29% of participants) were more likely to have an increase in anxiety (OR 1.50; CI 1.19-1.89; p=0.001) and depression scores (OR 1.84; CI 1.40-2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression score (OR 1.74; CI 1.34-2.26; p<0.001). In terms of support, only 36.0% had easy access to occupational health services, 44.0% to mental health services, 16.5% to 24 hour rest facilities and 14.2% to 24 hour food and drink facilities. Participants from a country with a low Human Development Index were significantly less likely to have these measures in place.

Conclusion/Findings: This work has highlighted ways in which to improve conditions for the health workforce which will inevitably have a positive impact on the care received by patients.

57 - Social and Environmental Benefits of Virtual Fracture Clinics in Trauma and Orthopaedic Surgery: Reduced Patient Travel Time, Patient Cost and Air Pollutant Emissions

Jose Fort, Hannah Hughes, Usama Khan, Aaron Glynn

Our Lady of Lourdes Hospital, Drogheda, Ireland

Background: Several papers have analysed the clinical benefits and safety of Virtual Fracture Clinics (VFC). A significant increase in the use of Trauma and Orthopaedic (T&O) VFC was seen during the COVID-19 pandemic. This study aims to investigate the social impact of VFC on the travel burden and travel costs of T&O patients, as well as the potential environmental benefits in relation to fuel consumption and travel-related pollutant emissions.

Methods: All patients referred for T&O VFC review from March 2020 to June 2020 were retrospectively analysed. The travel burden and environmental impacts of hypothetical face-to-face consultations were compared with these VFC reviews. The primary outcomes measured were patient travel time saved, patient travel distance saved, patient cost-savings and reduction in air-pollutant emissions.

Results: Over a four-month period, 1359 VFC consultations were conducted. The average travel distance saved by VFC review was 88.6 kilometres (range 3.3-615), with an average of 73 minutes (range 9-390) of travel-time saved. Patients consumed, on average, 8.3 litres (range 0.3-57.8) less fuel and saved an average of €11.02 (range 0.41-76.59). The average reduction in air-pollutant vehicle emissions, including carbon dioxide, carbon monoxide, nitric oxide and volatile organic compounds was 20.3 kilograms (range 0.8-140.8), 517.3 grams (g) (range 19.3-3592.3), 38.1g (range 1.4-264.8) and 56.9g (range 2.1-395.2), respectively.

Conclusion: VFC reduce patient travel distance, travel time and travel costs. In addition, VFC confer significant environmental benefits through reduced fuel consumption and reduction of harmful environmental emissions.

71 - Covid-19 impact on distal Radius FractUre (CORFU): Do pandemics change orthopaedic clinical practice?

Ignatius Liew, Rosamond Tansey, Albert Ngu, Jaison Patel, Aaron Rooney, George Hourston, Hammad Sadique, Will Matthews, Saima Wassim, Kriti Singhania, Jeeshan Rahman, Abin Varghese, Abhilash Singhal, Abhilash Singhal, Sumon Huq, Kanatheepan Shanmuganathan, Maria Popescu, Vishal Kumar, Raisa Islam, Shahanoor Ali, Emily Crane, Rishi Dhir, Gohar Naqvi, Mira Pecheva, Wayne Ng, Sofia Eriksson, Ayla Newton, Humza Osmani, Ahmad Al-Sukaini, Jonny Lennihan, Daniel Bye, Lora Young, Anish Sanghraj, Niel Kang, Phillip Johnston, John Britton, Katerina Hatzantoni

East of England Orthopaedics, Cambridge, United Kingdom

The coronavirus pandemic has caused a shift in healthcare resources and the effects on distal radius fracture management are unknown. 

We aim to study the treatment of distal radius fractures. A multicentre prospective cohort study studied all distal radius fractures between 1st April 2020 and 31st May 2020. We classified the fractures using AO classification. Demographics and management were studied in accordance with NICE guidelines and British Orthopaedic Association Audit Standards for Trauma (BOAST). 8 NHS hospitals contributed. 316 patients were followed up with a total of 252 non-operative distal radius fractures and 67 (21%) operative distal radius fractures, of which 74% received a plate fixation. Due to the pandemic, 21.4% (54/252) of patients in the non-operative arm were discharged directly from 1st orthopaedic review and clinic, of which 18 patients receiving soft cast. 50/252 patients in the non-operative treatment group would have been operated in a non-pandemic situation, of which 34% (17/50) of patients reported short term complications (p=0003*). 5/50 patients refused surgery due to the pandemic. 5/252 patients required further surgery, 1 for extensor indicis proprius (EIP) rupture, 1 for displacement of fragment and 3 awaiting osteotomy. There was a significant variation in practice accordingly to BOAST, specifically length and type of immobilisation, methods of analgesia for manipulation and treatment modality.  

The indication for surgery to maintain function after a distal radial fracture should not differ from standard of practice recommended by evidence. There was a variation in practice as well as shift in management of these patients, potentially leading to longer term complications. We recommend that in these patients, guidance from the British Orthopaedic Association is required, in order to develop a strategy for potential elective procedures. We must ensure a shared decision-making process is achieved that is Montgomery compliant, especially in these unprecedented times.

156 - 120-day mortality rates for hip fracture patients with COVID-19 infection

Tobenna Oputa¹, Leanne Dupley¹, James Bourne²

¹Health Education North West, Manchester, United Kingdom; ²Lancashire Teaching Hospitals, Preston, United Kingdom

Background: Increased 30-day mortality rates have been reported for hip fracture patients with COVID-19.  Due to nosocomial spread and the variable incubation period, longer follow-up is required to evaluate the true mortality. We aim to assess 120-day mortality rates in hip fracture patients with COVID-19 compared to those without presenting during the same period.

Methods: We reviewed all patients aged ≥60 admitted with a hip fracture between 5^th April and 5^th May 2020 across nine U.K. trauma units. Gender, age, injury, treatment, comorbidities, time of diagnosis and death were recorded. Comparison was made using unpaired t-tests and Pearson’s Chi Squared test between patients with and without COVID-19. Kaplan-Mayer survival analysis and Cox regression analysis were performed to assess mortality rates and the association between patient characteristics and survival times.

Results: Data were collected for 265 patients. Eighty male, 185 female. Two-hundred and fifty patients underwent surgery. Forty-six patients had COVID-19, these patients were more likely to be male (p<0.01). Twenty-three patients were diagnosed with COVID-19 ≥14 days following admission. There was no difference in age (p=0.07) or Charlson Comorbidity Index (p=0.51) between those with and without COVID-19.  Mortality at 120 days was significantly greater in patients with COVID-19 at 63% compared to 17% in patients without (p<0.01). This was also increased on subgroup analysis by gender and surgical treatment. Multivariate analysis demonstrated decreased survival time in patients with previous MI (HR 2.87).

Conclusion/Findings: This is the only study reviewing 120-day mortality rates for hip fracture patients with COVID-19 infection, which we report is significantly increased at 63% compared to 17% for those without COVID-19. Previous MI was associated with increased mortality. This is useful when planning treatment, consenting and counselling patients. With 50% patients being diagnosed with COVID-19 ≥14 days, we highlight the importance decreasing nosocomial infection in hip fracture patients.

323 - Resuming Elective Orthopaedic Services During the COVID-19 Pandemic: Our Experience

Rongkagorn Chuntamongkol, Rebekah Meen, Sophie Nash, Nick Ohly, Jon Clarke, Nicholas Holloway

NHS Golden Jubilee, Glasgow, United Kingdom

Introduction: The Corona virus 2019 (COVID-19) spread globally at the start of 2020 led the National Health Service (NHS) to halt all non-essential and elective services in March 2020 (1). Data had also emerged that trauma and elective surgery were linked with increased morbidity and mortality associated with perioperative COVID-19 infection (2). As COVID-19 numbers declined in June 2020, planned elective services were able to resume, but a safe protocol to minimise risk of in-hospital COVID-19 transmission and associated perioperative morbidity and mortality had to be developed and employed to reduce risk to patients.           

Method: This was a prospective study of all elective orthopaedic patients within an elective unit running a green pathway at a COVID-19 light site. Rates of preoperative and 15-day postoperative COVID-19 symptoms or infection were examined for a period of six months in the first instance.  The unit resumed elective orthopaedic services on the 29^th June 2020 at a reduced capacity for a limited number of day case procedures with strict patient selection criteria, increasing to full service on the 29^th August 2020 with no patient selection criteria. 

Results: A total of 1352 cases were planned in the six-month study period. Surgery was cancelled in 35 cases, two of which were due to having a preoperative positive COVID-19 screening test result. Of the remaining 1317, 603 (46%) were male and 715 (54%) were female. The mean age was 65 years. Hip and knee arthroplasties accounted for the majority of the operations (76%). Fifteen patients were tested for COVID-19 within 15 days after discharge, only one patient tested positive (0.076%).  Contact tracing suggested this was family transmission rather than hospital transmission.

Conclusion: Through strict application of a COVID-19 green pathway, elective orthopaedic surgery could be safely delivered to a large number of patients with no selection criteria.

430 - Post Covid Sequelae orthopaedic associated symptoms of 60 patients: A case series with 8 months of follow up

Karun Jain Mch¹, Swathi Jami²

¹Shree Mahaveer Ortho Clinic, Delhi, India; ²Dr RML Hospital, Delhi, India

Introduction: Post Covid-19, pulmonary complications are well understood but there are no studies that specifically investigate the frequency, characteristics and presentation patterns of orthopaedic associated symptoms in COVID-19 recovered patients. 

Objective: to evaluate the variety of orthopaedic symptoms and their frequency, localization, and severity in covid recovered patients to understand better, impact of Covid-19 on musculoskeletal system. 

Methods: Diagnosed & recovered 60 cases of Covid-19, who were admitted between June & July 2020 & visited orthopaedic OPDs for regular monthly follow-up were prospectively analysed for 8 months. Clinical examination and questionnaire about orthopaedic symptoms and their frequency, localization, severity and their use of analgesics & overall quality of life. 

Results: 60 post covid recovered patient, who were available for 8 months of follow up were included. Complaints of the patients were 81.6% (49) fatigue, 73.3% (44) muscle cramps, 66.7 % (40) large joint arthralgia, 51.6% (31) Small joint arthralgia, 48.3 (29) headache, 36.7% (22) back pain, 23.3% (14) chest pain and 15% (9) non-specific pain. An average of 3 analgesic medicines per week were consumed by study patients. 28 patients were working office population and had taken average of 24 days off in 8 months follow-up. 

Conclusion: Our 8 months follow-up data revealed that fatigue, muscle cramps, large & small joint arthralgia and back pain can be seen in patients at varying rates for a longer duration after covid recovery, which in turn affects their day-to-day life and PQLI. Long term analgesic intake is another area of concern.

Keywords: Post covid sequelae, Orthopaedic symptoms, arthralgia, COVID-19, Cramp, Pain

564 - 120-day mortality rates for hip fracture patients with COVID-19 infection

Tobenna Oputa¹, Leanne Dupley¹, James Bourne²

¹Health Education North West, Manchester, United Kingdom; ²Lancashire Teaching Hospitals, Preston, United Kingdom

Background: Increased 30-day mortality rates are reported for hip fracture patients with COVID-19. Due to nosocomial spread and variable incubation period, longer follow-up is required to evaluate the true mortality. No studies have examined mortality rates beyond 45 days. We assess 120-day mortality rates in hip fracture patients with and without COVID-19 presenting synchronously.

Methods: We reviewed patients aged ≥60 admitted with a hip fracture between 5^th April and 5^th May 2020 across nine U.K. hospitals. Demographics, injury type, treatment, commodities, time of diagnosis and death were recorded. Comparison was made using unpaired t-tests and Pearson’s Chi Squared test between patients with and without COVID-19. Kaplan-Mayer survival analysis and Cox regression were performed to assess mortality rates and analyse the association between patient characteristics and survival times.

Results: Data were collected for 265 patients. Eighty male, 185 female. Forty-six had a diagnosis of COVID-19. Patients with COVID-19 were more likely to be male (p<0.01) Twenty-three (50%) were diagnosed with COVID-19 ≥14 days following admission. There was no difference in age (p=0.07) or Charlson Comorbidity Index (p=0.51) between those with and without COVID-19. Mortality at 120 days was at 63% (95%CI 49%-77%) in patients with COVID 19 and 17% (95%CI 12%-22%) in patients without. This was also increased on subgroup analysis by gender and surgical treatment. Previous MI was shown to be the only indicator of decreased survival on Multivariate analysis (HR 2.87).

Conclusion: At the time of writing, this is the only study to report 120-day mortality rates. We report that this is significantly increased at 63%. Previous MI predicts increased mortality. This information is useful for clinicians when planning treatment, consenting and counselling patients. With half of patients being diagnosed with COVID-19 at ≥14 days following admission we also highlight the importance decreasing nosocomial infection in hip fracture patients.

872 - Corticosteroid injections are safe to use in the shoulder and elbow during COVID-19 pandemic

Parag Raval, Matthew Baguley, Rajesh Bhatt, Radhakant Pandey

University Hospitals of Leicester, Leicester, United Kingdom

Background: During the initial part of the COVID-19 pandemic corticosteroid injections (CSI) were stopped. Subsequently the BOA/NHS advised a cautious approach to CSI including a reduced dose, suggesting it could lead to greater susceptibility to COVID-19 or more severe symptoms.

Aim: Whether patients undergoing CSI for shoulder and elbow conditions have an increased risk of developing COVID-19 infection or have worse symptoms.

Methods: Patients who underwent CSI to the shoulder and elbow between July 2020- February 2021 were included. Patients were consented for the possible increased risk of COVID-19. CSIs were performed in outpatient setting using 40mg or 20mg of Depomedrone with 0.5% Marcaine. Patient were followed up at 6 and 12 weeks and asked in detail from an exhaustive list about COVID-19 symptoms/tests which were recorded.

Results:  All 76 patients having CSI were included. Mean age 57 (29-76).  Female: Male (32: 44). 4 patients had diabetes. 3 patients received 20mg of Depomedrone, the rest had 40mg. Indications were: 11 Acromioclavicular Joint osteoarthritis (OA), 17 Frozen shoulder and 1 elbow OA. 35 patients for subacromial impingement or calcific tendonitis, 10 Tennis elbow and 2 for Golfer’s elbow. At follow up no patient had suffered any COVID-19 symptoms, from the comprehensive list, nor required testing. 10 patients subsequently went on to have surgery, requiring pre-operative COVID-19 testing and were all negative. Additionally, post-surgery no patients has yet developed COVID-19 symptoms.

Conclusion: In our study group no patients who was given a CSI for shoulder and elbow conditions developed clinical symptoms of COVID-19 nor tested positive post injection. We suggest that CSI is a safe intervention in the shoulder and elbow during the pandemic especially when opportunities for surgical intervention are limited.  Appropriate precautions like mask wearing and hand washing as well as clear discussion with patients are important.

878 - Increased rate and severity of self-harm related orthopaedic injuries among children and adolescents during lockdown: a major trauma centre experience

Gemma Green, Anouska Ayub, Mathew Sewell, Nicholas Birkett, Fady Sedra, Manoj Ramachandran, Claudia Maizen, Paulien Bijlsma, Dimitrios Manoukian, Gregory Firth

Royal London Hospital, London, United Kingdom

Introduction: COVID-19 has had a significant impact on health services worldwide. Given the dramatic change in social circumstances imposed to prevent disease transmission, it was hypothesised that there would be an increased demand on secondary care in the treatment of children and adolescents with mental health conditions, and that in the case of deliberate self-harm related orthopaedic injuries, there would be an increase in severity.  

Methods: A retrospective cohort study was performed including the 10 months prior to and 10 months following the first national lockdown on March 23rd 2020 in the setting of a single UK based large urban major trauma centre. 78 patients pre-lockdown and 143 peri-lockdown were included, mean age 15 (range 8-18). Main outcome measures were the number of mental health related attendances; subdivided into deliberate self-harm, overdose, or pure mental health crisis. Severity was graded for each category.

Results: 82% increase in number of admissions observed after 23rd March 2020, with an increased proportion of these involving DSH. Overall the severity of admissions presenting was unchanged using the paediatric trauma score and toxbase indicators, however significantly more patients post-lockdown required orthopaedic treatment (0 pre-lockdown/8 post-lockdown, p<0.05).  

Conclusion: Lockdown was associated with almost double the rate of mental health attendances in children to a UK major trauma centre, with significantly more severe DSH patients requiring orthopaedic treatment. This highlights the negative impact of social restrictions and COVID-19 on our vulnerable younger population, which may have long term repercussions.

1186 - Meta‑analysis and metaregression of risk factors associated with mortality in hip fracture patients during the COVID‑19 pandemic

Firas Rahean¹, Djamila Rojoa¹, Jvalant Parekh¹, Reshid Berber², Robert Ashford¹

¹Leicester Royal Infirmary, Leicester, United Kingdom; ²University Hospitals of Nottingham NHS Trust, Nottingham, United Kingdom

Background: Incidence of hip fractures has remained unchanged during the pandemic with overlapping vulnerabilities observed in patients with hip fractures and those infected with COVID-19. We aimed to investigate the independent impact of COVID-19 infection on the mortality of these patients. 

Methods: Healthcare databases were systematically searched over 2-weeks from 1st–14th November 2020 to identify eligible studies assessing the impact of COVID-19 on hip fracture patients. This study was registered at the International Prospective Register of Systematic Reviews, PROSPERO, (CRD42020219709) and is reported according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards. Meta-analysis of proportion was performed to obtain pooled values of prevalence, incidence and case fatality rate of hip fracture patients with COVID-19 infection. 30-day mortality, excess mortality and all-cause mortality were analysed using an inverse-variance mixed-effects model. 

Results: 22 studies reporting 4015 patients were identified out of which 2651 (66%) were assessed during the pandemic. An excess mortality of 10% was seen for hip fractures treated during the pandemic (OR 2.00, p=0.007), in comparison to the prepandemic controls (5%). Estimated mortality of COVID-19 positive hip fracture patients was four-fold (RR 4.59, p<0.0001) and 30-day mortality was 38.0% (HR 4.73, p<0.0001). The case fatality rate for COVID-19 positive patients was 34.74%. Between-study heterogeneity for the pooled analysis was minimal (I²=0.00) whereas, random-effects metaregression identified subgroup heterogeneity for male gender (p<0.001), diabetes (p = 0.002), dementia (p=0.001) and extracapsular fractures (p=0.01) increased risk of mortality in COVID-19 positive patients.

Conclusion: This study has shown an increased overall and 30-day mortality of hip fracture patients treated during the COVID-19 pandemic with concomitant COVID-19 infection being an independent risk factor of mortality. We highlight the impact prevalence and hospital occupancy has had on mortality as surrogate markers of overburdened healthcare systems.

87 - The incidence of surgical cancellations: Lessons learned from the resumption of elective orthopaedic operating after the first wave of COVID-19

Emlyn Amutharasan, Karan Malhotra, Amit Zaveri, Matthew Welck

Royal National Orthopaedic Hospital, London, United Kingdom

Introduction: In the aftermath of the first wave of COVID-19, there was a significant backlog of elective orthopaedic cases. To address this problem, efficient running of theatres with optimal theatre utilisation was paramount. However, as new processes were introduced to reduce transmission risk, ‘last-minute’ cancellations of patients were inevitable. We report our experience of resuming elective work, with particular focus on surgical cancellations, and lessons learned.

Methods: This was a retrospective, single centre audit at a specialist elective orthopaedic hospital. We identified and examined all cancellations in foot and ankle cases between June and October 2020. Data was analysed and cancellations were categorised into groups by reason of cancellation.

Results: There were 36 cancellations out of 193 patients listed (19%). Twenty-one cancellations (57%) were directly related to COVID-19 and its processes. These comprised six patients (17%) with COVID-19 swab related issues including: booking errors, transport problems, non-attendance, and invalid swabs. Three patients (8%) contracted COVID-19 preoperatively. Nine patients (25%) cancelled their procedure at short notice amidst fears of contracting COVID-19 perioperatively. Three (8%) cancellations were due to the patient being unfit on the day of surgery – these issues were not routinely identified at pre-assessment appointments as face-to-face pre-assessment clinics had been suspended. A further 15 cancellations (42%) were due to non-COVID-19 reasons including lack of beds, unwell patients, and patients cancelling for other personal reasons.   

Conclusion: Mitigation of cancellations is a key factor in maintaining theatre utilisation. Based on our experience we recommend thorough counselling of patients regarding the importance of self-isolation prior to surgery and of the pre-operative swab. Having a designated team to manage COVID-19 swabs is also critical. Reinstatement of face-to-face pre-operative assessments may help identify evolving issues and prevent last-minute cancellations. These lessons are pertinent to trusts, particularly as we emerge from subsequent waves of COVID-19.

91 - The impact of Orthopaedic Consultant presence in the Minor Injuries Unit (MIU) during COVID-19: A retrospective analysis

Hamza Akhtar, Ashtin Doorgakant, Richard Gray, Venkat Potluri, Roy Bhati, James Williamson

Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, United Kingdom

Background: Redeployment of orthopaedic consultants (OCs) to a minor injuries unit (MIU) during the COVID-19 pandemic provided a unique opportunity to assess the impact of early senior specialist input on patient management.

Methods: Patient demographics, diagnosis, location of injury and disposal method were compared between three seven-day periods; during the April 2020 COVID-19 lockdown (Period-A), one month prior to Period-A (Period-B) and one year prior to Period-A (Period-C). OCs staffed MIU during Period A, and emergency nurse practitioners (ENPs) staffed MIU during Periods B and C.

Results: Period-A witnessed higher rate of fracture diagnoses than Period-B and Period-C (42% vs. 15% vs. 20%, respectively, p<0.001), and lower rate of soft tissue injury diagnoses (21% vs. 51% vs. 47%, p<0.001). This suggests increased injury severity either due to modified activities or altered healthcare-seeking behaviours during lockdown.

For fractures, there was lower rate of referral to fracture clinic (39% vs. 100% vs. 86%, p<0.001) and higher rate of discharge (39% vs. 0% vs. 9%, p<0.001). The mean time to fracture clinic was also longer (19 days vs. 7 days vs 10 days, p<0.001), indicating earlier institution of definitive care, often bypassing the first fracture clinic assessment.

There were no other significant differences between the periods, with MIU waiting times, radiology alerts and complaints received remaining largely unchanged.

Conclusion: Early senior orthopaedic input in the patient journey from MIU had clear benefits and this was most true for fracture diagnoses. Earlier definitive management planning was observed as lower rates of fracture clinic referral, higher rates of discharge, and deferred first fracture clinic reviews.

Implication: This study highlights the benefits of greater partnership between A&E and orthopaedics. As the pandemic subsides and redeployed staff are withdrawn, a modification of this model could be utilised to ensure this partnership is sustainable.

1051 - Foot and Ankle Surgery through two national lockdowns: What have we learned? Results from Phase 2 of the UK Foot and Ankle COVID-19 National (UK-FAlCoN) Audit

Lyndon Mason¹, Jitendra Magwani², Karan Malhotra³, Linzy Houchen-Wolloff⁴

¹Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom; ²University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; ³Royal Orthopaedic Hospital, London, United Kingdom; ⁴University Hospitals of Leicester NHS Trust, Leicester, UAE

Objectives: The primary aim was to determine the differences in COVID-19 infection rate and associated mortality in patients undergoing foot and ankle surgery between the two phases of the UK-FALCON audit, spanning the first and second national lockdowns. 

Design: Multicentre retrospective national audit.

Setting: This was a combined retrospective (Phase 1) and prospective (Phase 2) national audit of foot and ankle procedures in the UK in 2020. The audit period for Phase 1 was between 13^th January 2020 and 31^stJuly 2020. This phase encompassed the first UK national lockdown. Phase 2 was between 1^st September 2020 and 30^th November 2020 and captured the second UK national lockdown.

Participants: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland.

Results: 10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. There was a significant increase in confirmed COVID-19 cases in Phase 2; with 35 confirmed cases of COVID-19 in Phase 1 (0.53%) versus 43 confirmed cases in Phase 2 (1.02%) (p=.003). However, there were significantly fewer respiratory complications as a result of COVID-19 during Phase 2 (25.58% vs 71.43%, p<.05), and the proportion of patients needing any form of treatment for COVID-19 was also significantly lower in Phase 2 (18.60% vs 54.29%, p=.013). In Phase 1, there were nine patients (25.71%) with a mortality associated with COVID-19. However, this number was significantly lower in Phase 2 with two (4.65%) COVID-19 related mortalities (p = 0.01).

Conclusions: COVID-19 infection was rare in foot and ankle patients. Although a higher rate of COVID-19 infection was seen in foot and ankle surgery in phase 2, there was a significant decrease in complications and mortality.

248 - Mechanical Testing of the Jaipur Foot against low, mid and high activity prosthetic feet

Jeremy Telford^1,2, Tim Drew², Graham Arnold²

¹University of Sheffield, Sheffield, United Kingdom; ²University of Dundee, Dundee, United Kingdom

The Jaipur Foot is low-cost prosthetic foot developed in Jaipur, India. Despite its worldwide use, little data is available on its mechanical properties. In general, there is a lack of objective data on the mechanical performance of prosthetic feet, hindering the objectivity of the prosthetic foot prescription process.

Objectives: To compare the properties of the Jaipur Foot with three prosthetic feet of differing activity levels (a SACH foot and two ESPFs), specifically loading-displacement relationships and energy-storing properties.

Study design: Mechanical testing of four prosthetic feet (BMVSS Jaipur Foot, 1D10 Dynamic, 1C30 Trias and 1C60 Triton)

Methods: Static proof testing was performed on the four prosthetic feet, utilising ISO:10328 methods. Loading-displacement graphs for the forefoot and heel were produced, from which mechanical and energy-storing properties were calculated.

Results: The Jaipur Foot demonstrated the lowest forefoot stiffness and the lowest energy return of the four feet. The SACH foot demonstrated the lowest heel stiffness, and the ESPFs demonstrated the highest energy returns.

Conclusion: Although low cost and cultural requirements should be taken into account, this data has demonstrated the inferior mechanical and energy-storing properties of the Jaipur Foot compared with western prosthetics, using ISO methods to allow future cross-study comparison.

281 - Epidemiology of fractures and their treatment in Malawi: Results of a multicentre prospective registry study to guide orthopaedic care planning

Alexander Schade^1,2, Foster Mbowuwa³, Paul Chidothi³, Peter MacPherson^1,2,4, Simon Graham⁵, Claude Martin⁶, William Jim Harrison^6,7, Linda Chokotho⁸

¹Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi; ²Liverpool School of Tropical Medicine, Liverpool, United Kingdom; ³AO Alliance, Blantyre, Malawi; ⁴London School of Tropical Medicine, London, United Kingdom; ⁵University of Liverpool, Liverpool, United Kingdom; ⁶AO Alliance, Davos, Switzerland; ⁷Countess of Chester NHS Hospital, Chester, United Kingdom; ⁸College of Medicine, Blantyre, Malawi

Background: Low- or middle-income countries represent 90% of all road traffic deaths with most non-fatal injuries being musculoskeletal. Trauma registries are an effective way to monitor injuries, therefore, a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements.

Methods:  In this prospective registry study, demographics, characteristics of injuries and treatment details were collected on all fracture cases that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period. We used descriptive statistics and regression analysis to investigate associations with admission and operative management.

Results: Between September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10-35 years), of whom 68.7% (16,315/23,568) were male. The most common injuries were radius/ulna fractures (n=8,682, 36.8%), tibia/fibula fractures (n=4,036, 17.0%), humerus fractures (n=3,527, 14.9%) and femoral fractures (n=2,355, 9.9%). A majority of cases (n=21,729, 91.6%) were treated by orthopaedic clinical officers (OCOs), 88% (20,885/22,849) of fractures were treated non-operatively, and 62.7% (14,897/23,733) were treated and sent home the same day. Open fractures (OR:53.19, CI:39.68-72.09), distal femoral fractures (OR:2.59, CI:1.78-3.78), patella (OR:10.31, CI:7.04-15.07), supracondylar humeral fractures (OR:3.10, CI:2.38-4.05), ankle fractures (OR:2.97, CI:2.26-3.92) and tibial plateau fractures (OR:2.08, CI:1.47-2.95) were more likely to be treated operatively compared to distal radius fractures.

Conclusions/Findings: This study is the largest prospective cohort study to suggest that the majority of fractures occur in 10-19-year-olds and were managed non-operatively by orthopaedic clinical officers in Malawi.

Implications: The current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres and supervise OCOs to manage fractures non-operatively in both district and central centres.

Disclosure: AO Alliance funded this study as part of the Malawi Country Initiative.

306 - Comparative analysis of radiological evaluation and early functional outcome of total knee arthroplasty using accelerometer-based handheld navigation system with conventional instrumentation - a randomized controlled prospective study

Nuthan Jagadeesh^1,2, Hiranya Kumar¹, Vishwanath Shivalingappa³, Varma S¹

¹Vydehi Institute Of Medical Sciences, Bangalore, India; ²Wrightington Wigan and Leigh NHS foundation trust, Wigan, United Kingdom; ³Vydehi Institute Of Medical Sciences, Bangalore, India

Background: Accelerometer-based handheld navigation systems(HHNS) for TKA do not require the large consoles needed for computer-assisted navigation systems (CAS) and have shown to decrease component malalignment in Total Knee Arthroplasty(TKA). The purpose of this study is to compare the radiological evaluation and functional outcome of TKA using HHNS with conventional instrumentation. 

Materials and Methods: This study is a multi-surgeon, prospective, assessor-blinded comparative study of 70 patients who were randomly allotted two groups HHNS group and conventional group based on instrumentation used for TKA. Postoperative radiographic evaluation was done using tibial and femoral alignment angle, posterior tibial slope, tibiofemoral angle, and functional outcome was evaluated using Oxford knee score (OKS) and  Knee society score(KSS)  with the serial follow-up of up to 2 years. The data obtained were compared between two groups using appropriate statistical methods.

Results: The mean tibial alignment angle and the posterior tibial slope was 0.82±1.17°, 3.58±0.96° respectively in the HHNS cohort versus 1.59±1.19°, 2.52±1.92° in the conventional cohort which is statistically significant (p-value < 0.001). There was no statistically significant difference in femoral alignment angle. The overall alignment using the mean tibiofemoral angle was 179.21±1.55  in the HHNS group as compared to the Conventional group 178.68±1.71 and was statistically significant (p-value =0.002). No statistical difference was found in KSS and OKS at 2-year follow-up among the two groups. 

Conclusions: The use of HHNS in TKA significantly increases accuracy in limb and implant alignment but there was no difference in `functional outcomes at the end of 2 years' follow-up. 

314 - Does Bone Ninja application can serve as an alternative to PACS to measure preoperative deformity and postoperative alignment measurements in case of total knee arthroplasty? A comparative study

Nuthan Jagadeesh^1,2, Hiranya Kumar², Vishwanath Shivalingappa²

¹Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom; ²Vydehi Institute of Medical Sciences, Bangalore, India

Picture Archiving and Communication Systems (PACS) is the most commonly used software to measure perioperative radiological parameters mostly due to a lack of reliable and cheaper alternatives. Bone Ninja (BNA) is an upcoming alternative cheaper software application but its accuracy and reliability have not been peer-reviewed. The purpose of this study is to assess the accuracy of preoperative limb deformity and postoperative alignment measurements on the BNA compared to PACS and to determine the intra- and inter-observer variability among different orthopaedic practitioners.

Methods: After ethical committee approval, Three participants (two orthopaedists and a radiologist) measured preoperative limb deformity (tibiofemoral angle (TFA), the lateral distal femoral angle (LDFA), and the medial proximal tibial angle (MPTA)) and postoperative alignment parameters (tibiofemoral angle (TFA), tibial alignment angle (TAA), femoral alignment angle (FAA)) for 50 consecutive patients undergoing Total Knee replacement using both BNA and PACS using long length radiographs. The difference between the measurements obtained with the BNA and PACS was measured. We determined the consistency of the interobserver and intra-observer using the intra-class correlation coefficient (ICC) for both systems. No participant had any financial or developmental involvement in the BNA.

Results: There were no statistical differences in Preoperative (TFA, MPTA, LDFA with p = 0.78, 0.92, and 0.97 respectively) or postoperative (TFA, TAA, FAA with p= 0.82, 0.76, 0.92 respectively) measurements between BNA and PACS. Also, the intra-observer and interobserver ICC was similar between both the groups.

Conclusions: Bone Ninja is an accurate, reliable, and cheaper educational tool for measuring preoperative deformity and postoperative alignment parameters when compared to PACS.

829 - Delayed and late prosthetic joint infections following total knee replacement: a multicenter study of fifteen thousand patients

Ravikumar Mukartihal¹, Darshan Angadi¹, Sharan Shivraj Patil¹, Gurava Reddy AV², Vijay C Bose³, Pichai Suryanarayan³, Shanmuganathan Rajasekaran⁴, Natesan Rajkumar⁴, Palanisamy Dhanasekararaja⁴

¹Department of Trauma and Orthopaedics, SPARSH Super Speciality Hospital, Bengaluru, India; ²Department of Trauma and Orthopaedics, Sunshine Hospital, Secunderabad, India; ³Department of Trauma and Orthopaedics, Asian Joint Reconstruction Institute, Chennai, India; ⁴Department of Trauma and Orthopaedics, Ganga Hospital, Coimbatore, India

Background: Prosthetic joint infection (PJI) associated with total knee replacement (TKR) has significant implications for both the patients and healthcare systems alike. Currently, there is paucity of studies reporting the incidence of delayed and late PJI in the patients undergoing TKR in India. The aim of our study was to evaluate the incidence, causative organisms, risk factors associated with delayed and late PJI following primary TKR in India.

Methods: A review of prospective databases maintained in four tertiary care hospitals was undertaken. Data reported over a five year period (January 2010 to June 2015) consisting of 15,000 TKR patients was evaluated to identify risk factors and estimate the incidence of delayed and late PJI. Risk factors included skin infections, obesity, urinary tract infections, renal comorbidities, endoscopic and dental procedures. Infected cases referred from other institutions were excluded.

Results: Amongst the 15000 patients, 201 were diagnosed with PJI of which 27 patients (13.43%) were identified to have delayed and late PJI. Of the 27 patients, there were 12 males (44.44%) and 15 females (55.55%) with the mean age of at revision procedure being 64 ± 9.32 years. Mean duration between index and revision TKR was 4.45 years. Incidence of delayed and late PJI was 27/15000 (0.18%) and most common cause was gram negative infection (4/27). During tissue culture, no growth was detected in majority (23/27) of the patients. 14/27 patients (59.2 %) had diabetes mellitus (DM) and a significant association was found between DM and PJI (p = 0.004).

32 - Pathways to Competence: Exploring the Basis of Operative Competency Decisions in Trauma & Orthopaedic Training

Simon Fleming¹, Anita Berlin¹, Olwyn Westwood^2,1

¹Barts & The London School of Medicine and Dentistry, London, United Kingdom; ²Brunel University, London, United Kingdom

Background: Postgraduate training is based on the expectation that individuals acquire increasing levels of responsibility and independence, supported by objective assessments, within a competency framework. It is remains unclear and controversial as to whether current training frameworks are doing what they set out to achieve. The purpose of this research is, using trauma and orthopaedics as context, to explore and understand "what operative competence means and how it's assessed" by key stakeholders, and probe how they perceive competence, and make judgements about the competence of others. 

Methods: 17 participants were purposively sampled from two geographically distinct T&O communities, the UK (n = 5) and Canada (n = 11). Grounded theory, a qualitative methodology which prioritises participants’ experiences, and recognises that data is co-constructed by the participants and researchers, was used. Semi-structured interviews were the primary data collection method and were analysed in an iterative and emergent fashion using the constant comparative method.

Results: Components appeared to align with Four P’s (practical, prepared, planning and professional). This is encapsulated by individuals needing insight or self-awareness, to be deemed competent. This research also revealed the intangibility of operative competency, highlighting use of gestalts as well as work-based assessments as a tool for facilitating and evidencing a feedback conversation, rather than as actual assessments.

Conclusions: This the first ever deep dive into the role of insight in orthopaedic operative competency. The findings of this research suggest that displays of operative competence may not reflect cognitive, affective processes or skill. Technical competence is a small part of determining competence, with participants feeling that insight is the most valued marker. It also raises questions about the current way in with we judge or evidence competency, with more than one individual claiming to “know it when I see it”, but not having the assessment words yet.

267 - Planning and delivering a BOA Specialty Society Diversity and Inclusion survey

Simon Britten¹, Niall Breen², Albert Hamilton³, Om Lahoti⁴

¹Leeds Teaching Hospitals, Leeds, United Kingdom; ²Ulster Hospital, Belfast, United Kingdom; ³CARD Group, Belfast, United Kingdom; ⁴King's College Hospital, London, United Kingdom

Background: The BOA’s Diversity and Inclusion action plan highlighted T&O as the second largest surgical specialty, with the lowest percentage of female surgeons across all grades.  The plan includes working with Specialist Societies to challenge and improve this lack of diversity.

Methods: To guarantee anonymity and confidentiality, the British Limb Reconstruction Society employed CARD Group, a market research company, well versed in the legal requirements of GDPR.  A survey link, then regular reminders were sent to BLRS members, based on the NHS diversity monitoring questionnaire, which includes gender, age, health, ethnicity, marital status, religion, sexual orientation, and carer status.  The survey included free text boxes for participants to elaborate.

Results: The response rate was 52% (110 / 212) with on-line response rates >25% considered good.  The BLRS, unlike some Specialty Societies, accepts both surgeons and Allied Health Professionals (AHPs) as members, impacting on our gender diversity. Respondents matched the membership in terms of gender (M:F 66%:34%) and professional grouping (75% surgeons, 25% AHPs).  Most respondents were white (78%). Ethnic minorities were represented:  Asian/Asian British 12%, Black/Black British 3%, Mixed/Other 5%.  BLRS’ ethnic representation profile closely follows that of the wider NHS. Overall, 93% of respondents thought BLRS to be an inclusive organisation.  Those who felt BLRS was not inclusive were all surgeons, all heterosexual, in the majority male, all married, all Christian or non-religious, 43% were of non-white ethnic origin.  Free text responses suggested increasing AHP representation on the committee; promoting more diverse conference speakers rather than ‘the usual suspects’; avoiding / challenging discriminatory language; and promoting diverse role models.

Conclusion: An important 7% of our membership felt that the society was lacking in some aspects of diversity and inclusion. The BLRS has introduced a transferable voting system to promote wider diversity and greater inclusivity.

272 - Teaching large joint clinical examination: Is there a role for educational videos to augment teaching? A randomised single blinded control trial

Ellie Flatt¹, Paul Brewer¹, Malek Racy¹, Faisal Mushtaq², Rachael Ashworth³, James Tomlinson¹, Fazal Ali⁴

¹Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; ²University of Leeds, Leeds, United Kingdom; ³University of Sheffield, Sheffield, United Kingdom; ⁴Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, United Kingdom

Background: Good clinical examination skills can both increase the quality of care and reduce its cost. A number of studies have found that these skills are often lacking in undergraduate and postgraduate trainees.

A previous study by our group demonstrated face-to-face training is the gold standard for teaching these skills. It is unclear if high quality educational videos can augment this teaching.

Aims: To establish if a custom educational video significantly augments learning when compared with the gold standard of face-to-face teaching alone.

Methods: 42 Medical Students naïve to large joint examination were recruited and block randomised to two groups. The control group had face-to-face (F2F) teaching alone. The intervention group (F2FV) had their teaching augmented with a custom educational video designed for this study and accessed via a web portal.

Participants were assessed on their examination of a large joint using a previously standardised assessment tool at baseline and seven days post intervention. Assessors were blinded to intervention type. 

Results: There was no significant difference in the mean baseline scores. Mean baseline scores were 3.35 (F2F control group) and 2.65 (F2FV intervention group) [p=0.137]. 

There was a significant difference in post-intervention scores. Mean post-intervention scores were 18.5 (F2F control group) and 23.4 (F2FV intervention group) [p=0.005].

Conclusion: A custom-made educational video significantly improves the teaching of clinical examination skills. Given the critical importance of clinical examination skills there is a role for these resources in augmenting traditional teaching.

Implications: High quality educational video resources can augment face-to-face teaching of clinical examination skills, thus increasing quality of patient care. Given the cost implications of poor examination skills teaching there is also the potential for a significant return on investment, although cost effectiveness studies are needed to assess this further.

426 - The influence of Gender on Operative Autonomy in Surgical Training (GOAST) – Regional Pilot Study

Jennifer Cherry¹, Samantha Downie¹, Thomas Harding¹, TORRCo Authors¹, Sarah Gill², Simon Johnson³

¹Ninewells Hospital, Dundee, United Kingdom; ²Queen Elizabeth University Hospital, Glasgow, United Kingdom; ³Perth Royal Infirmary, Perth, United Kingdom

Background: Global surgical literature suggests that female trainees have less operative autonomy than their male counterparts.  This pilot study had the primary objective to identify difference in autonomy by gender, and to power a national study to carry out further quantitative and qualitative research on this subject.

Methods: This was a retrospective, cross-sectional study utilising eLogbook data for all orthopaedic trainees (ST2-8) and consultants with CCT date 2016-2021 in a single Scottish deanery.  The primary outcome measure was percentage of procedures undertaken as lead surgeon (supervised-trainer scrubbed, unscrubbed, performed or training trainee).  Data analysis comprised the Chi-square test for categorical variables (significance p<0.05).

Results: 15 trainees and four recent consultants participated, of which 12 (63%) were male (mean grade 5.2), and 7 (37%) were female (mean grade 4.3). Trainees were lead surgeon on 64% of procedures (17595/27558), with autonomy rising with grade (37% ST1 to 85% ST8, OR 9.4).  Operative autonomy was higher in male vs female trainees (66.5% and 61.4% respectively, p=<0.0001), with female trainees more likely to operate with a supervisor present (STU/S vs P/T, f 48%:13%, m 45%:20%).

Findings: This pilot study found that there was a significant difference in operative autonomy between male and female trainees, however this may be explained by differences in mean grade of male vs female trainees. Five trainees took time OOT, 4/5 of whom were female. Extension to a national multi-centre study should repeat the quantitative method of this study with additional qualitative analysis including assessing effect of time OOT to explore the reason for any gender discrepancies seen across different deaneries in the UK.

Disclosure: This study has received funding from the AO Foundation and Tayside Orthopaedic Research Collaborative. We have no conflict of interest to declare, and have received Ethics approval from University of Edinburgh.

478 - Whichdeanery.com – a useful resource for those applying to T&O specialty training

Amit Chawla¹, James Dalrymple², Gayathri Vakkalanka³, Alex Trompeter⁴

¹Lister Hospital, Stevenage, United Kingdom; ²University College Hospital, London, United Kingdom; ³St Mary's Hospital, London, United Kingdom; ⁴St George's Hospital, London, United Kingdom

Background: The results of a national survey conducted by the authors of 106 T&O specialty training applicants in 2019-20 highlighted that information available about training regions was limited according to 73% of trainees. 85% were in favour of a resource containing information to enable them to make informed decisions about preferencing. We addressed this by creating a free website named whichdeanery.com.

Methods: Information was gathered from all UK T&O training regions via an online Google questionnaire containing 20 questions carefully designed by two T&O trainees and a training programme director (TPD). Approval was sought from all TPDs before trainees were approached to complete the form. The project was also reviewed by the surgical heads of school (COPSS) meeting. Information was collated into a website created by the lead author. Data was gathered for web traffic and feedback from trainees applying in 2021.

Results:  Since the publication of the website on September 17^th 2020, over 1,700 visitors and 11,000 page visits have been recorded from across the UK. 

Feedback from 16 trainees has been collected. 88% reported more confidence with preferencing, and stated that the website impacted their choice of training regions. 94% agreed that the website provides valuable information that is not readily available elsewhere, and would recommend it to colleagues.

Conclusion:  The results demonstrate that Whichdeanery.com clearly benefited 2021 T&O applicants by providing valuable information and helped them to preference training regions.

The website’s success has been recognised by endorsement from the British Orthopaedic Trainee’s Association and formal sponsorship from the Royal College of Surgeons (Eng). 

Implications: Further collaboration has been sought from trainees in other surgical specialties and plans are underway to expand the website to include information about General & Vascular surgical training regions in time for the next round of applications.

653 - RLHOTS Mentorship Programme for Medical Students Improved Students Interest in Orthopaedics

David Ensor, Hassan Raja, Kash Akhtar

Royal London Hospital, London, United Kingdom

Background: Bart and the London Medical School contains approximately 2 weeks of Orthopaedics exposure for medical students over a 5 year medical degree. Our aim was to develop a trainee led pilot scheme to increase opportunities for orthopaedic exposure and networking at the Royal London through theatre attendance, workshops and bedside teaching outside of the normal medical school curriculum. 

Method: We recruited 25 medical students from Barts Medical School to a programme, allocating them to weekend theatre lists, bedside teaching with junior doctors and a single day of teaching on basic orthopaedics and a workshop of women in orthopaedics over the course of 1 academic year between 2019 and 2020. We conducted an end of programme qualitative questionnaire to gather feedback.

Results: 25 of 25 students completed the questionnaire.

84% felt that the programme increased their interest in orthopaedics.

88% felt that the programme improved their understanding of orthopaedics.

88% felt that the programme improved their understanding of the application process.

96% felt that the programme provided more insight into life as an orthopaedic doctor.

88% felt that the programme provided more opportunities to assist in theatre and gain new skills.

76% felt that the programme provided an opportunity for bedside teaching and gained insight into orthopaedic clinical practise. 

73% felt that the 'women in orthopaedics' workshop provided insight into work-life and training balance for a female orthopaedic trainee. 

96% would recommend the programme to someone else.

Conclusion: Exposure to orthopaedics is limited at medical school. Our pilot scheme for improving orthopaedic exposure was overall well received by the medical students involved and it is an important tool to encourage wider access and engagement for students with the orthopaedic community.

930 - UK Orthopaedic trainees covering medical Covid-19 wards and still meet Joint Committee on Surgical Training trauma procedure guidelines: A successful multifaceted collaborative model

David Ferguson, Rory Cuthbert, Edward Karam, Cameron Dott, Lilly Wickramarachchi, Asif Parkar, Shivakumar Shankar, Krishna Vemulapalli

Queens Hospital, Romford, United Kingdom

Background: The UK Government’s national lockdown from 23 March 2020 coupled with the British Orthopaedic Association guidance on non-operative management of trauma reduced trauma operating nationwide during the Covid-19 pandemic. The aim of this study was to determine if despite orthopaedic registrars moving to a Covid-19 rota with medical duties, a multifaceted collaborative approach between trainee orthopaedic registrars could result in a maintenance of trauma theatre activity similar to standard practice levels. 

Methods: Electronic logbook data was collected from all participating trainee registrars in the department. Two time periods were determined; a pre Covid-19 baseline equivalent to previous standard 6-month orthopaedic rotation, and a Covid-19 rota period equivalent to the duration of the first full UK lockdown.

Results: 2162 total potential hours of trauma operating under pre Covid-19 rota were compared to 631 hours under Covid-19 rota conditions. Departmental daily mean rate of registrars acquiring the Joint College of Surgical Training (JCST) indicative trauma numbers did not change between pre Covid-19 rota and Covid-19 rota periods (0.26 [0.19-0.38] vs 0.40 [0.15-0.72] p = 0.140). Similarly, the mean rate of registrars acquiring total trauma numbers did not change between the same rota periods (0.37 [0.19-0.49] vs 0.53 [0.15-0.85] p = 0.254). 

Conclusion: Through a multifaceted collaborative approach, orthopaedic registrars were able to maintain a constant rate of acquiring indicative and total trauma cases, despite changing work schedules. The number of cases acquired surpassed the yearly JCST requirement for satisfactory Annual Review of Competency Progression (ARCP).

Implications: If large scale emergency changes in clinical practice occur in the future, the method we present provides an opportunity for trainees to continue baseline skill acquisition whilst also contributing to a wider public health need. 

1111 - Virtual Orthopaedic Trainee Education: Lessons learnt during COVID-19

Rosemary Hackney¹, Thomas Howard¹, Gavin Brown¹, Emily Baird²

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²Royal Hospital for Sick Children & Young People, Edinburgh, United Kingdom

The COVID-19 pandemic halted formal Orthopaedic teaching. To address this ‘Virtual Orthopaedic Trainee Education’ (VOTE) was introduced. We measured the success of this, identified challenges and barriers, and make suggestions for future learning.

Nine teaching sessions were delivered per week covering the FRCS (Tr&Orth) curriculum using Zoom Video Communications (CA, USA). Specialist consultants chaired sessions, with two specialty trainees, level 1-8, providing supplementary teaching. Sessions were recorded and uploaded to a secure online platform, providing a resource for future use. Trainees completed surveys measuring satisfaction using SurveyMonkey Inc. (CA, USA).

The 11-week programme provided 90 hours of teaching. Survey response rate was 59% (16/27). 93% participants found the course very or extremely useful. 56% of participants had already used the recorded material and 94% of participants said they would use it in future. Session attendance ranged from 6 to 23, with a mean of 14. The online teaching afforded an opportunity for trainees to remain engaged with colleagues during lockdown. Responses indicated however, that it should not replace face-to-face teaching and the resulting chance to socialise. Pitfalls of using Zoom included difficulty interacting with trainers, responding to questions and engaging in group discussion. Trainees appreciated the teaching being in their own home.

VOTE provided an excellent opportunity to re-assess teaching and training strategies, and learn what is important to trainees. As a consequence of the feedback obtained, all sessions are now recorded, provide an opportunity for trainee-led teaching and cater for all levels of training. We have now reinstated face-to-face teaching with on-going high levels of satisfaction. As expected, trainees have enjoyed the opportunity to interact with colleagues in line with government restrictions. Receiving and responding to live feedback will remain imperative.

40 - The Benefits of Education in Trauma Radiology for Foundation Doctors Working in a Regional Major Trauma Centre: A Multi-Departmental, Regional Quality Improvement Project

Sara O'Rourke¹, Daniel Christmas², Tom Blankenstein³

¹Department of Major Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ³Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background: Radiology in trauma management is particularly relevant today as Scotland develops its Major Trauma Network. Nevertheless, radiology is scarcely covered in current foundation programme curricula, despite its growing use as a diagnostic and interventional tool. Currently, the majority of radiological investigation requests are made by foundation doctors. These doctors are also often the first to be notified of results. Accordingly, there is an urgent need to ensure foundation doctors feel adequately trained in trauma radiology.

Aim:

• To address the dearth of current trauma radiology teaching in Scottish foundation curricula through the development and delivery of a teaching programme that is both comprehensive and reproducible. 
• To improve foundation doctors’ knowledge of radiology in trauma to better equip them to work in a Major Trauma service.

Methods:

• Multi-departmental project covering General Surgery and Trauma and Orthopaedics of 46 foundation doctors over the course of 14 months (October 2019 – December 2020.)
• Audit of self-reported knowledge of indications, limitations and basic interpretation methodology for common radiological investigations used in trauma, using a numeric scale.
• Development of regional trauma radiology teaching programme in conjunction with speciality consultant leads.
• Delivery of multiple evidence-based, thematic teaching sessions: AXR, C-Spine, Shoulder, Elbow, Hand and Wrist, Hip and Pelvis, Foot and Ankle.
• Re-audit of self-reported indicators on completion of individual sessions and of the programme as a whole.

Results:

• 100% increase in confidence in ordering trauma radiological investigations
• 50-75% increase in understanding of indications and basic interpretations of common trauma radiological investigations.
• 100% agreed radiology was insufficiently covered in the foundation curriculum.

Conclusion

• Education improves foundation doctors’ understanding of radiological investigations for trauma.
• The foundation curriculum would benefit from regular, multidisciplinary radiology teaching, in parallel to the demands of a growing national trauma network. 
• Our teaching programme is suitable for delivery across the network.

737 - Trauma teams: How can a change in work pattern impact training?

Thomas Harding, Jospeh Littlechild, Peter Davies, Sankar Sripada, Fraser Harrold, Douglas Robinson, Stephen Dalgiesh

Ninewells Hospital, Dundee, United Kingdom

Background: The COVID pandemic enforced a complete re-design of the trauma rota in our Major Trauma Centre. The consultant and registrar workforce were split into 4 trauma teams, each providing cover for all trauma duties in a 4 weekly cycle. In terms of training, JCST sets quality indicator targets of 3 supervised theatre sessions, and 2 clinic sessions each week per trainee (60 theatre, 40 clinic sessions per 6 months). IST set a benchmark of trainees attending 60% of all consultant activity. The aim of this study was to assess the impact of the new working pattern on training and assess if these basic standards were being met.

Methods: Prospective data of registrar activity during the first 6 months (10 August 2020 – 31 January 2021) of the new Trauma Team system was compared with the same 6 month period from the previous year. The primary outcomes were theatre and clinic sessions attended. Secondary outcomes were lost clinic/theatre opportunities due to compulsory zero/nights, and percentage of own consultant practice attended. The two periods were compared to each other and the JCST quality indicators.

Results: Junior trainee (ST1-4) theatre activity increased by 41.5% (47 to 66.5 sessions per 6 months). Senior trainee (ST5-8) theatre activity increased by 25% (78.6 to 98.4 sessions per 6 months). Junior trainee clinic activity increased by 80% (12.5 to 22.5), with senior activity increasing by 20% (28.8 to 34.5). Lost junior trainee sessions reduced by 63% (n160-60). All trainees attended greater than 60% of consultant activity.

Conclusions: Our new Trauma Team working pattern, with coordinated consultant and trainee working patterns, led to a significant increase in training opportunities. There was a significant reduction in lost training sessions for junior trainees. By taking a departmental approach to service delivery and rota design, training opportunities are maximised.

1021 - The trauma meeting – encouraging educational value for all trainees

Angharad Davies, Luke Duggleby

Royal United Hospitals, Bath, United Kingdom

Background: Trauma meetings provide educational opportunities. Meeting the educational needs of Foundation Training doctors in orthopaedics is required to prevent the loss of these posts. Little is known about the hidden curriculum and educational needs of junior doctors rotating through, but not pursuing a career in orthopaedic surgery. 

Methods: An online questionnaire was created from thematic analysis of semi-structured interviews. A cohort of senior house officers were invited to participate. Comparative groups were created, ‘interested’ versus ‘not interested’ in a career in orthopaedics. Quantitative measures were the use of Work Based Assessments (WBAs). Qualitative measures explored educational components of the meeting and potential learning barriers, through ratings and free text.

Results: 14 trainees were surveyed (8 FY2s, 4 CT1s and 2 CT2s). 50% were not interested in a career orthopaedics. 90% of learners enjoyed trauma meetings and found them useful learning events.

Orthopaedically inclined trainees generated more WBAs from meetings (mean 4 vs 1.6). These trainees were more likely to send WBAs if the case was complex and generated discussion; whereas the opposite was true for the orthopaedically uninclined. Those interested in orthopaedics suggested a lack of educational opportunities for critical conditions. Common educational features appreciated by trainees were consultant enthusiasm for the case, direct questioning and case management.

Conclusion: Educational trauma meetings are valued by juniors, regardless of their chosen career pathway. Consultants encourage education by engaging with the case. Critical conditions are not proportionally represented. Orthopaedically uninclined trainees value transferable skills from trauma meetings.

Implications: Orthopaedically uninclined junior doctors should identify learning objectives from trauma meetings, focusing on presenting skills and radiographic interpretation. Developing transferable skills has the potential to upskill rotating junior doctors and increase work satisfaction. Educators should use these findings to consider how to encourage and promote the learning of trainees, including the orthopaedically uninclined.

1172 - Improving trauma and orthopaedic education for future doctors: A quality improvement project

Shayra Khanom, Vivien Nebo, Nicholas Garlick, Nimalan Maruthainar

Royal Free London NHS Foundation Trust, London, United Kingdom

Background: Conditions affecting the musculoskeletal are common in all branches of medicine in primary and secondary care. Education in this speciality is therefore fundamental for all doctors. The medical student experience of clinical placements is closely linked with quality of teaching, varied educational opportunities and sense of belonging within the team. Surgical rotations such as Trauma and Orthopaedics (T&O) have a stereotype for being challenging which hampers the acquisition of knowledge. At a London teaching hospital student satisfaction in T&O was low (8% satisfaction) as assessed by feedback. This project aimed to improve the quality of educational experiences and overall student satisfaction through a multifaceted quality improvement (QI) approach.

Methods: We reviewed the feedback from end of placement student evaluation reports from academic years 2016 to 2019 to create a QI driver diagram for improvement based on the themes raised in the feedback. These were 1) formal teaching, 2) structure and organisation, 3) curriculum content and 4) student engagement and belonging. Each theme was subdivided into multiple achievable strategies to improve overall student experience while attached to T&O. This included allocated clinic and theatre sessions, bedside teaching time, tutors, curriculum map, WhatsApp communication and a dedicated clinical teaching fellow in the department.

Results: As a result of the implemented QI strategies, student satisfaction improved over the subsequent semesters to 100%, 89% and 100%, with a greater number of students providing responses to the feedback questionnaires.

Conclusions: The project achieved greater student satisfaction of T&O education and validates student feedback as a valuable tool in developing medical education. It is hoped that this will translate to better understanding of musculoskeletal disease for our future doctors. 

42 - Do baseline patient-reported outcomes predict outcome in Hallux Valgus correction? An analysis of 1015 consecutive cases

Nicholas Hutt, Anji Kingman, Simon Fay, David Townshend

Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom

Introduction: Hallux Valgus correction is a well-established and common foot procedure. The aim of surgery is to improve pain and function with correction of deformity. The Manchester Oxford Foot Questionnaire (MOXFQ) is a foot and ankle specific patient reported outcome measure (PROM) sensitive to change following surgery at 6 months. It is not known if baseline scores predict the change in PROMs, and therefore if they can help identify which patients will benefit most from surgical intervention. This study aimed to assess this.
 
Methods: Data was collected prospectively on patients undergoing consecutive Hallux Valgus correction between April 2014 and March 2019 by both Orthopaedic and podiatric surgeons in the trust. Pre-operative and 6-month post-operative MOXFQ PROMs data were included. Patients with complete data were suitable for analysis. A comparative analysis was undertaken for combined MOXFQ and subdomain scores for walking/standing (WS), pain (P) and social interaction (SI).
 
Results: 1228 patients were identified, 1015 (83%) had complete data. There was a statistically significant (p<0.001) and clinically important improvement between pre- and post-operative MOXFQ PROMs Combined, WS, P and SI (39.3, 39.2, 37.2, 41.2). There was a statistically significant (p<0.001) correlation between pre-operative scores and change in score for MOXFQ Combined, WS, P and SI (r=0.63, r=0.67, r=0.59, r=0.71). There was a statistically significant (p<0.001), but less strong correlation between pre and post-operative scores for all domains respectively (r=0.27, r=0.27, r=0.30, 0.20).
 
Conclusion: Hallux Valgus correction provides statistically and clinically significant improvement in all MOXFQ domains. Baseline scores correlated strongly with the change in scores, and less strongly with post-operative scores, suggesting that pre-operative PROMS are predictive. Patients with worse pre-operative scores showed a greater improvement, but also had worse post-operative scores. This is useful to identify which patients may benefit most from surgical correction and will inform pre-operative discussion.

115 - Achilles Tendinopathy Management (ATM): A single blinded placebo controlled multicentre randomised clinical trial of Platelet Rich Plasma Injections for midportion Achilles tendinopathy

Rebecca Kearney¹, Chen Ji¹, Jane Warwick¹, Nicholas Parsons¹, Jaclyn Brown¹, Paul Harrison², Jonathan Young³, Matthew Costa⁴

¹University of Warwick, Coventry, United Kingdom; ²Birmingham University, Birmingham, United Kingdom; ³University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom; ⁴University of Oxford, Oxford, United Kingdom

Background: There is a wide range of treatments for chronic Achilles Tendinopathy. Platelet rich plasma injections have grown in popularity. The 2020 global PRP market was $261 million USD.

Objective was to assess function, quality of life, pain and complications in adults treated with a single platelet rich plasma injection vs. placebo injection for midportion Achilles tendinopathy.

Methods: Single blind multicentre randomised clinical trial registered 28th October 2015 (ISRCTN 13254422). 

24 UK hospital trusts recruited participants 18 years or over, with midportion Achilles tendon pain for longer than three months (tendinopathy confirmed by ultrasound and/or MRI). Exclusion criteria included systemic conditions; pregnancy; prior Achilles tendon surgery or rupture; prior major ankle injury; fracture of a leg long bone in the previous six months; prior platelet rich plasma treatment; or contraindication to receiving a platelet rich plasma.

Participants received a single intra-tendinous platelet rich plasma injection (n=121) or a single placebo injection consisting of a subcutaneous injection of a dry needle (n=119). The primary outcome was the Victorian Institute of Sport Assessment – Achilles (VISA-A) score six months after randomisation, analysed by Intention-to-treat. Range 0-100, an asymptomatic person would score 100.

Results: 240 participants were randomised, mean age was 52 years (SD 11 years) and 58% were female. At six months 92% (n=221) completed the study. There was no difference in primary outcome between the platelet rich plasma and placebo injection groups at six-months (Mean difference (platelet rich plasma group – placebo group): -2.7; 95% CI -8.8 to 3.3, adjusted analysis) or in the secondary, imputed or per protocol analyses. 

Conclusions: We found no evidence that platelet rich plasma injections are an effective treatment for chronic midportion Achilles tendinopathy.

Disclosure: Funded by Versus Arthritis (Versus Arthritis 20831). The views expressed are those of the authors and not necessarily those of the funder.

147 - Management of Open versus Closed Pilon fractures: Comparison of Outcomes and Complications

Victor Lu¹, James Zhang¹, Azeem Thahir^2,1, Matija Krkovic²

¹School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom; ²Department of Trauma And Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, United Kingdom

Background: Despite the low incidence of pilon fractures, their high impact nature presents difficulties in surgical management. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences between patients treated with open reduction internal fixation (ORIF) or fine wire frame (FWF).

Methods: 135 patients over a 6-year period were included. Primary outcome was AOFAS score at 3, 6, 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, follow-up time. AO/OTA classification was used (43A: n=23, 43B: n=30, 43C: n=82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807).

Results: Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p=0.001) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively).

The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43-B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p=0.011, respectively), ORIF-treated 43-C closed fractures had shorter time to union (p<0.001).

Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). All occurred more frequently in FWF-treated patients.

Conclusion: Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

219 - Functional outcome of early weight bearing on conservatively managed complete Achilles Tendon rupture

Rajib Naskar, Laura Oliver, Patricia Valezquez Ruta, Baljinder Dhinsa

East Kent Hospital University Foundation Trust, Ashford, United Kingdom

Introduction: The optimal management for Achilles Tendon (AT) ruptures is controversial and still continues to encourage debate. Historically, operative repair was favoured secondary to lower rates of re-rupture. Recently we have seen more promising result with conservative management particularly with functional weight-bearing orthosis. However result for complete AT ruptures is still unclear. The aim of this study is to see the functional outcome of early weight bearing in a functional orthosis for conservatively managed complete AT rupture.

Methodology: In this prospective study we have analysed data from 41 patients with US diagnosed compete AT ruptures, with gap less than 5 cm. Every patients were treated in a functional weight-bearing orthosis (VacoPed) for 8 weeks with early weight bearing following a specific treatment protocol, followed by rehabilitation with trained physiotherapist for 3 months. At their final follow-up at 1 year, we recorded the functional outcome measurements like calf girth, heel height differences, single heel raise repetition and ATRS score.

Result: The mean ATRS score was 82.1, with re-rupture rate of only 2%. The average calf bulk difference was 1.6 cm, average heel raise height difference was 1.8cm and a heel raise repetition difference was 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p=0.02). However there was no significant correlation between ATRS score and heel raise height or single heel raise repetitions. 

Conclusion: Conservatively managed AT ruptures in a weight-bearing orthosis provides excellent result with very low re-rupture rate even for complete ruptures. However, a multidisciplinary approach with a guided rehabilitation programme is essential for good functional outcome.

234 - Elective removal of metalwork following Lisfranc injury fixation: Results of a national consensus survey of practice

Amanda Rhodes¹, Robin Elliot¹, Daniel Marsland¹, Louise McMenemy²

¹Hampshire Hospitals NHS Foundation Trust, Basingstoke, United Kingdom; ²Royal Navy, Basingstoke, United Kingdom

No consensus exists regarding whether metalwork should be routinely removed following fixation of a Lisfranc injury. When metalwork is removed, notable variation in the timing of surgery is reported in current literature.

With the support of the British Orthopaedic Foot & Ankle Society (BOFAS) and the Orthopaedic Trauma Society (OTS) an online 10-question survey was distributed and completed by a total of 205 consultant surgeons in the UK between April – June 2020.  

Excluding the 20 consultant responses from a regional pilot survey, 185 responses were used to form the main analysis. Over one third (69/183, 37.7%) of surgeons reported they routinely remove metalwork following Lisfranc injury fixation at a median time of 6 months post fixation (interquartile range 4-10).

The two most commonly chosen reasons for removal of metalwork were ‘to optimise physiological function’ and ‘to reduce the risk of broken metalwork and risk of making subsequent surgery more difficult’ (55/78 responses, 70.5%).

Over two thirds of survey respondents (126/184, 68.5%) expressed interest to participate in a randomised controlled trial to compare outcomes of metalwork retention versus removal following Lisfranc injury fixation.

Community clinical equipoise exists nationally regarding routine metalwork removal following Lisfranc injury fixation. Considering the paucity of literature, the current survey supports the development of a randomised controlled trial to establish the risks and benefits of metalwork retention versus removal, and would be of value to foot & ankle and trauma surgeons in the UK.  

491 - Outcomes of Posterior Malleolar Fixation in Adult Ankle Fractures in a Major Trauma Centre

Lucky Jeyaseelan, Nelson Bua, Lee Parker, Catrin Sohrabi, Amaury Trockels, Nima Heidari, Alexandros Vris, Francesc Malagelada

Barts Health NHS Trust, London, United Kingdom

Introduction: Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The theoretical benefits of posterior malleolar fixation now widely accepted as restoration of articular congruity, restoration of fibular length and stabilisation of the syndesmosis.

The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes.

Methods: A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, between January 2012 and January 2018, with minimum 2 year follow-up. The Manchester-Oxford Foot Questionnaire (MOXFQ) summary index score at final follow-up, was the primary patient outcome measure. Complications and all cause reoperation rates were also noted.

Results: Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p =0.04). Outcomes were worse with increasing size of posterior malleolar fragment. When compared with either posterior malleolus fixation alone or syndesmotic stabilisation alone, poorer outcomes were seen when the posterior malleolus fixed with additional syndesmotic stabilisation, with mean MOXFQ scores of 21.73 (0-60), p =0.057.

Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%), p=0.03). Re-operation rate was double (34/160 (21.2%) vs 16/160 (10%), p = 0.03). 

Conclusion: This pragmatic study is the largest published series that assesses patient reported outcomes in posterior malleolar fixation. We demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.

686 - Quantitative assessment of dorsal sagittal lateral column instability in unilateral adult acquired flatfoot deformity (AAFD)

David Chrastek¹, Mahmoud Elmousili¹, Ahmad Al-Sukaini², Isabel Austin³, Chandra Pasapula¹

¹Queen Elizabeth Hospital King's Lynn, King's Lynn, United Kingdom; ²Colchester Hospital, Colchester, United Kingdom. ³Cambridge Medical School, Cambridge, United Kingdom

Background: AAFD comprises ligamentous failure and tendon overload mainly focused on the symptomatic posterior tibial tendon and the spring ligament. Increased lateral column (LC) instability arising in AAFD is not defined or quantified. This study aims to quantify the increased LC motion in unilateral symptomatic planus feet, using the contralateral unaffected asymptomatic foot as an internal control.

Methods: Ethical approval was obtained. Inclusion criteria included patients with a unilateral stage 2 AAFD foot and an unaffected contralateral foot. Exclusion criteria included bilateral AAFD, stage 3 AAFD and a high Beighton’s score. Lateral foot translation was measured as a guide to spring ligament competency. Medial and LC dorsal sagittal instability was assessed by direct measurement of dorsal 1st and 4th/5th metatarsal head motion using a digital Klauemeter and further quantified using video analysis and motion capture software.

Results: 13 patients with unilateral stage 2 AAFD were included. The mean increase in dorsal LC sagittal motion (between affected vs unaffected foot) was 5.5mm (95% CI [4.534 to 6.455]) (p<0.001) as confirmed by direct measurement with Klauemeter. The mean increase in the lateral translation score was 42.6 mm (affected vs unaffected foot)(95% CI [36.434 to 48.850]) (p<0.001). The mean increase in medial column dorsal sagittal motion was 7.09 mm (95% CI [6.06 to 8.106]) (p<0.001). Video analysis also showed a statistically significant increase in LC dorsal sagittal motion between affected and unaffected sides (p<0.001).  

Conclusion: This is the first study that quantifies a statistically significant increased LC dorsal motion in feet with stage 2 AAFD. Understanding its pathogenesis and its link to talonavicular/spring ligament laxity improves foot assessment and may allow the development of future preventative treatment strategies.

863 - The Use of Intramedullary Devices for Fixation of Metatarsal Osteotomies in Hallux Valgus Surgery – A Systematic Review

Amit Zaveri¹, Rateb Katmeh¹, Karan Malhotra^1,2, Matthew Welck^1,2

¹Royal National Orthopaedic Hospital, Stanmore, United Kingdom; ²University College London, London, United Kingdom

Background: Hallux valgus is a common foot deformity with numerous surgical techniques described. Minimally invasive surgery is becoming more popular, with resultant development of suitable fixation devices. The aim of this systematic review was to evaluate the evidence on the use of intramedullary devices in hallux valgus first metatarsal corrective osteotomies, to describe clinical and radiological outcomes, and deliver an overview of techniques and implants used. 

Methods: We conducted a systematic review of the literature using PubMed, Medline, Embase and EMCare databases, with studies included between January 2001 and January 2021, conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Radiological outcomes including the hallux valgus angle (HVA) and intermetatarsal angle (IMA) were recorded, as well as clinical outcome scores and complications. Methodological quality of included studies was assessed using the MINORS score.

Results: Eight studies were included from a total of 136 reviewed articles, comprising 649 feet in 617 patients. Data pooling and meta-analysis was not possible due to overall low quality of evidence. Three implants were reported (Endolog, ISO Plate, V-Tek Plate) and used with distal first metatarsal osteotomies, with improvement in HVA, IMA, and clinical outcome comparable scores to other fixation techniques. There were no reported cases of non-union. Complication rates were variable with an all cause range of 0-21% across all studies, and an overall low rate.

Conclusion: Intramedullary devices are viable and safe to use for hallux valgus first metatarsal osteotomies, with comparable radiological and functional outcomes to other techniques. However, the current evidence base is of low methodological quality according to MINORS scoring. Further studies to include randomised controlled trials are required to further evaluate these devices.

1016 - Comparison of 3D Surface Rendering CT to Plain Lateral Radiographs for Quantification and Characterisation of Posterior Malleolar Fracture Fragment Size and Morphology

Howard Stringer¹, Jake Cowen¹, Laura-Anne Lambert¹, Lois Duncan², Lizzy Weigelt¹, Lyndon Mason¹

¹Liverpool University Hospital Foundation Trust, Liverpool, United Kingdom; ²University of Liverpool, Liverpool, United Kingdom

Aims: The aim of this study was to compare the size of the posterior malleolar fracture (PMF) fragment on plain lateral radiographs compared to three-dimensional (3D) surface rendering CT imaging, and to compare both modalities in the characterisation of PMF morphology.

Patients and Methods: Measurements of 180 lateral radiographs of PMF’s were compared to their respective 3D surface rendering CT reconstructions, by two independent observers reviewing percentage articular involvement of the PMF fragment. Morphology of the PMF was categorised initially by the CT scan as classified by Mason and Molloy and was compared to this classification using radiographs. 

Results: When calculating the percentage joint surface involved by the PMF fragment, inter-observer variability was greater than 0.8 for radiographic and CT measurement. Significant differences in size of PMF on radiograph compared to CT were found for type 1 and type 2A fractures (p<0.001 type 1, p=0.002 type 2A). Radiographs consistently over-estimated the PMF fragment size, although in type 2B fracture patterns there was an equivalent number that were under-estimated due to the under appreciation of the posteromedial fragment. Comparison of fracture fragment morphology found that type 2A and 2B fractures (rotational Pilon’s) had poor agreement between radiographs and CT (34.15%).

Conclusions: This study shows that the use of a lateral radiograph in a PMF to estimate fracture size and morphology is poor. Additional CT imaging is imperative to allow for appropriate treatment planning in the management of PMF.

Clinical Relevance: Radiographs are unable to accurately assess either the fracture fragment size or morphology in a posterior malleolar fracture of the ankle.

1017 - First metatarsal rotation and hindfoot alignment in patients with hallux valgus

Ali Asgar Najefi, Amit Zaveri, Mohammad Alsafi, Rateb Katmeh, Frances Garrick, Shelain patel, Nicholas Cullen, Karan Malhotra, Matthew Welck

Royal National Orthopaedic Hospital, London, United Kingdom

Introduction: Recurrent hallux valgus may be related to malrotation of the first metatarsal. It is also thought that hindfoot alignment may be linked to rotation of the first metatarsal. We aimed to identify the range of first metatarsal rotation and hindfoot alignment in the largest reported series of patients with hallux valgus using weightbearing computed tomography (WBCT). 

Methods: WBCT scans were retrospectively analysed for 160 feet (80 patients). Hallux valgus angle (HVA), intermetatarsal angle, and anteroposterior/lateral talus-first metatarsal angle were measured. Patients were included with an HVA of greater than 16 degrees and excluded if they had previous foot surgery or hallux rigidus. Final assessment was performed on 110 feet. Metatarsal pronation (MPA), alpha angle, sesamoid rotation angle and CT4 sesamoid position was measured on standardised coronal CT slices. Pronation was recorded as positive. Hindfoot alignment angle (HAA) was assessed using dedicated software. 

Results: Mean HVA was 28.9±9.4 (range: 16-67) degrees. Mean MPA was 11.6±6.0 (range:-4-26) degrees and mean alpha angle was 11.7±6.9 (range -8-29) degrees. When considering the range in hallux valgus as within two standard deviations of the mean, the MPA was 0 to 24 degrees, and -2 to 26 degrees for alpha angle. There was no correlation between HVA and metatarsal rotation. There was a moderate positive correlation between MPA and alpha angle (Pearson’s coefficient 0.73;p<0.001). There was a weak positive relationship between HAA and MPA or alpha angle (Pearson’s coefficient 0.26 and 0.27 respectively; p<0.01). 

Conclusion: Metatarsal rotation is variable in patients with hallux valgus and cannot be predicted by the severity of HVA. Each case should be assessed on an individual basis to see if the metatarsal rotation is outside of the normal range, and their surgery planned accordingly. Further work is needed to correlate these findings with clinical outcomes postoperatively.

1056 - Is there a reduction in perioperative COVID-19 infection in patients undergoing foot and ankle surgery in designated COVID-19 green pathways?  Results from Phase 1 and 2 of the UK Foot and Ankle COVID-19 National (UK-FAlCoN) Audit

Karan Malhotra¹, Lyndon Mason², Jitendra Mangwani³, Linzy Houchen-Wolloff³

¹Royal Orthopaedic Hospital, London, United Kingdom; ²Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; ³University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Objectives: The primary aim was to determine the differences in COVID-19 infection rate in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second national lockdowns. 

Design: Multicentre retrospective audit.

Setting: This was a combined retrospective (Phase 1) and prospective (Phase 2) national audit of foot and ankle procedures in the UK in 2020. The audit period for Phase 1 was between 13^th January 2020 and 31^stJuly 2020. This phase encompassed the first UK national lockdown. Phase 2 was between 1^st September 2020 and 30^th November 2020 and captured the second UK national lockdown.

Participants: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway.

Results: 10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6,470) and 0.21% on a green pathway (9/4,280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p=.109), lockdown (p=.923) or post-lockdown (p=.577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p<.001) and lockdown periods (p<.001).

Conclusions: There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways; however the success of the pathways only became significant in phase 2 of the study. The study shows a developing success in using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

72 - Access and Feasibility of Orthopaedic Training in the Independent Sector - A Deanery’s Experience

Jonathan Lenihan, Albert Wee Tun Ngu, ORCA Collaborative

Addenbrookes Hospital, Cambridge, United Kingdom

Introduction: Coronavirus (COVID-19) has negatively impacted healthcare around the world. It has had a major impact on orthopaedic training. The independent sector has been proposed as a facility for future training. Our aim was to provide an overview of the current higher surgical trainees’ experience in the independent sector in the East of England (EOE).

Method: Training orthopaedic registrars within the EOE deanery were asked to complete an electronic questionnaire of their training experience in the independent sector between 5th November to 2nd December 2020. 

Results: 57 of 64 registrars (89%) from across all thirteen regional training hospitals responded. 25 trainees (44%) attended the independent sector, but 7 only assisted. No third year trainees went, however there was an even spread of other training years attending a mean of 4 sessions. 66 indicative procedures were performed in the time period, all with supervisors scrubbed. Second year trainees performed the most cases with 4 on average. Completion of work based assessments was low.

20% trainees reported a negative experience. 80% enjoyed themselves. 52% felt they achieved their goals. 29% trainees felt that independent sector operating would compensate for the shortfall in training brought about by COVID-19.

The main obstacles were lack of access and opportunity (51%) and poor induction and paperwork issues (22%)

Conclusion: This is the first deanery-wide assessment of access to and training within the independent sector due to COVID-19. Independent sector operating for orthopaedic trainees is feasible on scale and should be embedded to supplement training in the future. In their current state independent sector facilities are not easily and universally accessible to fulfil training needs. 

Implications: We challenge the governing bodies to look to the future to organise an established framework for trainees to access opportunities within the independent sector and create a culture of training. #NoTrainingTodayNoSurgeonsTomorrow.

136 - A clinical complexity scale combining local and systemic factors, identifies a Black Swan Patient Group not recognised by the UK National Joint Registry

Sunny Deo, Lynn Hutchings, Jordan Evans, Magnus James, Rute Castelhano

The Great Western Hospital NHSFT, Swindon, United Kingdom

Background: A 4-part scale was developed for improved stratification based on two principle factors: systemic patient comorbidity criteria and local complexity, specific to issues at the site of index condition. This differs from the UK National Joint Registry (NJR) which mainly focuses on systemic factors.

The complexity (C) scale is:
CN - Complexity Nil: patients have no local or systemic complexity.
CL – Complexity Local: patients have local complexity at the site of surgery, but no systemic complexity
CS – Complexity Systemic: patients have systemic complexity but no local complexity
CLS – Complexity Local & Systemic: patients have both local and systemic complexity

Key research questions were whether early outcomes and mortality differed by complexity scale

Methods: The cohort was 1,943 consecutive patients, having unilateral primary total knee arthroplasty (TKA) with complete data. Surgery time, length of stay and mortality were analysed. Group proportions were: CN 45%, CL 26%, CS 20%, CLS 9%.

There were increased mean operating times and lengths of stay in CL and CLS groups, with the longest times being in the CLS group which are statistically significant (t-test p<0.05) relative to the CN group. The CLS group had the highest mortality risk at both 1 and 5 years and was the only group with statistically significantly higher risk than that of the entire cohort, CN and CL groups (Fisher's Exact p<0.05).

Conclusions: Local complexity factors are significant in influencing short and longer term outcomes. The combination of local and systemic complexity, the CLS group, was associated with the worst results, representing a small sub-group of “black swan” patients. As local complexity data is currently inadequately captured, it is unrecognised as an influencing factor. 

Implications: Local complexity factors are important determinants of outcomes and require recognition. Further research is required to define these further to facilitate optimal national data collection.

353 - Efficacy of Vitamin-D supplementation in patients with chronic low back pain

Rahman Rasool Akhtar, Riaz Ahmed

Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan

Background: Chronic lower back pain is most common complaint among the pain of musculoskeletal structures. It may cause the loss of functional ability and also reduce the movements of the body as well. 

Objective: To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic low back pain.

Study Design & Methods: This prospective cohort study was conducted from 20th March 2015 to 19th March 2017. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline, 2, 3 and 6 months. 

Results: A total of 600 patients were included in the study. Mean age of patients was 44.21±11.92 years. 337 (56.17%) were male and 263 (43.83%) were females. 454 (75.66%) patients have deficient vitamin-D3 levels. Baseline mean vitamin-D3 levels were 13.32±6.10 ng/mL and increased to 37.18±11.72 post supplementation (P<0.01). 299 (66%) patients attained normal levels (>29 ng/mL) post supplementation. Significant reduction in VAS was observed at 2, 3, and 6 months (61, 45, 36) as compared to 81 at baseline (P = 0.001). A significant improvement in the functional ability was also observed at 2, 3, and 6 months (35,30 and 25) as compared to baseline 46(P = 0.001).

Conclusion: Vitamin-D supplementation in CLBP patients may lead to improvement in pain intensity and functional ability.

414 - Never Events in Orthopaedics: A Nationwide Data Analysis and Guidance on Preventative Measures

Ahmed Hafez¹, Islam Omar², Balaji Purushothaman³, Yusuf Michla³, Kamal Mahawar⁴

¹Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; ²Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland, United Kingdom; ³Department of Trauma & Orthopaedic Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland, United Kingdom; ⁴Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, Sunderland, United Kingdom

Background: Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties. The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England.

Methods: We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes.

Results: We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest "wrong implants" (n=94; 45.63% and n=91; 44.17% respectively). There were 197 "Wrong-site surgery" incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. Eighteen (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each. 

Conclusion: We identified common Never Events themes in the field of Orthopaedic Surgery. Increased awareness of these themes may help the development of targeted preventive measures and reduce their incidence in the future. 

Site marking can be challenging in the presence of cast and on operating on the digits and spine. Real-time check scan can avoid wrong implant while Fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.

490 - Tourniquet Use in Orthopaedics and a Novel Tourniquet Pressure Safety Margin

Abigail Johnson¹, David Warwick¹, Nick Aresti², Deborah Eastwood³, Lucky Jeyaseelan², Fergal Monsell⁴

¹University Hospital Southampton, Southampton, United Kingdom; ²Barts Health NHS Trust, London, United Kingdom; ³Great Ormond Street Hospital, London, United Kingdom; ⁴Royal Bristol Hospital for Children, Bristol, United Kingdom

Background: Tourniquets are widely used in orthopaedic surgery to reduce intra-operative time by limiting bleeding and improving the view of the surgical field. However, both systemic and local complications due to tourniquet use can occur. Tissue ischaemia can cause widespread endothelial cell injury from superoxide radical release. Local tissue damage such as nerve injury and muscle oedema following microvascular compression are also recognised. Use of the correct size and type of tourniquet at an appropriate pressure for a limited duration can help to mitigate these risks.

Methods: We conducted a literature review of orthopaedic tourniquet use, focussing on the evidence for various recommended limits concerning pressure, size and time. We combined formulae from the latest randomised controlled trials and population anthropometric data to calculate a new pragmatic safety margin for pressure settings on pneumatic tourniquets in orthopaedics.

Results: We calculated that adult patients should have a pneumatic tourniquet pressure set to systolic blood pressure plus 70 – 130mmHg for the lower limb and plus 50 – 100mmHg for the upper limb. We recommend using the lower end of the margin for patients with smaller limb circumference and/or lower systolic blood pressure and vice versa.

Conclusion: We suggest that this new safety margin provides a practical and more scientific method for setting tourniquet pressures than current standards of practice.

Implications: This tourniquet pressure safety margin should result in lower pneumatic tourniquet pressures being used for a significant proportion of patients compared to conventional recommendations. This has the potential to decrease pressure-related tourniquet complications in orthopaedic surgery.

542 - Computerised Adaptive Testing Dramatically Reduces the Length of Patient-Reported Hip and Knee Outcome Scores. An analysis of the UK National PROMs programme

Jonathan Evans^1,2, Chris Sidley-Gibbons³, Andrew Toms², Jose Valderas¹

¹Health Services and Policy Research Group, University of Exeter Medical School, Exeter, United Kingdom; ²Royal Devon and Exeter Hospital Foundation Trust, Exeter, United Kingdom; ³MD Anderson, Texas, USA

Background: The NHS England Patient-Reported Outcome Measures (PROMs) programme, is the world’s largest repository of hip and knee replacement outcome scores, with over 160,000 participants per year. However, only 50% of the data can be analysed due to incomplete records, problematic electronic linking and paper to digital transfer.

This studies aim was to reduce the patient and infrastructure burden associated with large PROMs datasets using modern psychometric techniques.  

Methods: The 2018/19 National PROMs programme pre-operative 12-item Oxford Hip and Knee Scores (OHS and OKS) were evaluated for dimensionality, local dependency, item fit, and marginal reliability. We used the Graded Response Model to develop item-specific difficulty and discrimination parameters. We used patient data from 2017/2018 to simulate a CAT. We compared the item responses, precision and length of both CAT and full-length versions of the OHS and the OKS.  

Results: We conducted IRT analysis using 40,432 OHS and 44,714 OKS observations. Both were unidimensional (Root Mean Square Error of Approximation (RMSEA) of 0.08 and 0.07 respectively). Marginal reliability (MR) was 0.914 and 0.903. The CAT, with precision set at 90% and 80% required a median of 3 items (range 1-12)(r = 0.96) and median 2 items (1-7)(r = 0.90) respectively for the OHS, and median of 4 items (1-12)(r = 0.96) and 2 items (1-12)(r = 0.91) for the OKS. This represents a potential 82% reduction in PROM length and equates to up to 40,000 hours of reduced data collection time per year.  

Conclusion: We have established that the application of IRT to the OHS and OKS produces an efficient and substantially reduced CAT. By reducing the number of items required and applying a standardised measurement scale, we have demonstrated a path to reduce burden and potentially increase compliance for these ubiquitous outcome measures.    

545 - Common elective orthopaedic procedures and their clinical effectiveness: An umbrella review of level 1 evidence

Ashley Blom^1,2, Richard Donovan¹, Andrew Beswick¹, Michael Whitehouse^1,2, Setor Kunutsor^1,2

¹Musculoskeletal Research Unit, Bristol, United Kingdom; ²NIHR Bristol BRC, Bristol, United Kingdom

Importance: Common orthopaedic interventions often lack strong supporting evidence that they are better than no treatment, placebo or non-operative care. It is thus difficult to produce high-quality guidance as to the optimal use of surgical and non-surgical treatments for orthopaedic conditions.

Objective: We performed an umbrella review of meta-analyses of RCTs to determine the clinical effectiveness of common orthopaedic procedures compared with no treatment, placebo, or non-operative care and assessed the impact on clinical guidelines.

Data Sources: Ten of the commonest orthopaedic procedures, namely: arthroscopic ACL reconstruction, arthroscopic meniscal repair, arthroscopic partial meniscectomy, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, THR, and TKR were studied. MEDLINE, EMBASE, CENTRAL, and bibliographies were searched until September 2020. 

Data Extraction and Synthesis: Summary data were extracted by two independent investigators. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews Instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The NICE Evidence search was used to check if recommendations for each procedure reflected the body of evidence.

Main Outcomes: The quality and quantity of the evidence behind the commonest orthopaedic interventions were assessed, and comparisons were made to the strength of the recommendations in relevant national clinical guidelines.

Results: RCT evidence supports the superiority of carpal tunnel decompression and TKR over non-operative care. There were no RCTs that specifically compared THR or meniscal repair with nonoperative care. Trial evidence for the other six procedures showed no benefit over non-operative care. However, some of these procedures are still recommended by national guidelines in certain situations.

Conclusions and Relevance: Although they may be effective overall or in certain sub-groups, there is not a strong high-quality evidence base demonstrating that many commonly performed orthopaedic procedures are better than non-operative alternatives.

738 - Systematic review on the effectiveness of anti-embolism stockings; a need to re-evaluate the evidence

Mahmoud Awadallah¹, Martyn Parker¹, Sophie Easey¹, Kurinchi Gurusamy²

¹North West Anglia NHS Foundation Trust, Peterborough, United Kingdom; ²University College London, London, United Kingdom

Background: The effectiveness of anti-embolic graduated compression stockings (GCSs) has recently been questioned. The aim of this study is to systematically review all the relevant randomised controlled trials published to date.

Patients and Methods: We systematically reviewed all the randomised controlled trials comparing anti-embolism stockings with no stockings. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL, Cochrane Musculoskeletal Injuries Group specialized register and the reference lists of articles as well as hand search results. Trials were independently assessed and data for the main outcome measures; deep vein thrombosis (DVT), pulmonary embolism and skin ulceration, were extracted by two reviewers. 

Results: A total of 26 relevant RCTs involving 8279 participants were systematically reviewed. The occurrence of deep vein thrombosis was 306/4159 (7.3%) with the stocking to 492/4120 (11.9%) without the stockings (RR 0.49, 95% CI 0.39-0.62). The occurrence of pulmonary embolism was also reduced from 1.2% go 0.7% (95% 0.33-0.92). This initial finding was unsound due to the potential underreporting of negative studies and the subsequent changes to clinical practice. For the three large contemporary studies involving 5171 participants, these failed to show any statistically significant reduction in thrombosis, with DVT confirmed in 158 (6.1%) participants in those allocated to stocking, as opposed to 171 (6.6%) in the control group. 

Conclusion: The current recommendations regarding the use of thrombo-embolic stockings need to be reconsidered, as their effectiveness at reducing the occurrence of post-operative deep vein thrombosis is minimal at best, based on the current evidence and clinical practices. 

973 - Consent Plus - A Cost Consequence Analysis

James Brock¹, Paul Lee¹, Ullas Jayaraju²

¹Wales Deanary, Cardiff, United Kingdom; ²Wales, Cardiff, United Kingdom

Background: There is growing evidence to support the role of bite-sized eLearning videos that supplement the consent process in lower limb arthroplasty, post implementation of the Montgomery judgement. 

Methods: We performed a prospective cost-consequence analysis in 25 National Health Service (NHS), UK, Hospital Day Surgery centres.

A total of 3,143 consecutive patients undergoing Total Knee or Hip Replacement watched a series of bite-sized illustrative videos developed to enhance the consent process. Patients watched 13 educational videos each 1 minute long, then underwent an informal questionnaire to identify their material risk. Patients underwent the conventional consent process in the outpatient clinic setting.

The cost consequence analysis process identifies:

Costs: Any cost associated with developing and running the intervention, ConsentPLUS.

Consequences: Primary outcomes: ConsentPLUS will increase patient-surgeon contact time, attributable costs to additional contact time and overall reduction in consent clinic time/more efficiently run consent clinic.

Secondary outcomes: patient reported outcomes of patient satisfaction and knowledge. 

Results: The total cost of development and projected 10 year running fees will be £75,000. Running costs are projected over a 10 year period and include website maintenance, admin fees and update of information. The service is access free to all centres throughout the UK.

Mean exposure time per patient was 10 minutes 29 seconds equating to £185,437 of additional contact time according to National Tariffs. Mean clinic time was reduced by 17 minutes, due to earlier identification of material risk. Patient knowledge on average increased from 7.01 to 9.08 following eLearning, (paired t-test = 0.998). Overall 97% of patients were satisfied with ConsentPLUS.

Conclusion: This cost-consequence analysis provides clear and comprehensive information about the costs and benefits of ConsentPLUS to decision makers across the NHS. 

Implications: ConsentPLUS has potential to provide cost savings, reduced clinic time and improved patient contact time, knowledge and satisfaction.

1176 - Factors associated with non-union and its management in Atypical Femur Fractures. A 10-year retrospective study

Nimesh Nebhani, Christopher Ogbuagu, Gunasekaran Kumar

Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

Background: Risk of non-union is high in atypical femur fracture (AFF) surgery. Use of bisphosphonates for prevention of osteoporotic fractures is associated with increasing incidence of AFF. Current literature emphasizes on treating these fractures with intra-medullary nail. The aim of this study was to identify the factors associated with non-union and its management in AFF. 

Methods: This is a retrospective study of AFF fixations from 2010 to 2020. AFF were identified according to the criteria of the American society for bone and mineral research (ASBMR). Exclusion criteria: incomplete clinical or radiological data or lost to follow-up. In each case we analyzed the type and duration of bisphosphonate, type of fracture, implant used for fixation, time to union and method of fixation in revision surgery. 

Results: There were 57 patients with an average age of 72 years, majority being females (49). Site of fracture was subtrochanteric (30) and femoral shaft (27) and all were transverse fractures. 41/57 fractures united clinically and radiologically at 1 year follow up. Logistic regression of non-union versus age and duration of bisphosphonate was insignificant (p= 0.89). Correlation between type of implant (nail, plate) and non-union was not statistically significant (p= 0.5). Sub-optimal fracture reduction, implant position were associated with increased risk of non-union (p=0.05). During revision of non-unions, 15 were revised with better stability (dual implants, better construct) and 1 underwent arthroplasty. Moreover, three failed revisions were re done achieving union at 2 years.

Improved bone contact (osteotomy at non-union site), increased stability (nail-plate or double plate) and use of bone graft/osteoinductive substances during revision surgery resulted in union. 

In addition, 14 patients also underwent prophylactic opposite femur fixations. 

Conclusion: Sub-optimal fixation of AFF is associated with increased risk of non-union. Revision fixation of non-union also high complication rate.

53 - Patient engagement with an online patient education program is high irrespective of age, gender and operation

Rebecca Martin, Natalie Clark, Paul Baker

James Cook University Hospital, Middlesbrough, United Kingdom

Introduction: Patients should be actively engaged in decision making regarding their care and given information to support this. We have piloted an online patient education system (PES) that provides information and support for patients undergoing hip and knee arthroplasty. The aim of this study was to analyse how patients interacted with the platform based on their demographics and type of surgery.

Methods: Demographics for patients registered between 21/09/2017 and 28/05/2020 were obtained and engagement was assessed through the number of interactions and time spent on the PES. The association between age (categorised into 5 groups: ≤50, 51-60, 61-70, 71-80 and >80 years old), gender, type of surgery and engagement was assessed using non-parametric statistical comparisons.  

Results: 1195 patients were registered and 832 (69.6%) accessed their program. The mean total time spent on the program per patient was 83 minutes and with each access lasting an average of 4 minutes.  There was no difference in the proportion of patients accessing the PES dependent upon age (p=0.10) or gender (p=0.75). There was greater engagement for hip (75.5%) compared to knee (63.8%) patients (p<0.001). There were no differences in the number of times patients accessed the PES or total time spent on the platform dependent upon age (p=NS). The oldest age groups (71-80 years p<0.001; >80 years p=0.008) spent longer on the program per access when compared with patients aged <50 years. Females accessed the system more than males (p=0.03).

Conclusion: An online education platform providing information to patients is effective and demonstrates high levels of patient engagement irrespective of age. An online resource such as this does not discriminate against age or gender in terms of accessibility and can be useful for the delivery of information.

406 - The effect of sarcopenia on outcomes following orthopaedic surgery: A systematic review

Filip Brzeszczynski¹, Iain Murray^2,3, Andrew Duckworth^2,3, Joanna Brzeszczynska⁴, David Hamilton^3,5

¹Western General Hospital, Edinburgh, United Kingdom; ²Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ³University of Edinburgh, Edinburgh, United Kingdom; ⁴Unniversity of the West of Scotland, Glasgow, United Kingdom; ⁵Edinburgh Napier University, Edinburgh, United Kingdom

Background: Sarcopenia is characterised by generalised progressive loss of physical performance, skeletal muscle mass and strength. This systematic review evaluated the effects of sarcopenia on postoperative functional recovery outcomes and mortality in patients undergoing orthopaedic surgery and secondarily assessed the methods used to diagnose and define sarcopenia in orthopaedic literature.

Methods: A systematic search was conducted in MEDLINE, EMBASE and Google Scholar databases according to the PRISMA guidelines. Studies involving sarcopenic patients who underwent defined orthopaedic surgery and recorded postoperative outcomes were included. The quality of the criteria by which a sarcopenia diagnosis was made was evaluated and publication quality was assessed using Newcastle-Ottawa Scale.  

Results: A total of 365 studies were identified and screened, 26 full text records were reviewed and 19 publications included in the analysis. Papers reflected a variety of orthopaedic interventions, primarily for elderly trauma or degenerative conditions. Mean follow up was 1.9 years (SD: 1.9 years). There was wide heterogeneity in measurement tools and evaluated parameters across the included papers, however sarcopenia was associated with at least one deleterious effect on surgical outcomes in all 19 studies. Post-operative mortality rate was reported in 11 papers and sarcopenia was associated with poorer survival in 73% (8/11) of them. The most used outcome was the Barthel index (4/19) and sarcopenic patients recorded lower scores in 75% (3/4) of these. Sarcopenia was defined using the gold standard three parameters in 21% (4/19) of studies, using two parameters in 21% (4/19) studies and one in the remaining 58% (11/19). The methodological quality of included papers was moderate to high.

Conclusions: The literature base suffers from heterogeneity in outcomes and classification of sarcopenia diagnosis parameters, however available data suggests that sarcopenia generally increases postoperative mortality and impairs recovery. Sarcopenic patients could be targeted with pre-operative interventions, aiming to improve outcomes.

16 - A Meta-Analysis of Proximal Scaphoid Fractures - Does Terminology Affects Reported Union Rates?

Lambros Athanatos, Han Hong Chong, Kunal Kulkarni, Rohi Shah, Melinda YT Hau, Harvinder Singh

University Hospital of Leicester NHS Trust, Leicester, United Kingdom

Background: Proximal scaphoid fractures are reported to have higher non-union rate its blood supply. However, inconsistent definition of ‘proximal’ (rarely specified distinction between ‘proximal’, ‘proximal third’, ‘proximal fifth’, and ‘proximal pole) in the literature impacts the reported union rate.

Purpose: To review studies reporting outcomes of all variants of proximal scaphoid fractures to determine differences in union rates based upon the definition of ‘proximal’. 

Methods: A literature search was conducted to identify articles that reported descriptions and union rate of acute proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported (‘third’, ‘pole’, ‘fifth’ or ‘undefined). The data were pooled using a fixed-effects method to compare the relative risk (RR) of union rates against non-proximal fractures.  

Results: 12 articles were included in the qualitative review of classifications. 1 described ‘proximal’, 4 described ‘proximal third’, and 8 described ‘proximal pole’. Only 6 articles adopted an anatomical or ratio description. 15 articles were included for meta-analysis of union rates. Acute proximal (undefined) scaphoid fractures demonstrated a RR of 4.6 in developing non-union in comparison to non-proximal fractures. In contrast, proximal third and pole fractures demonstrated a lower non-union RR of 2.3 and 3.4, respectively. The overall risk of non-union in all proximal fractures was higher than their non-proximal counterparts. Operative management overall yielded lower non-union rates than non-operative for all fracture types (6% vs 18%). 

Conclusions: Non-union risk of proximal scaphoid fractures varies depending on definition, with less specific classifications adding heterogeneity to reported outcomes. We recommend an approach utilising fixed anatomical landmarks on plain radiographs (referencing one-fifth scaphoid radial border length and scapho-capitate joints) to standardise reporting of proximal pole fracture union in future studies.   

119 - A case series of patients treated with percutaneous intramedullary screws, for 5th metacarpal fractures, using the WALANT technique at Hinchingbrooke Hospital

Naufal Ahmed, Rory Norris

North West Anglia Foundation, Huntingdon, United Kingdom

Aims: To study the outcome of patients treated with percutaneous intramedullary screw fixation under WALANT for unstable 5th metacarpal fractures.

Methods: We used wide awake anaesthesia with 10-20 ml (1% Xylocaine and 1-2ml of 8.4% sodium bicarbonate as a buffer) infiltrated around the superficial tissues on the dorsal aspect of the 5th metacarpal including the periosteum.  The reduction technique used was the Jahss manoeuver to reduce the fracture under the guidance of a mini c-arm. All patients had a 3 mm medartis CCS (cannulated cancellous self tapping) screws which were inserted in a retrograde manner using a 5mm skin incision. The range of movement of the MCPJ was checked intra-operatively and shown to the patient to optimise their post operative rehabilitation. The patients were called for a 2 week follow up wound check, and to examine for any stiffness that may require hand therapy.

Results: We used this technique in 15 patients from 2019 to 2020. All patients had a good ROM at 2 week follow-up and the average time for them to return to their normal work was 2-4 weeks.  The DASH score measured at 6 weeks was satisfactory.

Conclusion: This case series shows that this is a quick and reliable alternative to fix unstable metacarpal fractures especially for high demand patients who require a short period of recovery before returning to normal activities.

128 - Cone-beam CT in the diagnosis of radiocarpal fractures: A Systematic Review and Meta-analysis

Emma Fitzpatrick¹, Vivek Sharma², Djamila Rojoa³, Firas Raheman¹, Havinder Singh²

¹Department of Trauma and Orthopaedics, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, United Kingdom; ²Department of Trauma and Orthopaedics, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, United Kingdom; ³Department of Plastics Surgery, Leicester Royal Infirmary, University Hospital of Leicester, Leicester, United Kingdom

Background: Occult radiocarpal fractures often present a diagnostic challenge to the emergency department. Accurate diagnosis of these injuries is crucial as missed fracture can lead to non-union, avascular necrosis, arthritis and instability. Radiographs have an unreliable sensitivity and specificity for radiocarpal fractures, with poor inter-rater agreement. Whilst Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans are more accurate, they are less accessible and more expensive. Cone Beam CT (CBCT) scan is a new imaging modality, with minimal radiation exposure and comparatively fast acquisition time. Our aim was to evaluate the use of CBCT in the diagnosis of radiocarpal fractures. 

Method: We conducted a systematic review of literature and included all studies that evaluated the use of CBCT in the diagnosis of radiocarpal fractures. We used a mixed-effects logistic regression bivariate model to estimate the summary sensitivity and specificity and constructed hierarchical summary receiver operative characteristic curves (HSROC). Inter-observer agreements for CBCT were meta-analysed using a mixed-effects model through calculated standard errors from the reported agreement coefficients.

Results: We identified 5 studies with 439 patients in total. CBCT was found to have 87.7% (95%CI 77.6-93.6) sensitivity and 99.2% (95%CI 92.6-99.9) specificity for scaphoid fractures. Radiocarpal fractures, CBCT were observed to have a pooled sensitivity and specificity of 93.5% (95%CI 81.1-98.0) and 99.9% (95%CI 91.6-1.00), respectively. The overall inter-rater agreement effect was shown to be 0.89 (95%CI 0.82-0.96), deemed to be almost perfect. 

Conclusion: CBCT is an accurate diagnostic tool for occult radiocarpal cortical fractures, which could replace or supplement radiographs. If used in the emergency setting, it could improve cost-effectiveness ratio, limit unnecessary immobilisations and reduce the requirement for follow-up MRI scan. We believe CBCT has a promising role in the acute radiocarpal fracture diagnostic algorithm in both emergency and trauma departments.

436 - The Value of Calibration of Radiographs in Total Wrist Arthroplasty

Nastaran Sargazi, Mattia Solari, Daniel Brown, Henry Crouch-Smith

Liverpool University Foundation Trust, Liverpool, United Kingdom

Introduction: Total wrist arthroplasty (TWA) is a relatively new concept, with a steep operator-dependent learning curve, thereby emphasising the need for careful operative planning. Pre-operative templating aims to improve intra-operative precision, however relies on correctly calibrated radiographs to aid optimal implant selection. This study aims to evaluate the role of calibration markers in hand and wrist x-rays. 

Method: Consecutive hand or wrist radiographs from patients referred to our regional elective hand unit between 15th-29th March 2021 were selected. External calibration markers were utilised at the time of the x-ray and magnification factor calculated. Multiple radiological parameters were measured and adjusted according to the calibration factor, with measurements obtained between the calibrated and uncalibrated images compared to assess for any statistical difference between the two groups. Data collection was undertaken by two independent reviewers and mean values obtained for each parameter.

Results: Twenty-two radiographs in were identified, with the cohort consisting of 7 male and 11 female patients, with an average age of 62.2 years (range 36-85). Average magnification factor was calculated at 0.969 based on the calibration markers. Metacarpal length, canal diameter at isthmus and cortical thickness was 63.96+/-4.562mm, 3.58+/-1.008mm and 2.56+/-0.713mm respectively in the uncalibrated group versus 62.02+/-4.423mm, 3.47+/-0.978mm and 2.48+/-0.092mm respectively in the calibrated group (p-value of 0.2046, 0.7452 and 0.7431 respectively). Capitate height and width was 22.01+/-1.428mm and 13.01+/-2.853mm respectively in the uncalibrated group versus 21.35+/-1.385mm and 12.61+/- 2.766mm respectively in the calibrated group (p-value 0.1768 and 0.6856 respectively). Metaphyseal diameter of the radius on AP and lateral views were 19.02+/-5.285mm and 12.53+/- 1.587mm in the uncalibrated group and 21.35+/-1.385 and 12.61+/-2.766 in the calibrated group respectively (p-value 0.7492 and 0.4979).

Conclusion: To our knowledge, this is the first study to illustrate that routine calibration of hand and wrist x-rays is not required for pre-operative templating of implants.

520 - The management of suspected scaphoid fractures in the United Kingdom: a national cross-sectional study

Benjamin Dean¹, Matt Costa¹, Chris Little², Nicholas Riley², SUSPECT study group³

¹University of Oxford, Oxford, United Kingdom; ²Nuffield Orthopaedic Centre, Oxford, United Kingdom; ³UK, UK, United Kingdom

Introduction: Current NICE guidance advises considering magnetic resonance imaging (MRI) direct from the ED for suspected scaphoid fractures (SS#s).   This study reports the current management of SS#s in the UK and assesses current compliance with NICE guidance.  

Methods: This national, multicentre, cross-sectional study was carried out at 87 Orthopaedic Departments in the UK, including 122 Emergency Departments (EDs), 184 Minor Injuries Units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for SS#s in EDs, MIUs and Orthopaedic Services (OSs).

Results: 11 of 87 centres (13%) had MRI directly available from ED.  

62 of 87 centres (71%) had a guideline for the management of SS#s.  14 centres (17%) used cross-sectional imaging direct from the ED: this was MRI in 11 (13%), CT in three (3%) and a mixture of MRI/CT in one (1%).  Four centres (6%) used cross-sectional imaging direct from the MIU: this was MRI in three (4%) and CT in two (2%).  Of 87 centres’ OSs, 74 (85%) obtained repeat X-rays, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in 3 (3%), and X-rays in 11 (13%).

Conclusions: Only a small minority of centres currently offer MRI directly from ED for patients with a SS#.  Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance.

687 - Custom-Fashioned Antibiotic Impregnated PMMA MCP Joint Arthroplasty in the Acute Settling Long Term Outcome: A Novel Technique Revisited: Our Own Experience

Frances Bowerman, Eleni Hadjikyriacou, Mohammad, Hywel Dafydd

National Health Service, Swansea, United Kingdom

Background: Osteomyelitis and septic arthritis in the hand can present with significant challenges which if not promptly and appropriately treated can result in long term significant morbidity, common complications including functional deficit and joint stiffness. Often osteomyelitis and septic arthritis in the hand are treated with a combination of antibiotics and surgical debridement. Arthroplasty is contraindicated in the context of an acutely septic joint with active infection, and when performed at a later stage, it is often too late to salvage function of the joint. We present a novel approach of MCPJ arthroplasty using bone cement impregnated with antibiotic beads (placos with 0.5g gentamicin) in order to enhance infection management whilst simultaneously salvaging joint function in a severely infected joint.

Method: Case study of patient 1, an 81 year old male who developed septic arthritis and osteomyelitis of the MCPJ, with a background of severe rheumatoid arthritis, osteoarthritis and pulmonary fibrosis for which he was prescribed prednisolone. Severe infection of the MCPJ necessitated multiple debridement and washout. Microbiology revealed staphylococcus aureus infection. He underwent arthroplasty of the joint using placos gentamicin custom made prosthesis of the proximal phalanx base. Infected bone and soft tissue was derided back to healthy bleeding bone and soft tissue. Cement was then moulded carefully to reconstruct the MCPJ, and range of movement was tested intraoperatively. A six week oral antibiotic regime followed. The patient was followed up for one year using clinical and radiological surveillance to ensure infection eradication and hand therapy to assess and enhance functional outcome. 

Result:  The primary outcome was joint salvage and complete infection eradication. Range of movement returned to pre-morbid baseline. 

Conclusion: A possible robust surgical approach to joint reconstruction following osteomyelitis and septic arthritis includes aggressive management of infection followed by a one stage reconstruction with antibiotic-impregnated cement. 

766 - Delaying fixation of distal radius fractures beyond the best practice guidelines does not affect the final outcome

Sanjay Chilbule, Jayanth Paniker

Rotherham District General Hospital, Rotherham, United Kingdom

Aims: BOA best practice guidelines recommending fixation of distal radius fractures (DRFs) within specific time periods (72 hours for intra-articular (IA) and 7 days for extra-articular (EA) fractures) have been contested. This study aims to assess our compliance with BOAST guidelines and the effect of delayed surgery on the outcome. 

Methods: 123 consecutive DRFs fixed internally were retrospectively reviewed and 101 patients with complete physiotherapy data were included. Demographics, the interval from injury to surgery, physiotherapy interval were pooled out from the hospital electronic records and analysed against the outcome criteria of range of movement (ROM), grip strength (GS) and time to return to work/expected activities. 

Results: Twenty males & 81 females (mean age- 60.7 years) had DRFs (EA in 60 and IA in 41). The mean interval from injury to surgery was 6.7 days, 7.2 for EA and 6 days for IA respectively (range 1-17). The patients had physiotherapy at a mean of 20.5 days and were discharged after a mean of 83.1 days. Significant improvement in the objective GS was seen from 12 to 20 kg (p=0.0001). Final ROM achieved was 60.1⁰ of wrist flexion, 54.7⁰ extension, 81.3⁰ supination, 85.5⁰ of pronation which was comparable to the normal ROM. Only 5 patients were unable to achieve the expected activities. 

Subgroup comparative analysis of patients who had surgery within and outside the recommended time frames showed no statistically significant difference in final GS, ROM and functional status. 

Conclusion: Results at our centre showed that IA & EA DRFs fixed within and outside the recommended time frame had similar outcomes. Our data also shows that delayed surgery up to 2 weeks for DRF does not appear to affect the outcome. 

790 - Association of trapeziometacarpal joint shape with clinical symptoms and radiological severity of thumb base osteoarthritis: Analysis of a cohort from the Osteoarthritis Initiative study using a statistical shape model

Jenna Shepherd¹, Fiona Saunders², Yajur Narang¹, Katharine Hamlin¹, David F.M. Lawrie¹, Benjamin Winter¹, Anna H.K. Riemen^1,2

¹NHS Grampian, Aberdeen, United Kingdom; ²University of Aberdeen, Aberdeen, United Kingdom

Background: Statistical shape modelling (SSM) has been used extensively to investigate the relationship between joint shape and hip, knee and spine osteoarthritis (OA), but trapeziometacarpal joint (TMCJ) shape and thumb base OA is less understood. We established a statistical shape model of the TMCJ to investigate joint shape variation in the Osteoarthritis Initiative (OAI) study to assess the association of joint shape with clinical symptoms and radiological OA severity.

Methods: 100 participants were selected at random from the OAI public access database. Bilateral hand and wrist radiographs with associated patient demographics and clinical outcome data were identified. SSM software was used to develop a model to characterise TMCJ shape which was applied to radiographs. Radiographs were graded using the Kellgren-Lawrence system to classify OA severity. Independent modes of variation in shape within the cohort were identified and correlation with clinical variables and radiological severity scores was analysed using SPSS v2x.0.

Results: Ten and nine modes of variation were identified in right and left models respectively. Less prominent distal projection of the ulnar side of trapezium joint surface between thumb and index metacarpals, described by right mode 1, is associated with presence of right-sided hand pain and stiffness (correlation co-efficient -0.228, p= 0.023). TMCJ shape is associated with carpometacarpal joint (CMCJ) and scaphotrapezoid joint (STJ) radiological OA severity, with significant correlation with left modes 1,2,6,8; right modes 1,6 and left modes 1,2,6,8; right mode 1 respectively. 

Conclusions: We show correlation between TMCJ shape and symptoms of hand pain and stiffness and radiological severity of thumb base OA through development and application of a statistical shape model. Joint shape analysis may have a potential role in prediction of thumb base OA and further investigation is needed to establish this.

805 - The Aberdeen outpatient dedicated percutaneous needle fasciotomy clinic for the treatment of Dupuytren’s Disease. A valuable resource in the re-establishment of orthopaedic service following the coronavirus pandemic

Yasmeen Khan, Katharine Hamlin, Clare Miller, David Lawrie

Aberdeen Royal Infirmary, Aberdeen, United Kingdom

Introduction: Reconfiguration of elective-orthopaedic-surgery as the country unlocks, presents challenges and opportunities to develop outpatient pathways to reduce surgical waiting times. Dupuytren’s disease (DD) is a benign progressive fibroproliferative disorder of the fascia in the hand, which can result in disabling contractures. Percutaneous-needle-fasciotomy (PNF) is an established treatment, which can be performed successfully in the outpatient clinic.

Method: The Aberdeen hand service has over 10 years’ experience running dedicated PNF clinics. NHSGrampian covers a vast area of Scotland receiving over 11749 referrals to the orthopaedic unit yearly. 250 patients undergone PNF in the outpatient department annually. This is a retrospective review of 100 patients who underwent PNF in outpatients (Jan2019-Jan2020).

Results: Patient demographics 79M, 21F. Average age 66 years range (29-87). 95 patients were right hand dominant. DD risk factors: 6 patients were diabetic, 2 epileptic, 87 patients drank alcohol. 76 patients had a family history of DD. Disease severity, single digit 20 patients, one hand multiple digits in 15 patients, bilateral hands in 65 patients of which 5 suffered from ectopic manifestation suggestive of Dupuytren’s diasthesis. Using Tubiana Total flexion deformity score pre and post fasciotomy. Type 1 total flexion deformity (TFD) between 0-45 degrees pre PNF n=60 post N= 85, Type 2 TFD 45-90 degrees pre PNF n=18 post N=9, Type 3 TFD 90-135 pre PNF n=15 post N= 5, Type 4 TFD >135 pre PNF n=1 post PNF N=1. Using Chi-square statistical test, a significant difference was found at the p<0.05 between the pre and post PNF TFD. 8 patients noted early recurrence and 1 patient sustained a skin tear during the procedure. No patients sustained digital nerve injury.

Conclusion: Outpatients PNF clinics are a valuable resource during the post-covid re-establishment of orthopaedic hand service in the treatment of Dupuytrens’s disease.

959 - Articular cartilage and soft tissue damage from radiofrequency thermal ablation wands at wrist arthroscopy

Grey Giddins¹, David Shewring², Nick Downing³

¹Royal United Hospital, Bath, Bath, United Kingdom; ²UHW, Cardiff, United Kingdom; ³Nottingham University Hospital, Nottingham, United Kingdom

Background: Radiofrequency electrosurgical devices can be used in arthroscopic surgery. In only one paper (published as a supplement) has there been a description of serious inadvertent thermal injury to the wrist during radiofrequency ablation (Pell and Uhl 2004). They reported three cases; 2 tendon ruptures and one full thickness skin burn.  

Methods: We report cases seen in clinical and medico-legal practice

Results:

Case 1: A 47-year-old woman had a superficial burn healing without problems 

Case 2: A 16-year-old woman suffered index finger extensor tendon ruptures requiring 2 operations with a moderate outcome

Case 3: A 42-year-old man suffered index and middle finger extensor tendon ruptures also requiring 2 operations with a moderate outcome

Case 4: A 37-year-old woman suffered extensive damage to the articular cartilage of the radio-carpal joint surfaces. She had five further operations: revision wrist arthroscopy and limited denervation; ulnar shortening osteotomy; total wrist arthrodesis and ulnar head replacement; extensor tenolysis; and revision extensor tenolysis and plate removal. She had a poor outcome.

Case 5: A 38-year-old man suffered a rupture of his EDM tendon requiring surgery with an unclear outcome

Case 6: An 18 year old man suffered disruption of his scapho-lunate ligament complex treated with a “modified Brunelli” reconstruction. At last review, 6 years after the “modified Brunelli” operation, he was noted to have established degenerative changes at the radio-carpal joint and marked scapho-lunate diastasis with a poor outcome

Conclusions: This is the first report of articular cartilage damage in the wrist from thermal wand use in the wrist. 

The risks appear due to a lack of fluid flow which is harder in a small joint and a manufacturing error with the collar of the wand getting very hot.

Implications: Hand surgeons need to use more irrigation and manufacturers need to change their designs.

140 - Internal plate fixation for extra-articular fractures of the proximal phalanx. An 11-year institutional retrospective case series

Rumina Begum¹, George Hourston², Aaron Rooney¹, Adrian Chojnowski¹

¹Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom; ²James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, United Kingdom

Background: Fixation of extra-articular fractures of the proximal phalanx should allow for fracture healing while preserving gliding motion of the flexor and extensor tendons. Various treatment methods are used for these injuries. We aimed to assess the outcome and complications following plate fixation of proximal phalangeal fractures.

Methods: We performed a retrospective review of patients with fractures of the proximal phalanx of all digits treated with open reduction and internal plate fixation at a single Trauma Unit between 2009 and 2020. Procedures performed for acute, closed, extra-articular injuries were included in the analysis with open or intra-articular injuries excluded. Demographic and complication data were collected. The primary outcomes were union and re-operation. Fisher’s Exact Test was used to compare re-operation rates between dorsal and lateral approach.

Results: We identified 56 fractures among 55 patients (24 female, 31 male) with an average age of 37.7 years (range 17 – 70 years). Fixation was via a dorsal approach in 41/56 patients with dorsal and lateral plates applied in 31 and 10 patients respectively. 15/56 underwent lateral plate fixation via a lateral approach. Follow up period ranged from 2 to 30 months post-fixation. Five patients (9.1%) required re-operation; two patients (3.6%) required removal of metalwork and three patients (5.5%) required removal of metalwork and associated tenolysis for stiffness. All fractures united and there were no infections in this series. There was no significant difference in re-operation rate between dorsal and lateral approach (p=0.11). 

Conclusions: Plate fixation for acute closed extra-articular fractures of the proximal phalanx proved efficient and reliable in our series. Union was consistently achieved with a low complication rate. Furthermore, the surgical approach did not significantly impact upon re-operation rate. This study suggests that open reduction and internal plate fixation for such injuries can achieve good clinical outcomes.

941 - Accuracy of the 'shuck' test in the assessment of distal radio-ulnar joint instability

Grey Giddins¹, Greg Pickering¹, Thomas Knapper¹, Nicola Fine²

¹Royal United Hospitals, Bath, Bath, United Kingdom; ²RD and E, Exeter, United Kingdom

Background: The 'shuck' test (palmar-dorsal movement of the ulnar relative to the radius) is the most commonly used clinical test for distal radio-ulnar joint (DRUJ) instability. We look to assess the accuracy of this test, when utilised by a group of specialist hand surgeons, in their assessment of DRUJ instability.

Methods: Thirty specialist hand surgeons (80% male, 80:20 orthopaedic:plastic surgery split) with a combined total of 468 years consultant practice (range 1-35 years) assessed for instability both DRUJs of four volunteers.

Volunteers had been previously tested with a validated measurement rig to assess and quantify their DRUJ translation/instability.

Results: The diagnosis was correct in 142 of 240 assessments (59%). There were seven false positives and 91 false negatives. The sensitivity of the test was only 24% whilst the specificity was 94%. The positive and negative predictive values were 81% and 55% respectively.

Conclusions: In conclusion the shuck test has very poor sensitivity in the diagnosis of DRUJ instability. Whilst specificity of the test is high, the low negative predictive value is little more than that of chance or a coin toss. Further work needs to be completed on the quantification of DRUJ instability and how this can be routinely measured. The validity of all research to date which uses this method as the primary determinate of laxity and instability is brought into question. Implications Clinical testing of DRUJ instability is insufficient in scientific papers calling into question the outcomes of previous scientific studies. And clinicians need specific training preferably with validated feedback to improve their clinical practice.

113 - An online patient education system to effectively deliver remote patient education and support for those undergoing carpal tunnel decompression surgery

Rebecca Martin, Natalie Clark, Emma Reay,

James Cook University Hospital, Middlesbrough, United Kingdom

Introduction: Remote access to patient education and support has become vital due to the COVID-19 related restrictions. We piloted an online patient education system (PES) using the GoWellHealth platform for patients undergoing carpal tunnel decompression. The aim of this study was to assess levels of engagement and interaction with the platform. This was then compared against patient demographics. 

Method: Demographic and engagement information was obtained for patients registered to the platform between 7^th September 2020 and 25^th January 2021. Engagement was assessed by analysing time spent on the PES, time of day it was accessed and device used.  The patient demographics used for the comparison was their age (categorised into 5 groups: <40, 40-49, 50-59, 60-69 and ≥70) and gender. 

Results: 47 patients were registered to the PES, 17 male and 30 female, and in total 30 (63.8%) accessed their platform. Male patients had a higher rate of accessing the platform (70.5%) compared to female (60%). There was no difference in rates of accessing the platform between different age categories (p=NS). The use of a computer was favoured by the older age groups (≥70 years 100%; 60-69 years 77%) whereas the youngest age group favoured the use of a phone (<40 years 85%). The oldest age groups spent longer on average per access when compared to the younger age groups (p<0.01). Females spent less time per access compared to male patients but overall there was no difference in their level of engagement (p=NS).

Conclusion: An online PES is an effective way of providing information and demonstrates high levels of engagement regardless of age or gender. A platform that can be used across a variety of internet ready devices is essential as older patient groups prefer using a computer and may not engage with an application based program. 

585 - The use of contrast-assisted cone beam computed tomography (CBCT) for ligamentous injuries of the wrist - A diagnostic test accuracy meta-analysis

Djamila Rojoa¹, Nicholas Cereceda-Monteoliva², Jvalant Parekh³, Firas Raheman¹

¹Leicester Royal Infirmary, Leicester, United Kingdom; ²Chelsea and Westminster Hospital NHS foundation trust, London, United Kingdom; ³University of Leicester, Leicester, United Kingdom

Introduction: Ligamentous injuries of the wrist, including scapholunate ligament (SLL), lunotriquetral ligament (LTL) and triangular fibrocartilage complex (TFCC) tears, may lead to severe consequences such as scapholunate collapse and chronic wrist arthritis if misdiagnosed. Diagnosis can be challenging with the absence of dynamic instability on radiographs. Our aim was to evaluate the accuracy of Cone-beam CT (CBCT) arthrography in diagnosing ligamentous injuries.

Methodology: A systematic review was conducted in compliance with Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA). A literature search was performed using Healthcare Database Advanced Search (HDAS). A mixed-effects logistic regression bivariate model was used to estimate summary sensitivity and specificity and hierarchical summary receiver operating characteristic (HSROC) curves were constructed to determine diagnostic accuracy of CBCT arthrography.

Results: We identified 5 studies assessing the accuracy of CBCT arthrography against wrist arthrography, MRI or intraoperative findings as reference standard. The pooled estimates for sensitivity and specificity of CBCT arthrography was 93%(95%CI 40-100) and 91%(95%CI 81-96) for SLL injuries, 83%(95%CI 37-98) and 64%(95%CI 42-81) for LTL injuries and 78%(95%CI 57-91) and 80%(95%CI 54-93) for TFCC injuries. The area under the curve was 0.91(95%CI 0.89-0.94), showing an excellent diagnostic accuracy of CBCT arthrography in SLL injuries. CBCT arthrography had an estimated mean effective dose of 3.2 mSv (2.0 to 4.8).

Conclusion: Our study confirms that CBCT arthroscopy has an excellent diagnostic accuracy for wrist ligamentous injuries. It has a comparably high sensitivity to conventional arthrography and a better specificity and has a reduced mean radiation dose compared to MSCT. Moreover, it may provide additional information on cartilage and cortical injuries.  Whilst further studies with more robust methodology are required to support its implementation in clinical practice, our analysis shows that it is a reliable option and has a promising future.

627 - Dorsal wrist ganglion: Randomised control trial comparing aspiration alone or combined with injection of platelet rich plasma

Katharine Hamlin, Yasmeen Khan, Alexandra Haddon, Clare Miller, David Lawrie

Woodend Hospital, Aberdeen, United Kingdom

Background: Prospective randomised control trial to assess a novel treatment of dorsal wrist ganglion. Current treatments including aspiration alone or with steroid or excision open or arthroscopically are plagued by recurrence and complications. We investigated platelet rich plasma (PRP) as a potential treatment for Dorsal wrist ganglion.

Methods: Aspiration alone was compared to aspiration plus injection of platelet rich plasma. Seventeen patients were enrolled between Dec 2018 and Feb 2020 (recruitment was cut short by COVID). Nine patients received aspiration plus PRP and eight aspiration alone. Patients were followed up at six weeks and one year; recurrence of the ganglion was recorded and Patient Evaluation Measure (PEM) scores were recorded. One patient was lost of follow up from the PRP group.

Results: At six weeks seven patients in the aspiration group had a recurrence and four in the PRP group, but by one year, this has increased to seven out of eight in the PRP group whereas in the aspiration group three had resolved leaving only four out of seven patients with a ganglion still present.

Conclusion/Findings: This is a small study to test the feasibility of platelet rich plasma as a treatment agent for ganglions. While we may be subject to a type 2 error, it is unlikely from our results that PRP will be more effective than other already established treatments.

Implications: We cannot recommend injection of platelet rich plasma as an adjuvant to aspiration for the treatment of dorsal wrist ganglion.

Disclosure: Equipment for the study was provided by a research grant from Arthrex (9 ACP double syringes).

809 - Outcome of headless compression vs. cortical screw for distal interphalangeal joint fusion

Aaron Rooney, Rumina Begum, Daniel Watts, Adrian Chojnowski

Norfolk and Norwich Hospital, Norwich, United Kingdom

Aims: This retrospective study is designed to look for differences of complication rate in patients that had a distal interphalangeal joint (DIPJ) fusion with either headless compression or cortical screw.

Methods: Patient lists were generated from electronic patient records. All patients were included from 2007 to 2020 in our local institution. The primary outcome was screw removal for irritation or infection.

Results: There were 161 fusions in 149 patients identified; 12 patients had two separate fusions performed during the same episode. In 102 of these cases a cortical screw was used (1 x 1.1mm, 51 x 1.5mm, and 50 x 2.0mm screws) and a headless compression screw was used in 59 cases (55 x 2.4mm, and 4 x 3.0mm screws). 

Most patients (117) had the operation performed for osteoarthritis, the second largest group (26) following a mallet injury. Final follow up was commonly at 6 weeks (83); this ranged from 2 weeks to 9 months, mean 11.1 weeks. Re-referral following discharge from clinic occurred up to 10 years later with cases of irritating metalwork and deep infection. 

Pain associated with metalwork necessitating removal of the screw was recorded in 20 cases, 17 of these were a cortical screw and 3 were a headless compression screw. The headless screw was therefore less likely to require removal for prominence; Odds Ratio 0.27, 95% CI 0.08 – 0.96. 

Infection requiring removal of metalwork were seen in 6 cases, of these 2 were at 2 months after the initial operation whilst 4 were late infections (range 3 – 10 years). Of the 6 screws removed, 5 were headless compressions screws. However, there were confounding factors. 

Conclusions: This study has shown that the cases of metalwork irritation requiring removal of the screw is decreased with the use of headless screws. 

981 - Outcome following acute suture anchor repair of the ulnar collateral ligament of the thumb

William Oliver¹, Zach Place², Katrina Bell¹, Samuel Molyneux¹, Andrew Duckworth^1,2

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²University of Edinburgh, Edinburgh, United Kingdom

Background: The aim was to report outcomes following acute repair of the ulnar collateral ligament of the thumb metacarpophalangeal joint (thumb UCL), using a suture anchor technique.

Methods: From 2011-2019, 40 consecutive patients (mean age 37yrs [16-70], 68% [n=27/40] male) undergoing acute thumb UCL repair (≤6wks post-injury) were retrospectively identified.  Operative complications were determined from medical records.  Patient-reported outcomes, including the QuickDASH, EuroQol 5-Dimension (EQ-5D) and Visual Analogue Scale (EQ-VAS), were collected via telephone survey at ≥1yr postoperatively. 

Results: At a mean of 2.3 months (0.9-6.9), complications included self-limiting sensory disturbance (7.5%, n=3/40), superficial infection (requiring oral antibiotics; 5%, n=2/40) and wound dehiscence (requiring debridement and re-suture; 2.5%, n=1/40).  Thirty-three patients (83%) completed the telephone survey at a mean of 4.3yrs (1.0-9.2).  No failures of thumb UCL repair occurred.  The mean QuickDASH was 3.7 (0-27.3), EQ-5D 0.821 (-0.041-1) and EQ-VAS 84 (60-100).  Forty-eight percent (n=16/33) reported residual pain: mild in 30% (n=10/33), moderate in 15% (n=5/33) and severe in 3% (n=1/33).  The mean pain score (0 = worst pain, 100 = no pain) was 89/100 (40-100).   Thirty percent (n=11/33) reported residual stiffness, which was generally mild (mean limitation score 1.3/10 [0-6]).   All patients were satisfied with their outcome (mean satisfaction score 9.8/10 [8-10]).  All patients returned to work at a median of 0.5wks (0-416) and the mean QuickDASH Work Module was 4.1 (0-50).  Of 24 patients playing sport prior to injury, 96% (n=23/24) returned at a median of 16wks (5-52) and the mean QuickDASH Sport Module was 4.6 (0-25).

Conclusions: Thumb UCL repair using a suture anchor technique is safe and effective.  Pain and stiffness may persist in the longer-term, but most report excellent upper limb function and health-related quality of life.  The majority return to work and sport and are highly satisfied with their outcome.

310 - Long-term results of the original C-stem cemented polished triple-tapered femoral implant in a consecutive series of 500 cases: A 14 to 19 year follow-up study

David Sochart

SWLEOC, Epsom, United Kingdom

Background: The C-stem was designed to load the femur more physiologically at the calcar, avoiding negative bone remodelling, maintaining bone stock and minimising aseptic loosening. This is the longest-term study to assess its complications and outcomes and is from a non-designer institution.

Methods:  Data was collected prospectively on 500 consecutive C-stems (455 patients) performed using a posterior approach and third generation cementing with Palacos R+G, between March 2000 and December 2005. 

Results: Age averaged 69.3 years (23-92), BMI averaged 29 (18-45), 282 patients were female (62%) and osteoarthritis was the most common indication (89.8%).

244 patients (265 THA) died, 23 (25 THA) declined follow-up, and 3 (3THA) were lost to follow-up. 180 THA in 159 patients underwent final radiological review at an average of 181 months (15.1yrs, 165-234).

Seven periprosthetic fractures (1.4%) occurred at an average of 95 months (24-138), with no typical fracture pattern. Distal femoral cortical hypertrophy (DFCH) occurred in 6 cases (1.2%), none with loosening. Subsidence averaged 0.8mm at one year and 1.54mm at 15yrs.

Seven femoral implants loosened aseptically (1.4%), all associated with rapid wear of the acetabulum, three of which have been revised. Another 11 stable femoral implants were revised, 10 during revision of a loose acetabulum (9 using a femoral cement in cement technique) and one for late deep sepsis. Survivorship at 15 years for revision for aseptic stem loosening was 99.2% (96.8 – 99.8%), for aseptic stem loosening was 97.5% (95% CI 94.0 – 99.0%), and for all-cause revision (cup+/-stem) was 91.6% (87.2 – 94.5%).

Conclusions: The C-stem polished triple-tapered implant performed well, with low complication and re-operation rates, but aseptic loosening was associated with rapid wear of ethylene oxide sterilised UHMWP acetabular components.

Implications: Improved long-term results could reasonably be expected when used in combination with modern highly cross-linked polyethylene bearings.

374 - Effect on health-related quality of life of the X-Bolt dynamic plating system versus the sliding hip screw for the fixation of trochanteric fractures of the hip in adults: the WHiTE Four randomised clinical trial

Xavier Griffin^1,2, Juul Achten³, Heather Marie O'Connor⁴, Jonathan Cook⁴, Matthew Costa⁴

¹University of London, Queen Mary, London, United Kingdom; ²Barts Health NHS Trus, London, United Kingdom; ³University of Oxford, NDORMS, Oxford, United Kingdom; ⁴University of Oxford, Oxford, United Kingdom

Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants may yield superior outcomes; this study compared the clinical effectiveness of the X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures.

We conducted a multicentre, superiority, randomized controlled trial. Patients aged over60 years with a trochanteric hip fracture were recruited in ten UK NHS hospitals. Participants were randomly allocated to fixation of their fracture with XHS or SHS. A total of 1,128 participants were randomized with 564 participants allocated to each group. Participants and outcome assessors were blind to treatment allocation. The primary outcome was the EuroQol five-dimension five-level health status (EQ-5D-5L) utility at four months. The minimum clinically important difference in utility was pre-specified at 0.075. Secondary outcomes were EQ-5D-5L utility at 12 months, mortality, residential status, mobility, revision surgery, and radiological measures.

Overall, 437 and 443 participants were analysed in the primary intention-to-treat analysis in XHS and SHS treatment groups respectively. There was a mean difference of 0.029 in adjusted utility index in favour of XHS with no evidence of a difference between treatment groups (95% confidence interval -0.013 to 0.070; p = 0.175). There was no evidence of any differences between treatment groups in the sensitivity analysis of the primary outcome or in any of the secondary outcomes. The pattern and overall risk of adverse events associated with both treatments was similar. There was no difference in tip-apex distance or radiographic outcomes between groups.

Any difference in four-month health-related quality of life between XHS and SHS is small and not likely clinically important. There was no evidence of a difference in the safety profile of the two treatments; both were associated with lower risks of revision surgery than previously reported.

474 - Dual mobility cup versus conventional total hip arthroplasty for femoral neck fractures: An international multi-registry study

James Masters^1,2, John Farey³, Alana Cuthbert⁴, Pernille Iverson⁵, Liza van Steenbergen⁶, Heather Prentice⁷, Sam Adie⁸, Adrian Sayers⁹, Michael Whitehouse⁹, Elizabeth Paxton⁷, Matthew Costa¹, Søren Overgaard⁵, Cecilia Rogmark¹⁰, Ola Rolfson¹⁰, Ian Harris^3,4,11

¹NDORMS, University of Oxford, Oxford, United Kingdom; ²University Hospitals Coventry and Warwickshire, Coventry, United Kingdom; ³Institute for Musculoskeletal Health, King George V Building, Royal Prince Alfred Hospital, Sydney, Australia; ⁴Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia; ⁵Danish Hip Arthroplasty Registry, Aarhus, Denmark; ⁶Dutch Arthroplasty Register, Hertogenbosch, Netherlands; ⁷Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, USA; ⁸St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia; ⁹Bristol Medical School, University of Bristol, Bristol, United Kingdom; ¹⁰Swedish Hip Arthroplasty Register, Gothenburg, Sweden; ¹¹Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia

Background: Dual mobility cup (DMC) total hip arthroplasty (THA) has been proposed as an alternative, design for THA that is purported to reduce the risk of dislocation compared to conventional THA (cTHA) in high-risk populations like femoral neck fracture (FNF). Data reporting the use of DMC THA in FNF are limited. We sought to summarise data from multiple arthroplasty registries reporting device usage and epidemiology of revision and mortality.

Methods: Six members of the International Society of Arthroplasty Registries (Australia, Denmark, Sweden, The Netherlands, United Kingdom, United States) provided data reports stratified by liner type (DMC THA or cTHA) for demographic data and usage of primary THA between January 2002 and December 2019. Revision risk for any cause, yearly cumulative percent revision (CPR), types of revision, as well as cumulative percent mortality (CPM) were calculated. 

Results: 15,024 DMC THA for FNF were performed during the study period, comprising 2.2-41.4% of primary procedures for each registry. The majority of registries demonstrated a lower all-cause CPR at 5 years for DMC THA compared to cTHA, ranging from 1.95% versus 2.71% in the United Kingdom to 4.7% versus 5.6% in Australia. The most common indication for revision varied by country, however, the percentage of primaries revised for prosthesis dislocation was consistently lower across all countries for DMC THA (range 0.32-1.53%) compared to cTHA (0.84-2.81%). The CPM at 5 years for DMC THA was consistently higher across all registries compared to cTHA.  

Conclusions: DMC THA use in FNF patients is increasing as a proportion of procedures year on year.  The reduced all-cause revision for DMC THA at 5-years post-operatively is not demonstrated consistently across registries but DMC THA may reduce the number of revisions for prosthesis dislocation.  Higher cumulative percent mortality for DMC THA compared to cTHA suggests a degree of patient selection bias.

486 - The Results: NIHR Feasibility RCT: Acetabular Fractures in older patients Intervention Trial (AceFIT: ISRCTN16739011)

Andrew Carrothers¹, Joseph Alsousou¹, Daud Chou¹, Jaikirty Rawal¹, Joseph Queally², Peter Hull¹

¹Addenbrookes, Cambridge, United Kingdom; ²St James Hospital, Dublin, Ireland

Background: Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence that the morbidity/mortality associated with these injuries is similar to the fractured NOF cohort. There remains significant controversy regarding treatment algorithms.

Methods: £250,000 NHS funding from NIHR, RFPB (Ref: PB-PG-0815-20054) and trial ethical approval Ref: 17/EE/0271. After national consultation, 3 trial arms were included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required an optimum recruitment 20 per arm. Inclusion criteria included patients >60 years with displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma.  Primary outcome measure was ability to recruit with EQ-5D-5L at 6 months. Secondary outcomes at 9 months included OHS, DRI, radiographic evaluation, perioperative physiological variables, surgery duration, blood loss, complications and health economics.

Results: 11 UK MTCs were enrolled which commenced December 2017. Failure of surgical equipoise was identified as an issue regarding recruitment.  Full trial recruitment (60 patients) was achieved with 333 patients screened. 66% patients recruited were male, median age 76 (range 63-93), median BMI 25 (range 18-37), 87% patients had full mental capacity, 77% were admitted from own home. 75% injuries were due to a fall from standing height. 60% fractures were classified anterior column posterior hemi-transverse. Trial feasibility was confirmed with full data acquisition completed in December 2020. Presented data shows secondary outcome measures that ‘signal’ improvement from baseline for only the fix and replace arm, with acceptable low complication rates. Issues are highlighted with conservative management in this patient cohort.

Conclusion: This unique RCT feasibility study represents the first opportunity to understand each of these treatment modalities. The primary outcome measure has shown feasibility for a fully powered RCT. Our RCT was required to provide treatment safety data, inform the necessary design and sample size calculation. 

527 - Long-term survivorship of a flexible, titanium, HA coated, medium length revision stem. 140 cases at 10 years with the Corail® Revision Stem

Paul Saunders¹, Rohit Singhal², Paul Siney², Steve Young¹, Tim Board²

¹South Warwickshire NHS Foundation Trust, Warwick, United Kingdom; ²Wrightington Hospital, Wigan, United Kingdom

Introduction: The ‘conservative’ philosophy of the CORAIL® Revision stem aims to achieve proximal bone preservation by ensuring adequate loading. Good mid-term survivorship has previously been demonstrated. We have combined data from two high volume units in the UK and conducted radiological analysis of cases to confidently perform a survivorship analysis and radiological analysis with long-term (10-year) follow-up.

Materials and Methods: A retrospective radiographic analysis was conducted of 140 consecutive revision hip arthroplasties using the CORAIL® Revision stem performed at two UK NHS centres prior to 31/12/2010. The mean age of patients at revision was 71 years (38-88 years). There were 31 type 1, 82 type-2, 25 type 3a and 2 type 3b Paprosky femoral deficiencies. Eight cases had an extended trochanteric osteotomy (ETO). Survivorship was confirmed as the date of the latest radiograph. A Kaplan-Meier survivorship analysis was performed for all cause revision and aseptic stem revision. Radiological assessment of bone preservation was conducted in cases with at least 10 year follow-up.

Results: Twelve cases were revised, 8 involving the stem. Reasons for stem revision were aseptic loosening (3), infection (2), peri-prosthetic fracture (2) and stem fracture. The survivorship for any-cause revision was 87.67% (CI 77.00-98.33) at 11 years and for aseptic stem revision was 94.12% (CI, 86.21-100.00) at 11 years. There were 3 cases with identified dislocations and one conservatively managed peri-prosthetic fracture. There were 62 cases with a minimum 10-year follow-up (mean 11.5 years); 39 were deceased, 12 revised27 were not contactable. Radiographic analysis demonstrated 92% of cases with 10-year follow-up had no stress shielding, including all those managed with ETO. 

Conclusion: This study reports good long-term survivorship of the CORAIL® Revision stem with evidence of proximal bone preservation at ten years.

551 - Defining the patient acceptable symptom state using the Forgotten Joint Score 12 following hip arthroscopy

Patrick G Robinson¹, Paul Gaston¹, Thomas R Williamson², Iain R Murray^1,3, Julian F Maempel⁴, Conor S Rankin¹, Deborah J MacDonald¹, David F Hamilton^1,5

¹Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²Edinburgh Medical School, The University of Edinburgh, Edinburgh, United Kingdom; ³Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA; ⁴Department of Trauma & Orthopaedics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; ⁵School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom

Background: The purpose of this study was to contextualize the Forgotten Joint Score (FJS-12) by identifying a patient acceptable symptomatic state (PASS) threshold for patients undergoing hip arthroscopy, and to investigate factors which correlated with postoperative FJS-12 score.

Methods: All patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) under the care of a single surgeon between January 2018 and November 2019 were prospectively identified and included. Exclusion criteria were Tönnis classification grade 2 or greater. Data (including FJS-12, EuroQol-5 Dimension-5L (EQ-5D-5L), Visual Analog Scale (VAS), and 12 item International Hip Outcome Tool (iHOT-12) scores) were available preoperatively and at a minimum of one year postoperatively. PASS was calculated using an anchor-based approach and receiver operator characteristic (ROC) curve analysis. Pearson correlation analysis was used to correlate pre- and postoperative factors with postoperative FJS-12 score. 

Results: Seventy-seven patients (54 female, 23 male, mean age 30.3 years (SD 8.2)) were included. Linked longitudinal follow-up data was available for 65 patients (84%) at a mean of 23.8 months (SD 6.4). Six patients required reoperation. Mean postoperative FJS-12 score was 46.5 (SD 33.1) and mean change in score was 27.2 (SD 30.6, p<0.001). The PASS threshold for the FJS-12 was 38.5 (sensitivity 80%, specificity 88%), and the area under the curve (AUC) was 0.852 (95% CI 0.752 – 0.951). 53.8% of patients achieved this score. Postoperative FJS-12 score has moderate correlations with preoperative EQ-5D-5L, iHOT-12, and FJS-12 scores, and strong correlations with EQ-5D-5L, iHOT-12 and VAS scores postoperatively. 

Conclusions: We report a postoperative PASS threshold of 38.5 points for the FJS-12 following hip arthroscopy for FAI in a UK population. This value can act as a quantifiable target for clinicians using the FJS-12 to monitor patient outcomes in practice. FJS-12 has strong correlations with EQ-5D-5L, iHOT-12 and VAS at minimum 12 months postoperatively.

622 - Managing the Interval in 2-Stage Revision for Prosthetic Joint Infection in Total Hip Replacement: Choice of Articulating Spacer?

James Coleman¹, Oliver Blocker², Stephen Jones²

¹Cardiff University, Cardiff, United Kingdom; ²Cardiff and Vale University Health Board, Cardiff, United Kingdom

Background: In 2-stage revision for Periprosthetic Joint Infection (PJI) a spacer is a common surgical option, with the potential to have both functional and therapeutic roles by maintaining mobility and enhancing antibiotic delivery. Our retrospective case series reports on the use of articulating spacers and the management of a safe interval, focusing on those that have received a constrained liner.

Methods: A retrospective case series of patients in our hospital treated for PJI using a 2-stage revision technique. Spacer design and complications were analysed through radiographic and clinical review.

Results: 68 spacers in 64 patients with a mean age of 67.1 years and a mean interval between procedures of 139.9 days.  There was an overall 5.9% mortality rate between stages. 8 complications occurred overall, 7 of which occurred in 55 articulating spacers (12.3%).  Spacers with a constrained liner had a lower complication rate (8.1%) than those without (16.1%). 

Conclusion: Complications related to interval spacers are an on-going issue. The use of a constrained liner completely avoided dislocation and had the lowest complication rate potentially offering surgeons a safer and more reliable option for interval prostheses.

643 - Do post-operative hip precautions prevent dislocation following elective primary total hip arthroplasty? An analysis of a national administrative data set in England

John Machin^1,2, William Gray², Lyndsey Smith³, Ally Roberts³, Andrew Manktelow⁴, Tim Briggs^5,2

¹Nuffield Orthopaedic Centre, Oxford, United Kingdom; ²National GIRFT programme, NHS England & Improvement, London, United Kingdom; ³East Suffolk and North Essex NHS Foundation Trust, Ipswich, United Kingdom; ⁴Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; ⁵Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom

Background: To determine whether there is a higher dislocation rate when post-operative hip precautions are discontinued for primary total hip arthroplasty (THA).

Methods: A survey was conducted of the hip precautions used by all orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database and mortality data from the UK Office for National Statistics (ONS) during the period 1^st April 2011 to 31^st December 2019 and subsequent dislocations of these prostheses up to 30^th June 2020. These were used to determine dislocations within 180days of primary operation and emergency readmissions within 30 days of discharge. A secondary analysis of THAs conducted between 1^st January and 31^st December 2019 were compared between hospitals that were known to have stopped hip precautions and those who still recommend hip precautions for a period of 6 or 12weeks. 

Results: Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total 1,807 (0.8%) dislocation were recorded at 180days post-surgery and 12,416 (5.4%) emergency readmissions within 30days of surgery. Within trusts where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant post-intervention trend towards fewer dislocations (p < 0.001). There was also a significant immediate change in median length of stay from 4 to 3 days (p < 0.001) but no significant trend in the proportion of emergency readmissions within 30days. 

Conclusion: There is no evidence of any increase in dislocation or 30days readmission rates on stopping post-operative hip precautions in primary THA. Reductions in length of stay associated with stopping hip precautions will reduce risks to patients of extended hospital stay and improve service efficiency. 

753 - Surgeon experience with hip arthroplasty in severely obese patients reduces the risk of major complications; time for a referral network to be considered?

Alexander Charalambous¹, Daniel Pincus¹, Sasha High², Fok-Han Leung², Suriya Aktar³, J. Michael Paterson³, Donald Redelmeier², Beeshma Ravi^1,2

¹Sunnybrook Health Sciences Centre, Toronto, Canada; ²University of Toronto, Toronto, Canada. ³Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada

Background: Severe obesity is a risk factor for major complications after arthroplasty surgery. The purpose of this study was to determine the relationship between surgeon experience with total hip arthroplasty (THA) in patients with severe obesity and the risk of major complications.

Methods: We defined a cohort of participants who received a primary THA for osteoarthritis and who also had severe obesity, (Body-mass index, (BMI) ≥40), at the time of surgery. These patients were identified using the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and physician claims from the Ontario Health Insurance Plan (OHIP). The primary study outcome was the occurrence of a major complication (revision, infection requiring surgery, or dislocation requiring open or closed reduction) within one year of surgery.

Results: A total of 4,781 eligible patients were identified between 2007 and 2017. Overall, 186 patients (4%) experienced a major surgical complication. After controlling for patient and hospital factors, greater “obesity-specific THA” surgeon volume, but not “overall THA” volume, was associated with a reduced risk of complications. We noted a steep decline in the risk of complications until the obesity-specific THA volume neared approximately 10 cases per year. The adjusted odds ratio (OR) in the high obesity-specific group was 0.65 per additional ten cases (95% confidence interval 0.47 to 0.89, p=0.007). The “overall THA” volume adjusted OR was 1.00 (95% confidence interval 0.99–1.00, p=0.24).

Conclusion: Specific surgeon experience with THA in severely obese patients was associated with a decreased risk for major surgical complications, irrespective of surgeon overall experience and hospital factors.

Implications: Surgeon experience can potentially mitigate some of the unique challenges posed by surgery in severely obese patients. Referral pathways to high obesity-specific THA volume surgeons could therefore be considered.

Disclosures: Financial support was received from the Canadian Institutes of Health Research (CIHR).

785 - Cemented Charnley total hip arthroplasty for osteoarthritis secondary to developmental dysplasia of the hip: 3-37 years follow up study

Samarth Arya¹, Hajime Nagai², Luke Farrow³, Paul Siney², Peter Kay²

¹Woodend Hospital, Aberdeen, United Kingdom; ²Wrightington Hospital, Wigan, United Kingdom. ³Aberdeen Royal Infirmary, Aberdeen, United Kingdom

Introduction: Total Hip Replacement (THR) in Developmental Dysplasia of Hip (DDH) with secondary degenerative changes presents a technical challenge. This can be done with or without the use of bone graft to reconstruct the acetabulum. We present our experience with follow-up of 37 years. 

Objective: To assess the long-term outcomes of cemented Charnley THA for OA secondary to DDH.

Methods: The retrospective study included consecutive 142 hips in 125 patients who underwent cemented Charnley THA for OA secondary to DDH operated by a single surgeon at a specialist centre between 1983-1988. Amongst them, 40hips (28.2%) in 37 patients were operated with structural autografts from femoral heads to reconstruct deficient acetabulum and 102 hips (71.8%) in 88 patients underwent THA without bone graft. Clinical and radiological outcomes were analysed. 

Results: Mean age of patients were 48 years (range 23-78) and the mean follow up time was 22 years (range 3-37). Thirty-four hips needed revision surgery. In non-bone graft group (group 1), 18 hips (17.6%) were revised with 9 for socket loosening only, 2 for stem loosening only, 2 for both components loosening, 1 for stem fracture and 2 due to recurrent dislocation. Two hips in this group needed conversion to pseudoarthrosis hip. In bone graft group (Group 2), 16 hips (40%) required revision surgeries with 1 for late infection, 12 for socket loosening and 3 for stem loosening. Furthermore, there were 6 cases with radiologically loose sockets and 1 loose dual component which were not revised in group 1. Therefore, overall survival rates in view of radiological fixation were 24.5% and 40% in non-bone graft and bone graft group, respectively. 

Conclusion: To our best knowledge, the longest follow up study in THA for dysplastic hip was reported.   Cemented Charnley THA for DDH offered good stem survival. There remains a challenge on the acetabular side regardless of usage of bone graft.

488 - The performance of ceramicised metal femoral heads in total hip arthroplasty: An analysis of international registry data

Edward Davis¹, Paul Souter², Christopher Saunders²

¹The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom; ²Smith + Nephew, Hull, United Kingdom

Background: Wear-related aseptic loosening is the main cause of revision in total hip arthroplasty. Bearing surface combinations are therefore a critical consideration in improving implant survivorship. The increasing concern over taper corrosion associated with metal femoral heads has also increased interest in the use ceramic and ceramicised metal (oxidised zirconium). Thus, an analysis of available arthroplasty registry data was performed to assess revision rates of ceramicised metal versus three other frequently used bearing combinations.

Methods: A systematic literature review was performed to identify national arthroplasty registries and publications analysing registry data that reported on 10-year cumulative percent revision data on ceramicised metal/cross-linked polyethylene (CMoXLPE), metal/cross-linked polyethylene (MoXLPE), ceramic-on-ceramic (CoC) and ceramic/XLPE (CoXLPE). Weighted cumulative percentage revision rates were determined for each bearing combination. The Australian Arthroplasty Register 2020 (AOANJRR), Register for the Italian Region of Emilia-Romagna 2000-2018 (R.I.P.O.), Dutch (LROI) and UK (NJR) Registry data were used. Although 10-year data from R.I.P.O., reporting survivorship for uncemented THAs (98.2%), was available, direct registry data was favoured to encompass all THA fixation methods.

Results: Data from 891,341 primary THAs were extracted from the four reports. Of the bearing surfaces assessed, MoXLPE (38.01%) was most frequently used, followed by CoC (30.06%), CoXLPE (26.56%) and CMoXLPE (5.36%). In each registry, the CMoXLPE bearing combination had the lowest cumulative 10-year revision rate. Weighted cumulative all-cause percentage revision rate at 10 years for each bearing combination was: CMoXLPE, 3.28%; MoXLPE, 4.11%; CoXLPE, 3.83%; CoC, 4.22%.

Conclusions: Compared to MoXLPE, CoC and CoXLPE bearing surfaces, CMoXLPE returned the lowest weighted cumulative percentage revision rate at 10 years across the international registry data available for analysis.

Disclosures: Professor Edward T Davis reports receiving consulting fees (Smith + Nephew); research funding and speaker fees (Smith + Nephew; Stryker). Paul Souter and Christopher Saunders are employees of Smith + Nephew.

526 - The forgotten joint score‐12 is a valid and responsive outcome tool for measuring success following hip arthroscopy for femoroacetabular impingement syndrome

Patrick Robinson¹, Conor Rankin¹, Iain Murray¹, Julian Maempel², Paul Gaston¹, David Hamilton¹

¹Trauma and Orthopaedic Department, University of Edinburgh, Edinburgh, United Kingdom; ²Department of Trauma and Orthopaedics, Royal Prince Alfred Hospital, Camperdown, United Kingdom

Background: The forgotten joint score-12 (FJS-12) is an outcome questionnaire designed to evaluate joint awareness. The responsiveness and validity of the English language version of the FJS-12 in patients undergoing hip arthroscopy for femo- roacetabular impingement (FAI) is not known.

Methods: Consecutive patients undergoing hip arthroscopy for a diagnosis of FAI were prospectively followed up over a 1 year period. Patients completed preoperative and postoperative FJS-12, EuroQol 5 Dimension (EQ-5D-5L), and the 12-item international hip outcome tool (iHOT-12). We evaluated construct validity with Spearman correlation coefficients for the FJS-12, and responsiveness by way of effect size and ceiling effects.

Results: Forty-six patients underwent hip arthroscopy, of which 42 (91%) completed post-operative PROMs at 1 year follow- up. Construct validity was strong with the iHOT-12 (r = 0.87) and also the EQ-5D-5L (r = 0.83). The median postoperative FJS score was 50.2 (IQR 64). The mean change in score for the FJS-12 was 31 points (SD 31) (p < 0.001), with an effect size (Cohen’s d) of 1.16. Preoperatively, three patients scored the lowest possible value resulting in a floor effect of 7.1%. Similarly, only three patients (7.1%) scored the best possible score post-operatively.

Conclusion: This is the first evaluation of the joint awareness concept in the English language version of the FJS-12 following hip arthroscopy for FAI. The FJS-12 is a valid and responsive tool for the assessment of this cohort of patients.

534 - A comparison of the incidence and temporal trends of postoperative dislocation following the use of constrained acetabular components and dual mobility implants in primary total hip replacement: a systematic review and meta-analysis of longitudinal observational studies

Richard L Donovan^1,2, Harvey Johnson², Sherwin Fernando², Michael Foxall-Smith², Michael R Whitehouse^1,2,3, Ashley W Blom^1,2,3, Setor K Kunutsor^1,3

¹Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, United Kingdom; ²North Bristol NHS Trust, Southmead Road, Bristol, United Kingdom; ³National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom

Dislocation after primary total hip replacement (pTHR) continues to be one of the most common causes of failure after pTHR. Around 60% of dislocations occur within the first three months. Increasingly, constrained acetabular components (CACs) and dual mobility implants (DMIs) are being used to mitigate this burden in patients at high risk of dislocation or with significant intraoperative instability. This systematic review and meta-analysis sought to compare the incidence and temporal trends of postoperative dislocation when CACs and DMIs have been implanted.  

Longitudinal studies reporting postoperative dislocation following the use of CACs or DMIs in pTHR were sought from MEDLINE, EMBASE and CENTRAL from inception to September 03, 2020. Secondary outcomes included revision surgery secondary to dislocation, and revision surgery for all causes. Incidence rates (with 95% confidence intervals) were calculated. 

46 relevant studies were identified (three CAC; 43 DMI). 582 CACs and 18,748 DMIs were included. The pooled incidence of postoperative dislocation was 1.08% (95% CI: 0.00, 3.72) (range 0.27-2.60%) over a mean follow-up of 4.1 years for CACs, compared with a pooled incidence of 0.25% (95% CI: 0.08, 0.46) (range 0.00-4.72%) over a mean follow-up of 6.2 years for DMIs. For DMIs, there appeared to be a temporal decline in dislocation rates from the 1980s onwards, and dislocation rates generally remain low (<1%) until 15 years postoperatively. There were insufficient datapoints for a similar analysis of CACs. All studies were assessed to be of high risk of bias. 

DMIs demonstrated a lower incidence of postoperative dislocation compared to CACs; however, there was a relative absence of CACs used in the context of pTHR in the literature compared with DMIs. Temporal trends in postoperative dislocation have improved over time for DMIs. Larger volumes of data on the incidence of postoperative dislocation of CACs in pTHR is required. 

541 - A comparison of the incidence and temporal trends of postoperative dislocation following the use of constrained acetabular components and dual mobility implants in revision total hip replacement: a systematic review and meta-analysis of longitudinal observational studies

Richard L Donovan^1,2, Harvey Johnson², Sherwin Fernando², Michael Foxall-Smith², Michael R Whitehouse^1,2,3, Ashley W Blom^1,2,3, Setor K Kunutsor^1,3

¹Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, United Kingdom; ²North Bristol NHS Trust, Southmead Road, Bristol, United Kingdom; ³National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom

Introduction: Dislocation after revision total hip replacement (rTHR) continues to be a common cause of failure after rTHR, with the incidence reported up to 25%. Around 60% of dislocations occur within the first three months. Increasingly, constrained acetabular components (CACs) and dual mobility implants (DMIs) are being used to mitigate this burden in patients with recurrent instability or significant intraoperative instability. This systematic review and meta-analysis sought to compare the incidence and temporal trends of postoperative dislocation when CACs and DMIs have been implanted.  

Methods: Longitudinal studies reporting postoperative dislocation following the use of CACs or DMIs in rTHR were sought from MEDLINE, EMBASE and CENTRAL from inception to September 03, 2020. Secondary outcomes included revision surgery secondary to dislocation, and revision surgery for all causes. Incidence rates (with 95% confidence intervals) were calculated. 

Results: 64 relevant studies were identified (22 CAC; 42 DMI). 2,044 CACs and 9,648 DMIs were included. The pooled incidence of postoperative dislocation was 7.98% (95% CI: 5.53, 10.79) (range 0.00-28.57%) over a mean follow-up of 5.9 years for CACs, compared with a pooled incidence of 2.89% (95% CI: 1.94, 3.98) (range 0.00-21.43%) over a mean follow-up of 5.3 years for DMIs. Both CACs and DMIs demonstrated a temporal decline in dislocation rates from the 1980s onwards. Reoperation rates for all causes after CACs are used in rTHR were around 16%, compared to 7% after DMIs are used in rTHR. All studies were assessed to be of high risk of bias. 

Conclusion: DMIs demonstrated a lower incidence of postoperative dislocation compared to CACs in the context of rTHR. Temporal trends in postoperative dislocation have improved over time for both types of implants. Large prospective, multi-centre longitudinal trials would assist understanding if DMIs are truly superior to CACs with respect to future incidence of dislocation.

1084 - Long-term implant survival following arthroplasty for fractured neck of femur: An analysis of commonly used prosthesis constructs using Australian National Joint Registry Data

Ben Tyas¹, Martin Marsh², Mike Reed³, Richard de Steiger⁴, AOANJRR Statistician⁴, Simon Jameson⁵

¹Health Education North East, Newcastle, United Kingdom; ²Royal Victoria Infirmary, Newcastle, United Kingdom; ³Northumbria Healthcare NHS Foundation Trust, Northumbria, United Kingdom. ⁴University of Melbourne, Melbourne, Australia; ⁵James Cook University Hospital, Middlesbrough, United Kingdom

Introduction: In the UK, around 35,000 arthroplasties are performed annually for the treatment of intracapsular hip fracture.  There is no clinical benefit of a modern, costly modular construct over a traditional, inexpensive mono-block design.  Data on long-term outcomes are limited.  The aim of this study was to establish whether there is a survival benefit of specific prosthesis concepts. 

Methods: Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to 31st December 2018 who had Stryker Exeter stem (unipolar/ bipolar hemiarthroplasty/THR), Exeter Trauma Stem (ETS) or Thompsons prosthesis (multiple manufacturers) for hip fracture, were included. Overall and age-defined 10-year cumulative revision rates were compared. A sub-analysis of Thompsons data, by type of material (Cobalt/Chrome or Titanium), was performed.

Results: 43596 arthroplasties were included. Exeter/Unitrax hemiarthroplasty was the most common construct (39% of procedures). 

Overall, cemented THR had the lowest revision rate of 4.5% (CIs 3.3,6.1). For hemiarthroplasty, revision rate of Cobalt/Chromium Thompsons (6.3%, CIs 4.7,8.6) was comparable to that of ETS (5.9%, CIs 4.0,8.6) and Exeter/Unitrax (7.6%, CIs 6.7,8.6). Titanium Thompsons had the highest 10-year revision rate at 10.5% (CIs 7.8,14.1). Co/Cr Thompsons and ETS had the lowest rates in patients aged >80. 

10-year mortality rates were similar for ETS (87.9%), Exeter/Unitrax (80.0%) and Cobalt/Chromium Thompsons (90.7%), reflecting a similar level of frailty of patients receiving these implants. This contrasts with a 50% 10-year mortality for those receiving an Exeter V40 with a cementless cup. 

Conclusion: 10-year implant survival of the inexpensive Cobalt/Chromium Thompsons is equivalent to the ETS and Exeter/Unitrax. In contrast, Titanium Thompsons are associated with higher revision rates. This study complements the published data on functional outcomes, and supports the use of Cobalt/Chromium Thompsons implant as a cost-effective option for frail hip fracture patients.

153 - Uncemented total hip arthroplasty can be used safely in the elderly population

Jacob Feathers¹, Fady Awad², Peter Lewis², Faiz Khan²

¹Leeds Teaching Hospitals Trust, Leeds, United Kingdom; ²Cwm Taf Morgannwg Health Board, Merthyr Tydfil, United Kingdom

Background: Total Hip Arthroplasty (THA) has revolutionised the lives of innumerable patients. There remains controversy surrounding the optimal approach in fixating implants. Getting It Right First Time (GIRFT), along with UK NHS Best Practice Tariff (BPT), have published directives advising the universal use of cemented prostheses in patients aged over 65/69. We aim to investigate any correlation between age and functional outcome following elective uncemented THA.

Methods: Our study compares the functional THA outcomes of 1,004 uncemented Corail/Pinnacle implants. The series was conducted by a single surgeon following identical pre and post-operative pathways over 9 years. Implant information, survivorship and regular Oxford Hip Score (OHS) were collected and comparisons undertaken of patients aged under and over 65/69. Minimally important change (MIC), defined as the minimum increase in OHS to elicit a clinical benefit, was compared between groups

Results: In total revision rate was 1.3%, with a greater number of revisions taken in those aged over 65, although this did not reach significance. The reason for revision was predominantly implant independent. Analysis of the single components demonstrated a 99.9% and 99.6% survivorship for the uncemented cup and femoral component respectively. Patient reported outcome measures (PROMs) outperformed national averages throughout all age groups. Patients aged over 65/69 achieved MIC and maintained a significant improvement in OHS compared to the younger patients (p<0.05 and 0.01 respectively). Mortality within the NJR notifiable window for the whole cohort was 0.30%. NJR notifiable revisions were sustained in 13 hips. The majority of revisions consisted of debridement, antibiotics and implant retention.

Conclusion: Our study demonstrates that this THA uncemented system can be used efficaciously and safely within the elderly population. Functional hip outcome was not correlated to patient age. Our findings do not support the current GIRFT or NHS BPT prosthetic recommendations.

223 - Are the outcomes of total hip arthroplasty for hip fractures comparable with matched elective cohort? A prospective study

Tze Khiang Tan¹, Jun Wei Lim², Nourah Alkandari³, David Ridley³, Sankar Sripada³, Arpit Jariwala³

¹Sir Charles Gairdner Hospital, Perth, Australia; ²Aberdeen Royal Infirmary, Aberdeen, United Kingdom; ³Ninewells Hospital, Dundee, United Kingdom

Background: It is not yet clear whether the total hip arthroplasty (THA) undertaken for trauma setting are comparable with THA undertaken for elective setting. Our previous matched retrospective study highlighted a higher medical, surgical complications and death rate in the trauma THA cohort, but we were unable to provide any functional outcomes due to the nature of retrospective study. We conducted a prospective study to compare the outcomes of THA for hip fractures with a best-matched elective cohort.

Method: We prospectively reviewed patients underwent THA for hip fractures from 2017 to 2019. The modified Harris Hip Score (mHHS), any complications including death were recorded. Our control group was elective THA cases matched for the month of operation, age, gender, implants, side of operation and surgeon’s grade. Unmatched cases were excluded.

Results: Forty-one matched cases were included in our study. The total modified Harris Hip Score [mHHS (total)] was significantly lower preoperatively in elective cohort (41.4 vs 60.3, p<0.001) and achieved significantly higher score than trauma cohort 1-year postoperatively (88.2 vs 82.6, p=0.029). The trauma cohort has similar mHHS (function) pre- and postoperatively, and no significant difference was witnessed between the trauma and elective cohort postoperatively (35.1 vs 37.6, p=0.142). The mHHS (pain) was significantly higher in trauma cohort preoperatively (19.8 vs 12.7, p=0.034), but the score was significantly higher than trauma cohort one-year postoperatively (42.7 vs 40.7, p=0.027). Both cohorts achieved similar complication rates.

Conclusion: This is the first matched prospective study on hip fracture patients received THA, with one year follow up results and the involvement of preoperative and postoperative functional outcomes. With careful patient selection, hip fracture patients who received THA were able to return their pre-injured function within a year and had comparable function scores with elective patients, without increased complication rates. 

515 - The incidence and risk factors for development of post-operative acute kidney injury (AKI) in neck of femur (NOF) patients

Molly Bowman, Rajiv Sanger

Warrington and Halton NHS Foundation Trust, Warrington, United Kingdom

Background:  AKI is associated with poorer outcomes and longer hospital stays. Evidence shows that NOF fractures are the most common cause of AKI, and the most common cause of death as a result of AKI 3. 

Methods: A retrospective review of patients that underwent surgical NOF management between January - October 2019. Renal function tests were reviewed pre-operatively and at intervals post-operatively (24, 48, 76 and 96 hours), applying KDIGO guidelines to identify AKI. Possible risk factors were reviewed including baseline CKD, nephrotoxic medications, AMTS <7, peri-operative haemoglobin drop and operation delay. 

Results: 12.4% of patients developed AKI, and of these the vast majority (76%) were KDIGO stage 1. 65% of AKI positive patients had evidence of prior renal impairment, compared with 33.9% of AKI negative patients. 84% of AKI positive patients were taking nephrotoxic medication on admission, compared with only 59% of the total dataset. A post-operative haemoglobin drop >20g/L was identified in 89% of AKI positive patients, compared with only 60% of the AKI negative group. 61% of operations were delayed (>36 hours) in the total dataset, compared with 53% in the AKI positive group. Cognitive impairment was identified (AMTS <7) in 47% of AKI positive patients, compared with 31% of the total dataset. 18% of AKIs were unresolved at two weeks post-op. 

Conclusion/findings: Risk factors for developing AKI post-operatively include CKD stage 3 or above, nephrotoxic medication (particularly ACE-I and CCBs), perioperative haemoglobin drop >20g/L and cognitive impairment. There was no evidence that a delay of over 36 hours to operation impacted AKI development.

Implications: High risk patients can be identified using the outlined risk factors, and appropriate measures can be taken to reduce the risk of peri-operative AKI. This may include nephrotoxic cessation, optimised peri-operative hydration, nutritional support for those with cognitive impairment, or blood transfusion.

574 - Medium term survivorship of cannulated hip screws for undisplaced intra-capsular fractures in patients over 60 years old with minimum 5 year follow-up

Joseph Boktor, Abdul Badurudeen, Manhal Yasseen, Mohamed Eissa, Simon White

University Hospital of Wales, Cardiff, United Kingdom

Background: In UK, around 76,000 hip fractures occur per year with undisplaced intra-capsular fractures representing 10-15%. There is considerable debate among clinicians as to whether internal fixation is the most appropriate treatment for undisplaced fracture for elderly osteoporotic patients. 

Aim: Survivorship analysis for patients ≥ 60 years old with undisplaced intra-capsular fractures who had fixation with cannulated screws.

Methods: Retrospective data collection from major trauma hospital for all patients ≥ 60 years old whom had internal fixation with cannulated screws for Garden grade: 1, 2 hip fractures from March 2013 to March 2016. The primary outcome was further same side hip surgery. Descriptive statistics were used to summarize the data and Kaplan-Meier estimates calculated for the cumulative implant survival.

 Results: A total of 121 Cannulated screws operations were performed for 119 patients. Mean age 79.6 (9.3 SD). Mean follow up was 6.3years (Range 5-8).11 patients (9.3%) had subsequent hip surgery, 6 of them (5%) revision to THR, 1 (0.8%) revision to hemiarthroplasty, 3 (2.5%) removal of screws, 1 (0.8%) had washout due to prolonged wound leakage. 30 patients (25.4%) died within five years of the hip fixation. There was no Mortality at thirty days. 1 year Mortality was 10.8% (13 patients). Five year mortality was 13.9% (17 Patients). No deaths were related to the operations. Kaplan-Meier estimates showed 96.6% 1 year survival and 89.4% survivorship of cannulated screw fixation at five years (95% confidence interval (CI) 81.6% to 95.4%) 

Conclusions: This study shows that Cannulated hip screw fixation for undisplaced intra-capsular fracture has excellent implant survivorship at five years with low revision rate for patients ≥ 60 years old. We recommend cannulated screws as a reliable treatment with a low complication and revision rate for Garden 1, 2 fracture for this age group and surgeons can be comfortable considering fixation rather than perform arthroplasty. 

607 - Cement-in-cement versus uncemented modular stem revision for Vancouver B2 periprosthetic fractures

Ian Kennedy¹, Alex Hrycaiczuk², Nigel Ng¹, Owen Sheerins², Sanjeev Patil¹, Bryn Jones², Andrew Stark², Dominic Meek¹

¹Queen Elizabeth University Hospital, Glasgow, United Kingdom; ²Glasgow Royal Infirmary, Glasgow, United Kingdom

Background: Periprosthetic fractures (PPF) of the femur following total hip arthroplasty represent a significant complication with a rising incidence. The commonest subtype is Vancouver B2 type, for which revision to a long uncemented tapered fluted stem is a widely accepted management. In this study we compare this procedure to the less commonly performed cement-in-cement revision. 

Methods: All patients undergoing surgical intervention for a Vancouver B2 femoral PPF in a cemented stem from 2008 – 2018 were identified. We collated patient age, gender, ASA score, BMI, operative time, blood transfusion requirement, change in haemoglobin (Hb) level, length of hospital stay and last Oxford Hip Score (OHS). Radiographic analysis was performed to assess time to fracture union and leg length discrepancy. Complications and survivorship of implant and patients were recorded.   

Results: 43 uncemented and 29 cement-in-cement revisions were identified. There was no difference in patient demographics between groups. A significantly shorter operative time was found in the cement-in-cement group, but there was no difference in transfusion requirement, Hb change or length of hospital stay. OHS was comparable between groups. A non-significant increase in overall complication rates was found in the revision uncemented group, with a significantly higher dislocation rate. Time of union was comparable and there were no non-unions in the cement-in-cement group. A greater degree of stem subsidence was found in the uncemented group. There was no difference in any revision surgery required in either group. Three patients in the uncemented group died in the perioperative period, compared to none in the cement-in-cement group. 

Conclusion: With appropriate patient selection, both cement-in-cement and long uncemented tapered stem revision represent appropriate treatment options for Vancouver B2 fractures. 

697 - Mortality following fractured neck of femur in the peri-centenarian population

Chloe Chan, Thomas Stringfellow, Paul Heard, Pranai Buddhdev

Broomfield Hospital, Mid & South Essex NHS Trust, Chelmsford, United Kingdom

Background: Orthopaedic trauma services are predicted to treat an increasing number of elderly patients. Those over 99 years sustaining Neck of Femur (NOF) fractures represent a uniquely complex patient group. The 2020 NHFD reported a 30-day mortality rate of 6.5%. We investigated the mortality and outcomes in the peri-centenarian population.  

Methods: A retrospective single-institutional study of NOF fracture patients ≥99years old presenting from 2009-2020 was conducted using an electronic trauma database and NHFD. Data collection included patients’ demographics, diagnosis, functional and cognitive status (AMTS), length of stay (LOS) and mortality. Fisher’s exact test was used to analyse categorical variables. 

Results: A total of 67 patients with mean age 101 years (range:99-107) presented during the study period; 57(85%) were female with an even distribution of intra:extracapsular fractures. Mean follow-up time post-injury was 6.24years (9months-11.5years). Male patients were more likely to sustain intracapsular fractures (80%vs46%). Patients were largely admitted from their own home (39, 58%), with 88% (n= 59) having surgery within 36-hours. Mean LOS was 14.4days, shorter than NHFD reported 19.3days. 11 deceased during primary admission; only 3 of the remaining 56 patients required escalation of care post-discharge. 

Overall crude mortality rate was 78% (median time 89 days); extracapsular fractures had increased mortality (91% vs. 62%, p=0.0087). Cumulative mortality rate was 21%, 39%, 46% and 49% at 30days, 3, 6 & 12 months respectively. There was no statistical correlation between residential status, mobility levels, AMTS scores, ASA-grade or LOS and mortality rate.

Conclusion: 89% of peri-centenarian patients returned to their pre-admission residential institutions with over half surviving 1-year. The 30-day mortality rate was 21% with a predominance in extracapsular fracture patients. It is important not to assume patients over 99 years do poorly after NOF fractures and timely treatment should be prioritised in this patient group. 

830 - Survivorship of the dual mobility construct in primary total hip arthroplasty. A systematic review and meta-analysis including joint registry data

Andrew Gardner, Hamish Macdonald, Jon T Evans, Adrian Sayers, Michael Whitehouse

University of Bristol, Bristol, United Kingdom

Introduction: Total hip replacement (THR) is a successful operation performed worldwide. Dislocation following THR is a major complication.  Specific patient groups are high risk for dislocation and are often treated with a dual mobility construct (DMC). We aimed to report survivorship of DMCs used in primary THRs and net dislocation rates. 

Methods: A systematic search was performed in Medline, Embase, Web of science, Cochrane Library and national arthroplasty registry reports. Studies were included if they published revision (all cause) survival estimates and confidence intervals. DMC for revision and neck of femurs fractures were excluded. A meta-analysis was performed weighting each series on the overall pooled estimate. 

Results: 35 studies reporting 37 series were identified of which 9 (10, 494 DMCs) were included. 11 series (16, 824 DMCs) from 4 national registries were also included. Pooled analysis of data extracted from joint registries of DMCs showed an all cause construct survivorship of 97.26% (95% CI 96.85 – 97.66) at 5 years and 96.07% (95% CI 94.01– 98.13) at 10 years. Results from case series showed DMC all cause construct survivorship of 99.51% (95% CI 99.27 – 99.75) at 5 years, 96.07% (95% CI 95.00 – 97.15) at 10 years and 77% (95% CI 73.20 – 80.80) at 20 years. 

Conclusions: When DMCs are used in primary THRs for all indications other than neck of femur fracture, there is good survivorship that is equivalent to conventional THRs. 

122 - Pre-operative Biopsy has a higher sensitivity, specificity and likelihood of detecting a polymicrobial flora in Prosthetic Knee Joint Infection than aspiration alone

Michael Clarke¹, Omer Salar¹, Jon Evans², Morgan Bayley¹, Hugh Ben Waterson¹, Andrew Toms¹, Jon Phillips¹

¹Exeter Knee Reconstruction Unit, RD+E Hospital, Exeter, United Kingdom; ²University of Exeter, Exeter, United Kingdom 

Background: Prosthetic joint infection (PJI) is a significant cause of morbidity and mortality following knee replacement surgery. Identifying the causative agent(s) and their antibiotic sensitivities is critical in determining the choice of treatment methods used and the likelihood of successful eradication. The aim of this study was to investigate whether biopsy alone was superior to aspiration alone in specificity and sensitivity for diagnosing PJI following knee replacement. Secondly, we wished to investigate whether biopsy identifies the same microbiological flora as aspiration 

Methods: Since December 2014, the Exeter Knee Reconstruction Unit (EKRU) has prospectively collated data regarding all PJIs referred from our local and regional network via our Knee Infection Multi-Disciplinary Team meeting (MDT). We identified consecutive patients passing through this MDT between December 2014 and March 2020 and collated data retrospectively using electronic records. Statistical analysis was performed using Stata (Timberlake, February 2020) 

Results: 65 of the 100 patients identified had both pre-operative aspiration and biopsy. In 29% of positive patients, biopsy identified new or additional organisms not previously identified by aspiration.  Aspiration had a sensitivity of 70%, specificity of 88%, positive predictive value of 90.3% and negative predictive value of 64.7%. Biopsy had a sensitivity of 97.5%, specificity of 88%, and positive predictive value of 92.9% and negative predictive value of 95.7% 

Conclusion/Findings: Biopsy is superior to aspiration in the diagnosis of PJI and can be performed safely and successfully. Biopsy also identifies organisms when aspiration may be negative and identifies additional microorganisms in a polymicrobial setting not identified by aspiration alone (29% of positive cases). We would therefore recommend, where possible, aspiration and biopsy as routine pre-operative sampling in order to identify all causative agents and their susceptibilities prior to embarking on revision surgery 

342 - Superior tissue levels of vancomycin are achieved with intraosseous versus intravenous administration despite limited tourniquet use in primary TKA: A prospective, randomized trial

Mark Spangehl¹, Henry Clarke¹, Grant Moore², Mei Zhang³, Nicholas Probst¹, Simon Young⁴

¹Mayo Clinic, Phoenix, USA; ²Canterbury Health Labs, Christchurch, New Zealand; ³University of Otago, Christchurch, New Zealand; ⁴North Shore Hospital, Auckland, New Zealand

Background: Intraosseous administration of vancomycin produces 6 to 20 times higher tissue concentrations compared to intravenous administration in knee replacement. However, these superior levels are achieved when vancomycin is administered intraosseously distal to a tourniquet that is inflated for the entire procedure.  With increasing interest in avoiding tourniquet use during TKA we evaluated the tissue concentrations achieved with intraosseously administered vancomycin versus intravenous administration when the tourniquet was used only during exposure.

Methods: 24 patients undergoing primary TKA were randomized to two groups. The intravenous (IV) group received weight based (15mg/kg) vancomycin timed to finish before the incision. The intraosseous (IO) group received 500 mg of vancomycin injected as a bolus prior to the skin incision, through a needle in the proximal tibia below an inflated tourniquet. In the IO group, the tourniquet was deflated 10 minutes following the injection. The tourniquet was inflated for cementation in both groups.  Fat and bone samples were taken at regular intervals. Tissue vancomycin concentrations were measured using high performance liquid chromatography. 

Results: Mean vancomycin concentrations in fat and bone samples from all time points were 3-10 times greater in the IO group (all results, p<0.01).  At closure, mean vancomycin levels in fat were 6.0ug/g in the IV group vs 40.5ug/g in the IO group (p<0.001). Final bone levels were 8.3ug/g in the IV group vs 26.9ug/g in the IO group (p=0.009). 

Conclusion: Intraosseous administration of prophylactic vancomycin produces significantly higher tissue concentrations versus IV administration in primary TKA even with limited tourniquet use. 

Implications: Intraosseous administration appears to be a better delivery route for prophylactic vancomycin when needed in knee surgery even when tourniquet use is limited to during the surgical exposure.

343 - Cost-Effectiveness of Single versus Double DAIR with Antibiotic Beads for Acute Periprosthetic Joint Infections in TKA

Joseph Antonios¹, Kevin Bozic², Henry Clarke¹, Mark Spangehl¹, Joshua Bingham¹, Adam Schwartz¹

¹Mayo Clinic, Phoenix, USA; ²University of Texas, Austin, USA

Background: Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement or planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single versus double DAIR with antibiotic beads for acute PJI in total knee arthroplasty (TKA).

Methods: A decision tree using single or double DAIR as treatment strategies for acute PJI was constructed. QALYs and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision.

Results: Double DAIR with antibiotic beads was the optimal treatment strategy both in terms of the health utility state (82% of trials), and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective.  

Conclusions: This Markov analysis demonstrates that in the setting of acute PJI following TKA, a double DAIR with antibiotic beads is more cost effective than single DAIR from a societal perspective.

Implications: When evaluated from a national level, the most cost-effective strategy for managing patients with acute PJI after TKA is a two stage DAIR with antibiotic beads.

713 - The re-infection rate following 2 stage revision knee arthroplasty for peri-prosthetic joint infection: A retrospective review of 198 patients

Cameron Brown, Khairul Yusof, Ilja Perevalovs, Duncan Renton, Rahul Bhattycharya, Bryn Jones, Mark Blyth

Glasgow Royal Infirmary, Glasgow, United Kingdom

Background: The gold standard for managing peri-prosthetic joint infection (PJI) remains a 2-stage excision arthroplasty. The primary aim of this study is to define the re-infection, explantation and mortality rate following revision knee surgery. We also report the association between re-infection and co-morbidity, organism and patient reported outcomes. 

Methods: All patients undergoing 2-stage revision knee arthroplasty for PJI between 2004-2019 were included in the study. Surgery was performed by two revision knee surgeons in a high volume tertiary referral centre. Kaplan Meier survivorship graphs were used to analyse re-infection, explantation and mortality rate over time with cox regression used to determine associated risk factors (p<0.05 considered significant). The Charlson co-morbidity score (CCS) was used. The Oxford Knee Score (OKS) was recorded at 1,5 and 10 years.    

Results: 198 revisions (171 patients) were performed, mean age 68 years old (range 33-91). 153 (77%) R1, 35 (18%) R2, 9 (5%) R3 and 1 (<1%) R4. Re-infection rate was 10% at 1 year and 20% at 5 years with 36 revisions requiring explantation. Mortality rate at 5 and 10 years was 20% and 40% respectively. The CCS, organism type, number and growth at 1st vs 2nd stage was not associated with re-infection or explantation. Mean OKS was 32 at 1 year and 34 at 5 years. R1 patients had a higher score (32) than R2 patients (25) at 1 year.   

Conclusion: There was no increased risk of re-infection beyond 5 years in any ‘R’ group and no associated risk factors identified in this study. Patients who require multiple revisions have poorer outcome scores. 

794 - Prosthetic Joint Infection (PJI) – Is this correctly recorded as a ‘Reason for Revision’ on the National Joint Registry?

Irrum Afzal, Sarkhell Radha, Richard Field

South West London Elective Orthopaedic Centre, London, United Kingdom

Patients need to know the benefits, risks and alternatives to any proposed treatment. Surgeons discussing the risk of a revision procedure becoming necessary, after a hip or knee replacement can draw upon the orthopaedic literature and arthroplasty registries for long-term results. With over 2.52 million records, the National Joint Registry (NJR) in the United Kingdom is the largest arthroplasty registry in the world. It provides a powerful tool to monitor implant survivorship and influence different surgical strategies. Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We have investigated validity of the ´Reason for Revision´ for infection recorded in Consultant Outcome Publications on the NJR.

Of the 22,046 primary Total Hip Replacements (THR) and Total Knee Replacements (TKR) undertaken by 23 surgeons at our hospital, over an eleven-year period, 1.35% (297) were subsequently reported to the NJR as revised during the eleven-year period. Review and validation of ´Reason for Revision´ was undertaken using radiological imaging studies, pathology, histology, microbiology and electronic medical records.

Discrepancies in reporting to the NJR were identified for 41 cases (25.6%) for THR and 28 (20.4%) cases for TKR. Revision for infection was under-reported for both THR and TKR by 1.88% and 3.65% respectively. Once validated 16.86% of the cases for revision THR were revised for infection. Once validated 29.9% of the cases for revision THR were revised for infection.

If an average of 23% wrong data entry at a highly organised institution is replicated throughout the UK, a formal process to validate primary and revision data submitted to the NJR should be considered. Local scrutiny, review and validation of revision data are all vital to optimise the value of the NJR. Accurate data recorded to the NJR is imperative to provide safe and effective improvements in orthopaedic surgery.

1107 - Long term follow-up adult long bone osteomyelitis managed with the modified Lautenbach procedure

Umar Yousuf, Sanjeev Agarwal, Rhidian Morgan-Jones

Department of Trauma & Orthopaedics, University Hospital Llandough, Cardiff, United Kingdom

Background: Chronic osteomyelitis remains a major cause of morbidity. It is difficult and challenging to manage and has considerable health-economic implications in terms of the use of antibiotics, hospital stay and theatre time. The modified Lautenbach procedure (MLP) involves radical debridement, reaming of the medullary canal and on table irrigation and lavage until all the debris are cleared but not the continuous irrigation system originally described. We studied long term follow-up of this cohort of patients treated with MLP in order to ascertain remission and recurrence rates.

Methods: Retrospective analysis of 51 patients with long bone osteomyelitis treated surgically with MLP between 2002-2005 by the senior author (RM-J). Our antibiotic philosophy was systemic only antibiotic therapy; 5 days short intravenous course, early oral switch with dual therapy for 6 weeks. 4 patients were excluded from this study as the records were not available. Data on pre-operative inflammatory markers, bacteriology, pain scores, length of hospital stay was collected from prospectively-populated databases and electronic patient record.

Results: A total of 47 patients (32 male: 15 female) were included. The average age 47 years. Location of lesion was in tibia (48.9 %), femur (44.7 %) and in both bones (6.4%). 57.4% of the cases were post-traumatic; they involved removal of metalwork at the time of MLP. At 15.6-19.4 years there were 5 (10.6%) clinical recurrences of osteomyelitis. 8 (17.0%) required further surgery for another cause and there 5 unrelated deaths (10.6%).

Conclusions: MLP with systematic antibiotic therapy for long bone osteomyelitis gives a 91.5% remission rate in the long term. Further studies should look at the utility of local antibiotic therapy in the management of these patients. 

Implications: This study supports the use of the MLP with our systemic only antibiotic regimen with good long term remission rates in adult long bone osteomyelitis. 

507 - Infection in total knee arthroplasty; an overestimated problem?

Daniel RP Cadoux-Hudson, Douglas G Dunlop

Southampton General Hospital, Southampton, United Kingdom

Background: Infection in Total Knee Arthroplasty (TKA) surgery is a common cause of revision, morbidity and even mortality.  The National Joint Registry (NJR) uses a standard K2 form to record this information at revision surgery.  The recording of a cause of revision requires the surgeon to enter information based on available data.  The diagnosis of infection relies on clinical suspicion, microbiological, haematological and biochemical investigations. Often the results of these are not available at the time of revision.  This leaves the potential for an incorrect cause to be entered into the NJR at the time of revision surgery as new contradictory results arrive afterwards.

Methods: The NJR dataset was retrieved for all surgeons who work at our centre.  All revision TKAs on the dataset performed at the Southampton General Hospital between 2003 and 2020 were reviewed.  Notes, results and radiology records were analysed.  

Results: Of 118 revision TKAs, 37 had been initially recorded as being revised for infection. Of these 6 had no clinical, biochemical or microbiological evidence of infection. The true causes of revision were aseptic loosening (4), pain and instability (1 each).  There were 6 cases where data was unavailable as they were originally performed in the private sector. Therefore the rate of infection has been over estimated by at least 16%, assuming those lost to follow up were true infections.

Conclusions: Infection remains an important cause of revision, however the current recording of this information skews the dataset towards overestimating the burden of infection in TKA and potential under reporting of other causes.  There may be a role for quarantining the submission of data for revision arthroplasty until all relevant results are available in order to improve accuracy of the NJR.

556 - Musculoskeletal tuberculosis in Bradford: Incidence, treatment and outcomes in an ethnically diverse population

Samir Asmar¹, Andy Craig¹, David Shaw¹, Dinesh Saralaya²

¹Department of Trauma and Orthopaedics, Bradford Royal Infirmary, Bradford, United Kingdom; ²Department of Respiratory Medicine, Bradford Royal Infirmary, Bradford, United Kingdom

Introduction: Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. Incidence rates continue to fall globally (and in England) year on year since 2011.

Previous studies have highlighted the persisting high prevalence of TB and its musculoskeletal variant (MSK TB) in Bradford (1974; 2007), within its famously diverse population.

Methods: Data from the Bradford Hospitals TB database and Office for National Statistics (ONS) was collated and analysed over a 12 year period. Individual care records, outcomes, pathology results and imaging reports were reviewed for all cases.

Results: Between 2005 and 2017, 109 cases of MSK TB were diagnosed and treated in Bradford; mean incidence of MSK TB was 1.65 per 100,000 person-years. Incidence year-on-year continues to fall in this region. A small number of cases demonstrating antimicrobial resistance were encountered. A low rate of loss to follow-up was observed (3.7%). 94.5% of patients were successfully treated, this was predominantly achieved solely with the use of anti-tuberculous agents for between 6 to 12 months however some patients required accompanying surgical intervention (38 cases).

67% of patients reported their country of origin as either: India, Pakistan or Bangladesh; 3 of the top 5 “high burden” countries as defined by WHO. 

Conclusions: Bradford maintains a high prevalence of MSK TB infection relative to national figures, although overall incidence continues to fall. The proportion of TB within the local immigrant population remains grossly disproportionate. Public Health strategies appear to be having a positive impact on TB levels in Bradford.

Typical associated factors (HIV/Hepatitis co-infection, drug resistance), have modest prevalence, however, local socioeconomic factors such as deprivation and poverty appear germane as suggested by global literature.

We advocate a high degree of suspicion in treatment of atypical infection in any area with similar population factors.

956 - Surface Enhanced Spatially Offset Resonance Raman Spectroscopy (SESORRS) and 3D biofilms: A novel method for detection and investigation of orthopaedic joint infection

Gareth Turnbull¹, Evita Ning², Karen Faulds², Phil Riches², Will Shu², Fred Picard¹, Jon Clarke¹

¹Golden Jubilee National Hospital, Glasgow, United Kingdom; ²University of Strathclyde, Glasgow, United Kingdom

Background: Antimicrobial resistance (AMR) is projected to result in 10 million deaths every year globally by 2050. Without urgent action, routine orthopaedic operations could become high risk and musculoskeletal infections incurable in a “post-antibiotic era.” However, current methods of identifying MSK infections often rely on prolonged culture and 2D models of infection, forcing clinicians to take an initial “best guess” antimicrobial approach, potentially leading to an increase in AMR and treatment failure. 

Methods and Results: Two common bacterial causes of joint infection, Methicillin-resistant staphylococcus aureus (MRSA) and Escherichia coli (E. Coli), were initially 3D bioprinted using a novel bioink and an extrusion bioprinter to create 1 mm thick biofilms. Confocal microscopy was then used to confirm the formation of mature biofilms in 3D and allow visualisation of the biofilm life cycle and antimicrobial biofilm penetration in 3D.  3D biofilm structures were then combined with porcine bone and soft tissue to create a joint infection model that could be gradually increased in thickness. Gold nanoparticles functionalised with Raman reporters and aptamers against MRSA and E. Coli were then synthesised and exposed to the joint infection model. A hand held Surface Enhanced Spatially Offset Resonance Raman Spectroscopy (SESORRS) device was used to detect biofilm uptake of nanoparticles under increasing thicknesses of tissue. SESORRS allowed successful detection of biofilms under soft tissue depths of up to 2.1 cm for single bacteria and 1.5 cm for multiple bacteria.

Conclusions: This is the first report of adapting SESORRS to identify specific bacterial biofilms in a clinical model at depth of tissue. SESORRS offers great potential for a point-of-care test that can rapidly diagnose specific bacterial infections, potentially allowing earlier targeting of antimicrobial treatment. 3D biofilms also offer a novel method for investigating antimicrobial penetration and biofilm growth in 3D, more closely replicating the in vivo environment compared to traditional 2D biofilm models.

62 - The effect of the use and type of patella component on ODEP ratings of total knee prostheses

Pradyumna Raval¹, Paul Nicolai¹, Jonathan Phillips², Keith Tucker³

¹West Suffolk Hospital, Bury St. Edmunds, United Kingdom; ²Royal Devon and Exeter Hospital, Exeter, United Kingdom; ³Norfolk and Norwich Hospital, Norwich, United Kingdom

Background: The role of patella in total knee arthroplasty remains controversial. The National Joint Registry has reported brand survivorship with or without the use of patella. However, brand survivorship does not differentiate between other design features such as cruciate retaining or sacrificing prostheses and type of patella used. This detailed information is only available in ODEP data (Orthopaedic Data Evaluation Panel). The aim of this observational study is to investigate the effect of the patella component on ODEP ratings.

Methods: The ODEP website was used to produce a database with all total knee prostheses. The ODEP rating for each separate combination of femoral and tibial component, polyethylene insert and patella (or absence of patella) was collected and results were analysed in five different ways to assess the effect of the use and type of patella component on different implant characteristics.

Results: There are 217 different total knee prosthesis combinations with an ODEP rating. There was a higher percentage of A* ratings (highest survivorship) when any type of patella was used (53% with vs 41% without patella) but there was not much difference between different types of patella component.  Posterior stabilised (58% with vs 31% without patella) and fixed bearing implants (60% with vs 40% without patella) had higher percentages of A* ratings compared to all total knee prostheses with a patella component. Even within total knee brands there are substantial variations in ODEP ratings.

Conclusion: When assessing the role of the patella component in total knee prostheses there is substantial variation in ODEP ratings even within total knee brands. There was a higher percentage of A* ratings when any patella component was used but in particular with posterior stabilised and fixed bearing prostheses. 

Implications: This study will help surgeons make informed decisions about using a patella in TKA

193 - No difference of gait parameters in patients with image-free robotic-assisted medial unicompartmental knee arthroplasty compared to a conventional technique: a randomized controlled trial

Cecile Batailler¹, Timothy Lording², Alexandre Naaim³, Elvire Servien¹, Laurence Cheze³, Sébastien Lustig¹

¹Hospices civils de Lyon, Lyon, France; ²Melbourne Orthopaedic Group, Windsor, Australia; ³Université Claude Bernard Lyon 1, Lyon, France

Background: In recent studies, robotic-assisted surgical techniques for unicompartmental knee arthroplasty (UKA) have demonstrated superior implant positioning and limb alignment compared to a conventional technique. However, the impact of the robotic-assisted technique on clinical and functional outcomes is less clear. The aim of this study was to compare the gait parameters of UKA performed with conventional and image-free robotic-assisted techniques.

Methods: This prospective, single center study included 66 medial UKA, randomized to a robotic-assisted (n=33) or conventional technique (n=33). Gait analysis was performed on a treadmill at 6 months to identify changes in gait characteristics (walking speed, each degree-of-freedom: flexion–extension, abduction–adduction, internal–external rotation and anterior-posterior displacement). Clinical results were assessed at 6 months using the IKS score and the Forgotten Joint Score. Implants position was assessed on post-operative radiographs.

Results: Post-operatively, the whole gait cycle was not significantly different between groups. In both groups there was a significant improvement in varus deformity between the pre- and post-operative gait cycle. There was no significant difference between the two groups in clinical scores, implant position, revision and complication rates.

Conclusion: No difference of gait parameters could be identified between medial UKA performed with image-free robotic-assisted technique or with conventional technique. 

Disclosure: Study was funded by Smith and Nephew 

369 - Oxford Unicompartmental Knee Arthroplasty Versus Total Knee Arthroplasty - Long term functional outcomes and survival analysis

Elizabeth Lindsay¹, Jun Lim^1,2, Ben Clift¹, Gerard Cousins^1,3

¹NHS Tayside, Dundee, United Kingdom; ²NHS Grampian, Aberdeen, United Kingdom; ³NHS Highland, Inverness, United Kingdom

Background: End-stage unicompartmental knee osteoarthritis can be treated with either Total Knee Arthroplasty (TKA) or Unicompartmental Knee Arthroplasty (UKA) and controversy remains as to which treatment is best. UKA has been reported to offer a variety of advantages, however many still see it as a temporary procedure with high revision rates. A previous retrospective study of the same population showed the theoretical advantages of UKA were not borne out other than a lower rate of postoperative complications.

Aims: We aimed to clarify the role of UKA in the treatment of unicompartmental osteoarthritis and to build on the previous short-term (five-year) study to evaluate the long-term outcomes.

Methods: We retrospectively reviewed the pain, function and total Knee Society Score (KSS) for 602 UKA and 602 TKA in age and gender matched patients. The same study group was used as the initial five year study. Post-operative complications and revision rates were also investigated. 

Results: KSS (pain) was significantly better in the TKA group (44.39 vs 41.38 P= 0.007) at one year and at five years (45.33 vs 43.12 P=0.004). There was no statistically significant difference for KSS (total) in TKA and UKA at any point in the ten year follow-up. 16.3% of UKA and 20.1% of TKA had a documented medical complication. The average stay in hospital was 4 days for UKA (range 0-20 days) compared to 7 days for TKA (range 0-36 days). 79 UKA (13%) and 36 TKA (6%) required revision surgery. Performance for UKAs was inferior to TKAs in Kaplan-Meier cumulative survival analysis at 10 years (P<0.001).

Conclusion: Both UKA and TKA are viable treatment options for unicompartmental knee osteoarthritis, each with their own merits. UKA is associated with fewer post-operative complications whereas TKA provides better initial pain relief and is less likely to require revision.

462 - Clinical and cost-effectiveness of a new care pathway for patients with pain at three months after total knee replacement: the STAR randomised controlled trial

Vikki Wylde¹, Nicholas Howells², Wendy Bertram^1,2, Emily Sanderson¹, Sian Noble¹, Timothy Peters¹, Andrew Beswick¹, Ashley Blom^1,2, Andrew Moore¹, Julie Bruce³, David Walsh⁴, Christopher Eccleston⁵, Shaun Harris¹, Kristy Garfield¹, Simon White⁶, Andrew Toms⁷, Rachael Gooberman-Hill¹

¹University of Bristol, Bristol, United Kingdom; ²North Bristol NHS Trust, Bristol, United Kingdom; ³University of Warwick, Coventry, United Kingdom; ⁴University of Nottingham, Nottingham, United Kingdom; ⁵Bath University, Bath, United Kingdom; ⁶Cardiff and Vale University Health Board, Cardiff, United Kingdom; ⁷Royal Devon and Exeter NHS Trust, Exeter, United Kingdom

Background: Approximately 20% of people experience chronic pain after total knee replacement (TKR), but effective treatments are lacking. We evaluated a new intervention to optimise the treatment of chronic pain after TKR. 

Methods: We undertook a pragmatic, open-label, randomised trial in eight NHS hospitals. People with troublesome pain in their replaced knee at three months post-TKR were randomly assigned (2:1) to the Support and Treatment after Replacement (STAR) care pathway plus usual care, or usual care alone. The STAR intervention comprised an assessment appointment at three months post-operatively with an Extended Scope Practitioner, with subsequent telephone follow-up. The assessment aimed to identify underlying causes for chronic pain and enable onward referral for treatment. The co-primary outcomes were the Brief Pain Inventory (BPI) pain severity and interference scales at 12 months after randomisation (15 months post-operative), analysed on an ‘as randomised’ basis. Embedded qualitative interviews explored intervention acceptability. The trial was registered on ISRCTN:92545361.

Findings: Between 2016 and 2019, 363 participants were randomly assigned to the intervention plus usual care (n=242) or usual care alone (n=121).  At 12 months, the difference in means between groups was -0·65 (95% CI -1·17, -0·13; p=0·014) for pain severity and -0·68 (95% CI -1·29, -0·08; p=0·026) for pain interference, both favouring better outcomes in the intervention arm. The intervention over a 12-month horizon from an NHS and PSS perspective was the cost-effective option, incremental net monetary benefit at £20,000 per quality adjusted life year NICE threshold, £1234 (95% CI £162, £2305). Only one adverse reaction of participant distress in the intervention group was reported. Qualitative findings showed that patients found the STAR pathway acceptable.

Conclusion: STAR is a clinically and cost-effective intervention to improve pain outcomes over one year for patients with troublesome pain three months post-TKR.

463 - A matched comparison of the long term outcomes of cemented and cementless total knee replacements, based on data from the national databases: An analysis from the National Joint Registry of England, Wales, Northern Ireland and Isle of Man

Hasan Mohammad¹, Andrew Judge^1,2, David Murray¹

¹University of Oxford, Oxford, United Kingdom; ²University of Bristol, Bristol, United Kingdom

Background: Total knee replacement (TKR) can be implanted with or without cement. It is currently unknown how cemented and cementless TKRs compare overall and in different age groups in the long term.

Methods: The National Joint Registry database was linked to the National Health Service Hospital Episode Statistics and Patient Reported Outcome Measures databases. Using propensity matched scoring techniques 44,954 cemented and cementless TKRs were compared. Regression models were used to compare revision, reoperation and mortality. The Oxford Knee Score was compared between groups using appropriate non parametric tests. Subgroup analyses were performed in different age strata.

Results: The 10 year implant survival (revision endpoint) for cemented and cementless TKRs were 96.0% and 95.5% (Hazard Ratio (HR) 1.14, p=0.01). The 10 year reoperation survival was 82.7% and 81.4% respectively (HR 1.08, p=0.001). The rates of revision for pain were significantly higher in cementless TKRs (0.5% vs 0.7%, p=0.002) but the rates of revision for infection were significantly lower (0.8% vs 0.5%, p=0.003). No significant interactions existed between age; and revision (p=0.24), reoperation (p=0.30) or mortality (p=0.58). The six month postoperative Oxford knee score (OKS) for cemented and cementless groups were 35.3 (SD 9.7) and 34.3 (SD 9.9) (p<0.001). A significantly higher proportion of cemented TKRs had an excellent OKS (≥41) compared to cementless (32.1% vs 28.2%, p<0.001) and a lower proportion of poor (<27) scores (18.8% vs 21.5%, p=0.001). This was also observed for all age subgroups.  

Conclusions/Findings: We found that matched cemented and cementless TKRs both have 10 year implant survivals over 95%. However cementless TKRs had a significantly higher risk of revision (14%) and reoperation (8%). The rates of revision for infection were significantly lower in the cementless group, although the rates of revision for pain were higher. Age did not significantly affect the relative performances.

583 - Inflammatory Response in Robotic Total Knee Arthroplasty versus conventional Jig-based and the correlation with Early Functional Outcomes: Results of a Prospective Randomised Controlled Trial

Andreas Fontalis, Babar Kayani, Mazin S Ibrahim, Jenni Tahmassebi, Fares S Haddad

Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, United Kingdom

Background: The exact aetiology of patient dissatisfaction (up to 20%) in Total Knee Arthroplasty (TKA) is unclear, however the inflammatory response precipitated by surgery has been suggested to be implicated. Robotic TKA has been shown to result is minimal bone trauma and soft tissue release. The objective of this study was to compare the inflammatory response in conventional jig-based TKA versus robotic TKA and examine the relationship with early functional outcomes.

Methods: This prospective randomised controlled trial included 30 patients with symptomatic knee osteoarthritis undergoing conventional versus robotic TKA. Blood samples were collected for up to 7 days post-operatively and predefined markers of serum inflammation were measured. The local inflammatory response was assessed by analysing samples from the intraarticular drain fluid at 6 and 24 hours. The relationship with early functional outcomes was evaluated using the Spearman's rank correlation coefficient.

Results: A statistically significant reduction in serum inflammatory markers [interleukin-6(IL-6), tumour necrosis factor-a(TNFa), erythrocyte sedimentation rate(ESR), C-reactive protein(CRP), and creatine kinase(CK)] was evident in the robotic group on day 7.Patients in the robotic group also demonstrated reduced levels of IL-6 in the drain fluid at 6- hours [798.54 vs. 5699.2, p=0.026] and 24- hours and IL-8 at 6 hours. A statistically significant correlation was observed between self-reported pain and all serum markers except IL-1b on the 7th postoperative day; between drain IL-8 levels and pain on postoperative day 1 (r= 0.458), day 2 and 7; between knee flexion and extension and drain IL-6, IL-8 and TNF-a levels (6-hours).

Conclusion: Robotic TKA was associated with a reduction in early postoperative local and systemic inflammatory responses. We also found a moderate relationship with self-reported pain, knee flexion and knee extension. Future long-term data and their correlation with patient reported outcomes, will be key to developing the optimal TKA procedure.

688 - Applicability of the specific criteria for problematic knee replacement following revision TKA. Influence of diagnosis on mid-term outcomes

Andy Jones, Nick Howells, James Murray, Andrew Porteous

Southmead Hospital, North Bristol Trust, Bristol, United Kingdom

The BOA/BASK BOAST for investigation and management of problematic knee replacements describe SPECIFIC criteria suggesting diagnoses which may be surgically correctable. Several previous publications have proposed diagnostic categories but there has been no accepted standard, resulting in variability between reported series. In this study we have tested the applicability of retrospective categorisation using the SPECIFIC criteria to a large cohort of revision TKA patients.  

A consecutive series of 184 patients that underwent revision knee replacement using a single implant system between January 2012 and December 2016, were classified according to the SPECIFIC criteria. Classification was based on pre-operative imaging and medical notes including the operative record. Oxford Knee Scores were assessed pre-operatively and at four subsequent time-points.

It was possible to apply SPECIFIC criteria to all patients retrospectively. Of the 184 patients, there were 61 ‘Component Loosening (C1)’, 51 ‘Patella/component malposition or malrotation (P)’, 35 ‘Component wear/breakage (C2) and 26 ‘Infection (I1)’ as a primary diagnosis. The remaining 11 were classified as ‘Stiffness(S)’ and ‘Instability (I2)’ with no cases of fracture or extensor mechanism dysfunction in this cohort.

Mean OKS was 27(Range: 3-48) at 5 years, an increase from 15(range: 2-45) pre-operatively.  Patients undergoing revision for component loosening showed the greatest and most sustained improvement in OKS. In the 6 categories (from SPECIFIC list of 8) all groups showed a clinically significant improvement (mean=13.8) at 2 years.

We have shown that the SPECIFIC classification system is applicable to a cohort of revision knee replacement patients when applied retrospectively.  The relative improvement in subgroups provides useful information, both for the clinician and MDT as well as patients, in the decision-making process following the investigation of a problematic TKR.

731 - Does the RKCC classification predict the true cost of revision knee arthroplasty? A financial analysis of eighty-nine cases at a regional centre

Aris Alexiadis¹, Louay Al-Mouazzen², Patrick Reynolds³, Jonathan Phillips⁴, Andrew Toms⁴

¹University of Exeter, Exeter, United Kingdom; ²Royal Devon & Exeter, Exeter, United Kingdom; ³University Hospital Plymouth, Plymouth, United Kingdom; ⁴Royal Devon & Exeter Hospital, Exeter, United Kingdom

Background: The revision knee complexity classification (RKCC) stratifies revision knee operations depending on their complexity. It ranges from simple revisions (R1) to more complex cases (R3). We examined the cost of revision knee surgery in these categories and compared it against the Trusts’ existing financial codes.

Methods: We analysed 89 cases who underwent revision knee operations; R1 (n=48), R2 (n=28), and R3 (n=13). All operations were performed between 01/01/2019-31/12/2019 at the Royal Devon & Exeter Hospital. Costs include all patient-care related resources and were provided by the Trusts’ finance department. Tariffs were calculated based on the financial codes assigned to the patients’ episodes of care. Data are expressed as mean ± standard deviation. Unpaired t-tests were performed assuming unequal variance to determine statistical significance (p ≤ 0.05).

Results: The costs of R2 (£15,839.64 +/- 5547.47) and R3 (£17,857.24 +/- 7149.05) operations were significantly more expensive (p<0.00002; p<0.0014) than R1 operations (£9,658.93 +/-5890.76). There was not a significant increase in cost between R2 and R3 operations (p<0.38). The total cost of the revision operations was £1,139,291. Tariffs received for performing R2 (£8,859.94 +/- 2,370.15) and R3 (£11,402.97 +/- 5,536.27) operations were significantly higher than R1 operations (£7,649.57 +/- 2329.02) p<0.034; p<0.032 respectively. The increase in tariff between R2 and R3 operations (p<0.134) was not significant. The total tariffs received for the revisions was £763,496 resulting in a deficit of - £375,794.

Conclusions/Findings: More complex revision knee operations are associated with an increased cost. Current NHS financial codes do not accurately reflect the true cost of knee revision surgery leading to a net deficit.

Implications: RKCC provides both a good clinical guide of complexity and a useful guide to cost and the likely mismatch with tariff and may be a better model upon which Trusts could accurately estimate the cost associated with knee revision surgery.

772 - Provision of Revision Knee Arthroplasty services across Scotland: A national audit

Luke Farrow^1,2, Ian Kennedy³, Liam Yapp^4,5, Tom Harding⁶, SCOTnet Collaboration⁷, Phil Walmsley^8,9

¹University of Aberdeen, Aberdeen, United Kingdom; ²NHS Grampian, Aberdeen, United Kingdom; ³NHS Greater Glasgow and Clyde, Glasgow, United Kingdom; ⁴NHS Lothian, Edinburgh, United Kingdom; ⁵Scottish Arthroplasty Project, Edinburgh, United Kingdom; ⁶NHS Tayside, Dundee, United Kingdom; ⁷SCOTnet, Scotland, United Kingdom; ⁸NHS Fife, Kirkcaldy, United Kingdom; ⁹University of St. Andrews, St. Andrews, United Kingdom

Background: There is increasing evidence that both low surgeon and centre case volumes are associated with poorer outcomes following Revision Knee Arthroplasty (rTKA). This has led to discussions regarding potential national re-organisation of rTKR services. Given the unique challenges faced in Scotland relating to funding and geography, understanding details on the complexity of cases is required to guide development of future rTKA services. 

Methods: Utilising the Scottish Collaborative Orthopaedic Trainee Research Network (SCOTnet) a retrospective review of all Scottish 2019 rTKA cases was undertaken. Regional leads co-ordinated local data collection using individual case note review. The number of cases performed by regions, hospitals and individual surgeons were identified. Patient demographics and case complexity (Revision Knee Complexity Classification) were also collected. Results were compared against current BOA standards for Trauma and Orthopaedics (BOAST) guidance.

Results: 17 units performed rTKR, delivered by 77 surgeons. A total of 506 cases were included. The mean age of individuals was 69 years. 233/506 (46%) were male, with 147/506 (29%) cases performed due to infection. 35/506 (7%) had extensor mechanism compromise and 11/506 (2%) required soft tissue reconstruction.  According to the RKCC - 214/503 (43%) were classified as R1, 228/503 (45%) R2, and 61/503 (12%) R3.

5/17 (29%) units met the current BOAST guidelines for case volume per year, with only 11/77 (14%) surgeons meeting recommended individual case volume requirements. 37/77 (48%) surgeons performed ≤2 cases per year. 27/506 (5%) cases had dual consultant operating.

Conclusions: Most individual centre volumes could be increased by re-organising services or locations providing rTKA within a region. This should provide better access to MDT involvement. We recorded a significant number of very low volume surgeons (≤2 year). Dual consultant operating may help improve patient outcomes in complex surgery and provide opportunities for greater surgical experience.

1189 - Differences in Early Recovery following Unicompartmental Knee Replacement with Daycase and Standard Care Pathways, assessed using the Oxford Arthroplasty Early Recovery Score (OARS)

Azmi Rahman¹, Louise Strickland^1,2, Hemant Pandit³, Crispin Jenkinson⁴, Stephen Mellon¹, David Murray^1,2

¹Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Oxford, United Kingdom; ²Nuffield Orthopaedic Centre, Oxford, United Kingdom; ³University of Leeds, Leeds, United Kingdom; ⁴Nuffield Department of Public Health, Oxford, United Kingdom

Background: Daycase pathways are being introduced, aiming to discharge patients the same day (outpatient) following Unicompartmental Knee Replacement (UKR), whilst accepting that some patients will have to stay longer (inpatient). Compared to Standard pathways there are advantages in healthcare costs, but there is limited patient-reported data comparing these pathways. This study uses the Oxford-Arthroplasty-Early-Recovery-Score (OARS), and the SF-36v2-Acute (SF-36) to compare patient recovery across these pathways. 

Method: Our group works in two centres that had used the same Standard recovery pathway for UKR. In one centre, the Standard pathway was modified into a Daycase pathway. Three cohorts of patients were studied: 26 Daycase-Outpatients, 11 Daycase-Inpatients, and 18 Standard. The patients completed the OARS on Days 1-42, and SF-36 on Days 7-42, after UKR.

Results: The mean length-of-stay for each pathway was 0 (Daycase-Outpatient), 1.6 (Daycase-Inpatient), and 3.1 (Standard) days. Standard patients had much higher Day-1 scores than Daycase patients, but this difference rapidly diminished. From Day-3 onwards both groups had near-identical scores (OARS Day-1, 59v37, p=0.0015, stemming from differences in Pain, Nausea/Feeling-Unwell, Function/Mobility sub-scores p=0.0028, 0.014, 0.011. OARS Day-3 48v49, p=0.79).

Daycase-Outpatients had a higher overall OARS (p=0.002), recovering 2-3 weeks faster than Daycase-Inpatients. OARS sub-scores demonstrated that Daycase-Outpatients had better Pain, Nausea/Feeling-Unwell, Fatigue/Sleep scores (p=0.0195, 0.0004, 0.0193). 

SF-36 scores corroborate related OARS scores. At Day-42, SF-36 reports higher Mental-Health in Daycase-Outpatients vs Daycase-Inpatients (p=0.005) and better Physical-Functioning in the Standard vs Daycase cohort (p=0.006). 

Conclusion: The Standard cohort had better Day-1 scores than the Daycase cohort, likely because they did not mobilise early and had stronger pain medication; these differences diminished by Day-3. Daycase-Outpatients recovered substantially faster than Daycase-Inpatients, likely due to the factors that delayed their discharge. The convergence of scores at 6 weeks demonstrates that both pathways, despite differing cost implications, have similar outcomes in early recovery. 

415 - Comparative Evaluation of Orthobiology Ozonized PRP Platelet Rich Plasma-plus Hyaluronate Injection Therapy post Arthroscopic Suturing of Meniscal Degenerative Tear versus Partial Meniscectomy Treatment of Meniscal Tears in Degenerative Knee OA Follow up Study for 2 years

Ahmed Alkhuzai

Sulaimani University, Sulaimaniyah, Iraq

Background: Meniscal Tears of Knee joint Osteoarthritis degenerative OA, still some center treated by Arthroscopic Partial Meniscectomy (APM) followed by a physical therapy program lone. The high rate of progressive degenerative knee joint lead to evaluate the Orthobiology Ozonized PRP Platelet Rich Plasma plus Hyaluronate therapeutic treatment post (ASMT) Arthroscopic Suturing of meniscal degenerative tear of knee joint OA. 

Methods: A prospective comparative study 104 patients all presented with knee joint Osteoarthritis Degenerative Tear of Meniscus, were randomized according to inclusion exclusion criteria into two groups. Group A 55 patients receive intra-articular Orthobiology Ozonized PRP Platelet Rich Plasma plus Hyaluronate therapeutic, post (ASMT) Arthroscopic Suturing of meniscal tear treatment of knee joint OA degenerative type, they were presented with meniscal tear on MRI of knee joint, all patients were followed by physical therapy. Compare to group B 49 patients were prepare for Arthroscopic Partial Meniscectomy (APM) followed by a physical therapy. The patients followed up for 12, 24 Months period. The primary outcome measurements were clinical and functional outcomes according to modified Lequesne's and modified WOMAC scores.                                                                                                                                              

Results:  In both group A and B significant reduction in the mean of both modified Lequesne's and Modified WOMAC scores from baseline were seen at all follow up visit for 12, 24 Months. Also there were significant statistical improvements at 12, 24 Months for both Lequesne's and Modified WOMAC scores in group A superior to group B (p-value < 0.0001). There were No severe adverse events related to the method were observed in group A compare to group B were noticed infection, stiffness, wide spread of degenerative OA knee joint.                                       

Conclusion: We concluded that intra-articular Orthobiology Ozonized PRP Platelet Rich Plasma plus Hyaluronate therapeutic post (ASMT) Arthroscopic Suturing of meniscal tear of degenerative type knee joint OA, follow by physical therapy are superior to Arthroscopic Partial Meniscectomy (APM), for 2 years follow up.                                                                              

417 - A prospective comparative study between synovial joint biomarkers IL-1Beta, TNF-Alfa estimation before treatment by arthroscopic drilling plus stem cell therapy versus post therapeutic estimation of knee joint OA grade II, III, a clinical study for 2 years

Ahmed Alkhuzai

Sulaimani University/ Faculty of Medicine, Sulaimaniyah, Iraq

Background: Knee joint Osteoarthritis OA progressive staging-grading reaching advance OA changes. We evaluate soluble mediators' synovial biomarkers IL-1 Beta, TNF-Alfa in knee joints aspirates, before and after therapeutic treatment using Arthroscopic Drilling plus Stem Cell Therapy. 

Method: In prospective comparative study patients of knee osteoarthritis grade II, III. The rate of synovial aspirates of IL-1 Beta, TNF-Alfa biomarkers level, before and after therapeutic treatment using Stem Cell intra-articular injection plus Hyaluronate knee joints OA grade II, III. 106 Patients were randomized according to inclusion exclusion criteria into two groups. Group A 54 patients were synovial aspirates estimation of IL-1 Beta, TNF-Alfa biomarkers level from knee joints OA grade II, III early before treatment. Compared to group B 52 patients were depend on synovial aspirates finding estimation of IL-1 Beta, TNF-Alfa biomarkers level post therapeutic treatment of knee joints OA with the same grading II, III, using Arthroscopic Drilling with intra-articular injections of Stem Cell. The patients were followed up for 12, 24 months.                                     

Results: In group A detection of synovial fluid aspirates of IL-1 Beta, TNF-Alfa biomarkers level from knee joints OA grade II, III in early pretreatment show higher rate of these  biomarkers compare to post therapeutic treatment period were significant reduction of these biomarkers level in group B in compare to group A. With significant progressive clinical improvement depending on both Lequesne's and WOMAC scores, from baseline were seen at all follow up visit for 12, 24 Months for group B superior to group A (P-value < 0.0001). 

Conclusion: We concluded that these synovial biomarkers mediators IL-1 Beta, TNF-Alfa are important mediator’s detection for knee joint Osteoarthritis, plus post therapeutic treatment Follow up of knee joint OA grade II, III. Also progressive clinical improvement with progressive reduction in synovial biomarkers level for 2 years study.

573 - The effect of different alignment philosophies on femoral rotation in total knee arthroplasty; results from a randomised controlled trial

Robert Walker¹, Hugh Waterson¹, Petra Koopmans², Rowenna Stroud¹, Jonathan Phillips¹, Vipul Mandalia¹, Keith Eyres¹, Andrew Toms¹

¹Exeter Knee Reconstruction Unit, Exeter, United Kingdom; ²Signidat, Roderwolde, Netherlands

Background: The aim of our study was to compare femoral rotation of the Unity® (Corin, United Kingdom) total knee arthroplasty (TKA) system for two philosophies for knee alignment; mechanical alignment using measured resection (MR) and personalised alignment using a ligament balancer (LB).

Methods: Preoperative computed tomography scans (CTS) to assess limb alignment and native knee geometry were performed. Six weeks after total knee replacement surgery, the scans were repeated to compare alignment in the MR and LB groups.

The primary outcome measure was the inter-observer reliability between the relationship of the Anatomical Trans Epicondylar Axis (ATEA) and the Posterior Condylar Axis (PCA) on both pre and post-operative computed tomography scans (CTS) between two blinded assessors. The second outcome measure was to compare the differences in external femoral rotation post-operatively between the two groups.

Results: Pre- and post-operative CTS were analysed for 92 patients. Inter-observer Pearson Correlation Coefficient were high (all >0.97) for ATEA and PCA measurements.

There was no significant difference between the ATEA and PCA pre-operatively between the MR and LB groups (5.770 Vs 5.520; p=0.492 respectively).

Post-operatively the implant was more externally rotated with the MR technique (median 2.60 IQR 3.4, 2.1) in comparison to the LB technique (median 2.00 IQR 3.5, 0.9) although this was not statistically significant.

Conclusions: ATEA appears to be a reliable landmark to measure femoral rotation on CT.   The MR and LB alignment techniques produced similar femoral rotation in the axial plane postoperatively.

Disclosures: This trial was partially funded by Corin and one of the authors receives paid consultancy work and royalties from them; the analysis and formulation of results & presentation were undertaken in an NHS hospital independent from the funder.

576 - Early muscle and functional recovery following robotic-assisted unicompartmental knee arthroplasty

Emma Moon¹, Allison Bell¹, Paul Gaston^2,3, Sam Patton³, David Hamilton^2,4

¹Spire Murrayfield, Edinburgh, United Kingdom; ²University of Edinburgh, Edinburgh, United Kingdom; ³Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ⁴Edinburgh Napier University, Edinburgh, United Kingdom

Background: Robotic-assisted unicompartmental knee arthroplasty (rUKA) improves implant accuracy, however whether this translates to patient function is less clear. Patient muscle strength has not been previously investigated.

Methods: Patients undergoing rUKA for medial compartment osteoarthritis at a single centre were assessed pre-operatively, and at 6- and 12-weeks post-operatively. Maximal muscle strength was evaluated by biodex system-3 isokinetic testing (con/con knee flexion/extension at 60 degrees/sec). Muscle strength (peak torque) was assessed in quadriceps and hamstring groups. Functional (10m walk and timed-get-up-and-go), clinical (range of motion), and patient reported outcomes (OKS, FJS-12, and 0-10 NRS pain scale) were collected. Analysis was by Friedman’s 2-way ANOVAs, with post-hoc pairwise comparisons (Wilcoxon Signed Rank tests).

Results: 12 participants [2 Females and 10 Males, mean age 66.6 (SD 7.62)] were recruited. Maximal muscle strength changed over time in quadriceps (p=0.006) and hamstrings (p=0.018) in the operated limb, with no change observed in the uninvolved limb. Quadriceps strength reduced from 88.52 (39.86) to 74.47 Nm by 6-weeks (p=0.026), and then recovered to 90.41 (38.76) Nm by 12-weeks (p=0.018). Hamstring strength reduced from 62.45 (23.18) to 54.12 (20.49) Nm by 6-weeks (p=0.016), and then recovered to 55.07 (17.99) Nm by 12-weeks (p=0.028). By 12-weeks quadriceps strength was 75% of the un-operated limb and hamstrings 88%. Substantial improvement was seen in all other measures over time, with sequential positive changes between assessments; TUG (p=0.015), 10m walk test (p=0.021), knee flexion (p=0.016) and all PROMs (p<0.025).

Conclusions: This study charts substantial early physical recovery following rUKA and presents the first isokinetic data for muscle strength. In contrast to functional, clinical, and patient reported measures, strength values reduced between pre-operative and 6-week assessments but recovered by 12-weeks, highlighting the trauma of surgery, the rapid recovery from this, and the sensitivity of this form of physical evaluation.

606 - Safety and performance of the JOURNEY II Cruciate Retaining Total Knee System: A prospective, multicenter study

Jordi Villalba¹, James MacDonald², Tad Gerlinger³, James Chow⁴, Michael Swank⁵, Jeffrey Geller⁶, Herbert Cooper⁷, Jonathan Miles⁸, Amir Kamali⁹, Pramod Achan¹⁰

¹Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Parc Taulí de Sabadell- UAB, Barcelona, Spain; ²Anne Arundel Medical Center, Annapolis, USA; ³Midwest Orthopaedics at Rush, Chicago, USA; ⁴Orthopedic Institute of the West, Phoenix, USA; ⁵The Lindner Research Center, The Christ Hospital, Cincinnati, USA; ⁶Center for Hip and Knee Replacement at Columbia University Medical Center, New York City, USA; ⁷Columbia University Medical Center, New York City, USA; ⁸Royal National Orthopaedic Hospital, London, United Kingdom; ⁹Smith and Nephew, Leamington Spa, United Kingdom; ¹⁰Barts Health NHS Trust, Royal London Hospital & Barts Health Orthopaedic Centre, London, United Kingdom

Background: Novel total knee arthroplasty (TKA) devices aim to address postoperative patient dissatisfaction by achieving more-normal postoperative kinematics and restoration of native anatomy. The current study evaluates the safety and efficacy of the JOURNEY™ II Cruciate Retaining Total Knee System (JOURNEY II CR TKS).

Methods: Patients undergoing primary TKA with this implant were enrolled in a prospective, single-cohort, multicenter study and followed up at 3, 12, and 24 months postoperatively. Study outcomes included the Euroqol 5D visual analogue scale (EQ-5D VAS), 2011 Knee Society Score (KSS), Self-Administered Patient Satisfaction Scale for Primary Hip and Knee Arthroplasty; implant survivorship assessed using a cumulative Kaplan-Meier estimate with the endpoint of revision; and adverse events. 

Results: Overall, 170 patients (mean age, 63 years; mean BMI, 30.2 kg/m²; 35.3% male) were enrolled. From preoperative assessment to 3-, 12- 24-month follow up, there were noted improvements in mean EQ-5D VAS (70.5, 80.6, 82.3 and 84.3, respectively), KSS objective (46.6, 89.9, 91.7, and 92.9, respectively), function (40.1, 79.5, 79.1, and 81.4, respectively), and satisfaction (13.0, 30.3, 34.6, and 34.6, respectively) scores. A majority of patients were satisfied with surgery results at all follow-up points (90.2% at 3 months, 93.7% at 12 months, and 92.1% at 24 months). Implant survivorship was 98.7% [95% confidence interval [CI]: 95.0 -99.6] at 12 months and 97.7% (95% CI: 93.0- 99.3) at 24 months. There were 5 device-related serious adverse events (circulatory, deep vein thrombosis, arthrofibrosis, knee instability/buckling, dislocation). 

Conclusion: Interim results from this ongoing study indicate that the JOURNEY II CR TKS achieves early improvements in function, high levels of patient satisfaction, and an acceptable risk of revision. 

Disclosures: Drs Villalba, MacDonald, Gerlinger, Chow, Swank, Geller, and Cooper report receiving research support and/or consultant fees from Smith + Nephew (S&N). Dr Kamali is a paid S&N employee.

844 - Total knee arthroplasty: Quality assurance and improved longevity costs less

Fanuelle Gatchew¹, Lisi Hu¹, Irrum Afzal¹, Nick Clement^1,2, Philip Mitchell¹, Deiary Kader¹

¹South West London Elective Orthopaedic Centre, London, United Kingdom; ²Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

There is an accepted variation in the financial cost of total knee arthroplasty (TKA) implants but it is not known whether this cost is reflected by the evidence in support of their use. A cost analysis study was carried out to determine the total cost of consumables of a TKA, and whether this was related to the supporting evidence and survivorship data.

Intra-operative data for all unilateral, cemented, primary TKA over a 13 month period at a high-volume Orthopaedic Centre was collected. Level of evidence for each model was taken from the Orthopaedic Data Evaluation Panel (ODEP) website, and data from the UK National Joint Registry was used to assign survivorship (failure rates). Correlation was calculated using the Spearman rank correlation (r).

A total of 1301 TKA were performed at the study centre during the data collection period. The mean cost of consumables for a TKA with patella resurfacing (n=816) was £1,969.08 (range of £1061.46 and £5143.89), and without resurfacing (n=485) was £1,846.62 (range of £1118.98 and £4196.81). There was a negative correlation between price of implant and ODEP rating (r=-0.47), with increasing level of evidence being associated with a lower cost. There was a positive correlation between price of implant and rate of implant failure at the1-, 3- and 5-year time-points (r=0.55, 0.44, 0.28 respectively), with increasing cost being associated with a higher failure rate.

Higher financial cost of TKA prostheses was associated with a weaker level of supporting evidence and a higher failure rate. The increased financial cost of new implants may be justified as more data and evidence becomes available to support an advantage in its use over currently established implants.

905 - Accuracy of digital templating in total knee arthroplasty and the impact of level of training on templating precision

Anna Bogdanova-Bennett, Yiannis Vyrides, Irrum Afzal, David Sochart

South West London Elective Orthopaedic Centre, London, United Kingdom

Digital templating for Total Knee Arthroplasty (TKA) is a beneficial tool in planning for selection of implants. Our aim was to determine the accuracy of preoperative digital templating in TKA and to establish how the level of training of the person performing the templating affects the accuracy of the templates.

We compared the preoperative templated implant sizes with the actual implant size from the operation notes in patients undergoing TKA between 2019 – 2020. Based on the author of the templates, we established three level of training categories (consultant, fellow, generic login – used by visiting operating consultants and their registrars). 

The femoral component was templated within the same size as the actual prosthesis in 9 cases (42.9%) by consultants, 9 cases (45%) by fellows and in 22 cases (44.9%) by the generic group. Femoral component was templated within one size difference from the actual implant in 6 cases (28.6%) by consultants, in 6 cases (30.0%) by fellows and in 24 cases (49%) by the generic group. Tibial component was templated within the same size as the actual implant in 27 cases (55.1%) in the generic group, whilst only in 6 cases (28.6%) by consultants and in 4 cases (20.0%) by fellows. The actual tibial component size was within one size difference from the template in 10 cases (47.6%) by consultants, in 10 cases by fellows (50%) and in 18 cases (36.7%) by the generic group.

There was no statistically significant difference across the three categories in femoral component sizing (p=0.471), and in the tibial component sizing (p=0.802).

Knee templating provides good accuracy in predicting implant component sizes. Although there was no statistically significant difference in the templating across the level of training, our results suggested that consultant and generic group had higher accuracy and precision compared to fellows. 

940 - Outcomes from osteochondral defect fixation with bio-absorbable devices

Samuel J Everett, Simon Middleton, Vipul Mandalia

Exeter Knee Reconstruction Unit, Exeter, United Kingdom

Background: There are a variety of surgical treatment options for osteochondral defects (OCD). However, there is no consensus on the optimal way to manage them. The aim of this study was to investigate the efficacy and outcomes of bio-absorbable fixation methods.

Methods: A retrospective, single-centre cohort study was performed. 25 patients that underwent OCD fixation between February 2015 and March 2021 were included in the study. 12 patients underwent smart nail fixation, 10 patients had fixation with bio-compression screws and 3 patients had a combination of those devices. Mean follow-up was 11 months (range: 0-49). Osteochondritis dissecans (n=10) and traumatic osteochondral fractures (n=15) were included.

Primary outcome was return to theatre for diagnostic or therapeutic arthroscopy for ongoing pain, instability or mechanical symptoms.

Results: Overall, 27% (n=7) required a return to theatre. A sub-group analysis was performed and in the smart nail sub-group 33% (n=4) returned to theatre (mean follow-up 16 months), compared to 1 patient in the bio-compression screw sub-group 10% (n=1), (mean follow-up 5 months). 26% (n=4) in the traumatic osteochondral fracture sub-group required return to theatre and 20 % (n=2) from the osteochondritis dissecans sub-group; mean follow-up was 8 and 15 months respectively.

Additionally, 2 patients that underwent smart nail fixation for osteochondritis dissecans were offered further surgery for MRI suspected fixation failure but declined.

Conclusion: The overall return to theatre rate (>1 in 4) is high, reaffirming that these are challenging injuries to treat. There were 2 arthroscopically demonstrated fixation failures with OCD displacement requiring removal (1 smart nail patient and 1 bio-compression screw patient). The majority of other patients that returned to theatre underwent chondroplasty for their ongoing symptoms. Traumatic osteochondral fractures and defects secondary to osteochondritis dissecans treated with bio-absorbable fixation devices had a similar return to theatre rate (26% and 20% respectively).

191 - Limb salvage surgery: Progress since the Lower Extremity Assessment Project (LEAP) – a systematic review of the literature

Louise McMenemy^1,2, Iain Rankin¹, Spyros Masouros¹, Arul Ramasamy^1,2

¹Imperial College London, London, United Kingdom; ²Academic Department of Military Surgery and Trauma, Birmingham, United Kingdom

Background: Outcomes following limb salvage (LS) and amputation for lower extremity trauma were reported in the Lower Extremity Assessment Project (LEAP) as equivocal. LEAP finished recruiting over 20 years ago, in which time advances have occurred in LS techniques and amputee prosthetic design. LEAP excluded military patients; however complex trauma treatment seen during recent conflicts, has resulted in new data which may be used to ascertain whether amputation or LS results in superior outcomes. 

The aim was to perform a systematic review relating to outcomes from LS and amputation following lower extremity trauma since LEAP for civilians and military personnel. It was hypothesised that, due to the availability of advanced prosthetics within the military, amputation will have superior outcomes over LS for military personnel. 

Methods: PRISMA guidelines were followed to identify research related to minimum 12-month outcomes in LS and amputation between 2006 and 2019. Data were collected on functional and patient reported outcome measures (PROMs). Study quality was assessed using the American Academy of Orthotist and Prosthetists State-of-the-Science evidence guidelines protocol. 

Results: Thirty-nine studies were included reporting on 12,779 patients with a mean follow-up of 54-months. Nineteen studies were of high and 20 of moderate quality. Improved walking distances were reported for amputees compared to LS patients in both civilian and military populations (564 vs 483m; p<0.05). Improved PROMs were found for military patients following amputation (p<0.01) but remain equivocal for civilian patients.

Conclusions: There continues to be no difference in outcomes for civilian cohorts. In contrast, within military cohorts, amputees have superior outcomes compared to LS patients. Longer term follow-up is required to ascertain whether initial benefits from amputation are retained with advancing age. Advances in treatment and rehabilitation of LS patients are required to improve outcomes thus negating the need to amputate.

307 - Complex Ankle arthrodesis with a circular frame: A prospective multicentre cohort study showing 100% union rates and complete deformity correction

Thomas Donnelly, James McEvoy, Olivia O'Malley, Benjamin Fischer, Philippa Thorpe

Mersey Orthoplastics Group, Liverpool, United Kingdom

Arthrodesis is a common procedure used to treat end stage osteoarthritis on the ankle. There are differing approaches to this (open versus arthroscopic) and differing methods of stabilisation (internal versus external fixation).  External fixation is commonly used in complex patients, i.e. those with leg length discrepancies, infection, and significant deformity.  The union rates of external fixation have subsequently been shown to be inferior to that of internal fixation. The authors present a multicentre prospective cohort study, on their use of a circular frame to correct severe deformity and achieve 100 percent fusion rates.

Methods: Data was collected prospectively on 25 patients over a three year period including demographics and pathological factors such as age, gender, infection status, pre and post operative deformity, previous fracture time to union, smoking status and relevant past medical history including the presence of diabetes, and if there were any previous attempts at fusion in another centre. All surgery was performed via an open debridement and joint preparation, samples were taken for microbiological investigation.  A proximal ring was applied in order to facilitate distraction osteogenesis should it be warranted later in the patients treatment.

Results: Of the 25 patients, seven were smokers, six were diabetic, eight had an underlying infection, and of these cases seven had a two stage procedure.  The mean pre-operative coronal plane deformity was 15 degrees (0-38), and the mean post op deformity was 2 degrees (0-5).  All patients achieved union, and the mean time to union was 100 days (88-140). 6 patients went on to have lengthening procedures via distraction osteogenesis from a proximal metaphyseal osteotomy.

Conclusion: We suggest that by open debridement and joint preparation with subsequent stabilisation with a circular frame, we can achieve not only ankle arthrodesis but also correct severe ankle deformity and treat underlying infection.

392 - Tension band plating for the correction of leg length discrepancy

Jaap Tolk^1,2, Rajiv Merchant¹, Aresh Hashemi-Nejad¹, Deborah Eastwood^1,3

¹Royal National Orthopaedic Hospital, Stanmore, United Kingdom; ²Erasmus MC / Sophia Children's Hospital, Rotterdam, Netherlands; ³Great Ormond Street Hospital for Children, London, United Kingdom

Background: Dual tension band plates are commonly used as a means of temporary epiphysiodesis for longitudinal guided growth. The study aim was to assess rate of correction, identify development of femoral and tibial intra-articular deformity during correction, and recurrence of leg length difference (LLD) after plate removal. 

Methods: We performed a retrospective cohort study of 34 consecutive patients treated with dual tension band plates between 2012 and 2020: 24 at the distal femur, 6 at the proximal tibia and 4 at both. 25 female patients were operated on at a mean age of 11.6 (+/-1.4) years and 9 male patients at 13.5 (+/- 1.5) years. 

Measurements were performed on standardised long-leg radiographs and included LLD, joint line congruency angle, tibial roof angle, femoral floor angle and notch-intercondylar distance. Measurements were taken pre-operatively, at the end of length correction and at skeletal maturity. 

Results: LLD was reduced by a mean of 12.9mm (95%CI 10.2–15.5), mean residual difference was 8.4mm (95%CI 5.4–11.4). The mean correction rate for the proximal tibia was 0.40 (SD0.33) mm/month and 0.68 (SD0.36) mm/month for the distal femur. Only at femoral level, was a significant mean decrease in LLD (2.5 mm (95%CI 0.7–4.2) observed between plate removal and skeletal maturity. After length correction, tibial roof angle showed a significant between leg difference of 8.4° (95%CI 13.4–3.4). In femoral epiphysiodesis patients, no important articular differences were observed.

Conclusion: A significant reduction in LLD can be achieved using dual tension band plating. Change in intra-articular morphology was observed only in the proximal tibia and not in the distal femur. In the authors opinion tension band plating should not be recommended as the preferred technique for leg length correction, but can be a useful tool for younger patients or when residual growth is difficult to predict. 

480 - Management of severe congenital deficiency of the femur: Has much changed in the 21st Century?

George Cross¹, Ahmed Elsheikh¹, Jonathan Wright¹, Deborah Eastwood¹, Imad Sedki², Peter Calder¹

¹Royal National Orthopaedic Hospital, Limb Reconstruction Unit, London, United Kingdom; ²Royal National Orthopaedic Hospital, Limb Rehabilitation Unit, London, United Kingdom

Background: Congenital deficiency of the femur remains uncommon, with a wide spectrum of presentation from simple hypoplasia to complete absence. In cases of severe deformity and leg length discrepancy, prosthetic use remains the preferred management strategy. The aim of this study was to assess this group’s functional outcome and evaluate the influence of surgical intervention.

Methods: A retrospective review of the limb rehabilitation database identified 118 patients with congenital limb deficiency. 76 were excluded with no femoral deficiency, 24 had femoral shortening associated with another condition, leaving 18 patients with Proximal Femoral Focal Deficiency (PFFD) as the study group. Prosthetic mobility and functional scores were recorded. Quality of life was assessed using the PedsQL questionnaire. Outcome comparison was undertaken looking at age groups and those who had/had not undergone surgical intervention.

Results: There were 9 male and 9 females, with 11 children (mean age 9yrs; range 5-16yrs) and 7 adults (mean age 41yrs; range 23-63yrs). Better prosthetic scores were recorded in the paediatric group, as well as the locomotor capability index. The children also recorded better PedsQL scores in comparison to the adult group. Eight of 11 children and two adults had undergone surgery: Super-Hip procedure (5), knee fusion/Syme disarticulation (1), hip reduction/femoral osteotomy (2, including knee disarticulation in 1) and femoral lengthening (1), with resulting better prosthetic use but no difference in functional scores when compared to the non-operated group.

Discussion: The management strategy in severe PFFD is to optimise prosthetic fitting and limb function. Hip reconstruction appears to improve prosthetic scores. Overall scores appear to decline into adulthood, but not significantly, bringing added complexity when recommending treatment in this rare condition. Limited numbers, with a short follow-up following surgical intervention, prevents clear guidance on the benefit of surgery.

588 - Femoral offset angle: Correction of congenital distributed (multi-apical) deformity of the femur utilizing a novel technique

Khalid Al-Hourani, Tom Syer, Roger Atkins

Bristol Royal Infirmary, Bristol, United Kingdom

Introduction: Multiapical deformities of the femur represent a surgical challenge. Single level osteotomy in these femurs will lead to an abnormally shaped femur that will be functionally and cosmetically unacceptable. This paper describes a novel technique in describing and treating this deformity. 

Methods: Abnormal femora that presented to out tertiary referral center and treated were analysed. These were compared to 100 standard adult healthy femora selected at random, which were imaged in our department. We hypothesized that regardless of shaft deformity, a constant proximal femoral segment existed owing to the ossification centers of the femur. Additionally, varus shaft bowing and distal valgus angulation of the femur were measured. A reference point, named the “femoral offset origin” was described, which coupled with the femoral offset angle of the femur, is critical to analysing the deformity and undertaking a novel retrograde nailing technique with multiple corticotomies in order to correct bowing of the femur in congenital deformity.  

Results: In the normal femur, a varus shaft deformity of 2.1 degrees was observed (range 0.51-5.0). This was compensated for by a distal femoral valgus deformity of 5.7 degrees (range 2.04-8.02). The mean proximal femoral straight segment measured 14.2cm (SD 4.6cm). There was a significant difference between the femoral offset angle in the normal controls (4.9+/-1.1°) and the congenital femora (6.8+/-1.3°, p<0.0001). 

Conclusion: Based on the results of this study, abnormal femoral deformity can be corrected using a novel technique utilising multiple corticotomies via a retrograde nailing technique. The femoral offset angle based on the femoral offset origin is vital in analyzing the deformity and planning correction.

694 - Osseointegration for Transtibial Amputees Confers Mobility Benefits with Limited Complications through Two Years

Muhammad Adeel Akhtar^1,2,3, Jason Hoellwarth⁴, Yao Chang Tan⁴, William Lu⁴, Kevin Tetsworth⁴, Munjed Al Muderis⁴

¹NHS Fife, Kirkcaldy, United Kingdom; ²University of Edinburgh, Edinburgh, United Kingdom; ³University of St Andrews, St Andrews, United Kingdom; ⁴Macquarie University Hospital, Sydney, Australia

Background: Transfemoral osseointegration consistently improves amputee quality of life (QOL) and mobility. However, there are only six publications describing 27 total procedures for transtibial osseointegration (TTOI). This study describes the differences in the subjective and objective outcomes, and complications following TTOI.

Methods: We prospectively studied adult patients undergoing transtibial osseointegration between April 2014 and October 2018. Demographic details, indications for surgery, complications and functional outcomes using Short Form 36 (SF-36), modified Questionnaire for Persons with a Transfemoral Amputation (QTFA) surveys, Timed Up and Go (TUG) test, Six Minute Walk Test (6MWT) and K-level were studied before osseointegration and postoperatively for at least two years.

Results: 102 procedures were performed for 91 patients. Statistically significant improvements were noted following transtibial osseointegration: prosthesis use (>13 daily hours 40% versus 86%, p<0.001), SF-36 physical component score (40.1 ± 9.5 versus 50.3 ± 11.4, p<0.001), QTFA subjective score (>“Good” 35% versus 69%, p<0.001), K-level (1.4 ± 0.9 versus 3.0 ± 0.5, p<0.001), TUG (9.9 ± 2.6 versus 8.2 ± 1.7 seconds, p<0.001), and 6MWT (339 ± 94 versus 437 ± 117 m, p<0.001). Thirteen patients (13%) required surgical debridement only, another 9 (9%) eventually required implant removal, including 2 patients (2%) who required transfemoral amputation for infection. Unplanned stump refashioning and nerve reinnervations occurred in 8 patients (8%) each. No periprosthetic bone fractures occurred. One patient died due to atherosclerosis-induced myocardial infarction after nearly three years.

Conclusions: Transtibial Osseointegration confers subjective and objective improvements for the majority of transtibial amputees experiencing difficulty using a Traditional socket prosthesis. Complications are manageable and should decrease with surgical and implant improvements.

848 - Tibial bone defects: Analysis of time to union and direct medical costs using distraction osteogenesis with an Ilizarov frame or the Masquelet technique

Ganesh Mohrir, Nikolaos Kanakaris, George Chloros, Paul Harwood, Peter Giannoudis

Leeds General Infirmary, Leeds, United Kingdom

Background: Successful management of segmental bone defects remains one of the biggest clinical challenges.

Aim of this study to define the direct medical cost of the surgical treatment of tibial bone defects using Ilizarov bone transport (ILF) vs. the internal fixation staged Masquelet (MIF) in a single tertiary referral centre for acute vs. secondary bone loss caused due to infection/non-union.

Methods: Prospectively collected data were reviewed and analysed. Random selection of patients treated with MIF or ILF was performed. Data collected included demographics, comorbidities, severity of trauma, bone defect size, inpatient and outpatient course including interventions and investigations etc, time to defect union, and time to final discharge.

A cost-effectiveness assessed using descriptive statistical analysis.

Results: Twenty patients (10 in each group treated with ILF and MIF) were included in this analysis. The mean defect size was 5.59cm, the mean time to union was 12.91 months, with an overall cost of £453,974.

The overall direct medical cost of the MIF group was 74% of that of the ILF.  There was statistically significant difference favouring the MIF group on the average time-to-union (10.03 vs 15.55 months, p=0.02), the cost per cm of defect (£1935 vs. 3799, p=0.047), and the overall cost of treatment (£18131 vs £26126, p=0.011).

The mean time to union (7.91 vs. 12.67months, p<0.001), as well as the cost of outpatient follow up (£1368 vs. £3122, p<0.001) were significantly lower in MIF group for management of acute vs non-union defects whereas no difference found in ILF group.

Conclusions: There were clear differences in the direct medical costs between the 2 most common procedures for this indication. Even with an uncomplicated clinical course, cost of the implants, considerable time to union, and follow up and secondary procedures, highlights the importance of robust reimbursement strategies, since both techniques are indispensable.

902 - A multi-centre 10-year review of elderly, osteoporotic and low energy Schatzker V and VI injuries managed with Ilizarov Circular Frame Constructs in Northern Ireland

Mark Robinson¹, Rebecca Mackey², Niall Breen², Michael McMullan¹, Christopher Andrews¹, Luke Ogonda²

¹Royal Victoria Hospital, Belfast, United Kingdom; ²Ulster Hospital Dundonald, Belfast, United Kingdom

Tibial plateau fractures fixation in the elderly poses a unique challenge due to poor bone stock, comminution and co-morbidities.  There is limited evidence available in older patients sustaining Schatzker V and VI injuries.  In our institutions these injuries have traditionally been managed with circular frame fixation, often augmented with cross knee frame extension, internal screw fixation +/- bone graft substitutes.

This study aims to retrospectively review the over 60-year-old cohort to better understand this complex injury.  

Methods: Electronic fracture databases were queried for ‘tibial plateau fracture’ and ‘Ilizarov frame’ between July 2009 and 2019.  Inclusion criteria; >60 years; CT identified Schatzker V or VI injury; Ilizarov fixation; adequate follow-up data.  

Patient demographics, fixation technique, time to frame removal, varus/valgus, tibial slope malunion, joint incongruity, significant complications and progression to salvage TKR were reported. 

Results: 35 patients >60 years were treated with Ilizarov frame techniques for Schatzker V/VI injuries. 84% were female. Average age 68 (62-81). 94% of those investigated for osteoporosis had evidence of poor bone stock. 

94% were Schatzker VI injuries.  22 cases required cross knee extension with a frame duration 155 days (range 103-317). Those without had a frame duration 128 days (range 93-212). 20 cases had a combined internal/external fixation technique and 9 cases required allograft or bone substitute.  There was one case of non-union requiring salvage to constrained TKR. Three cases (9%) of metalwork removal, one for deep infection. There were no VTE events and there was 0% mortality in the two post-operative years to date. The minimal residual deformity in the coronal plane and in the tibial slope following frame removal do not appear clinically significant.  

Conclusions: Ilizarov techniques are highly successful at achieving union with associated low morbidity rates in an older higher risk population. 

Implications: Managing complex lower limb fragility fractures.

942 - Achieving distal fixation and early mobilisation in patients with severe femoral bone loss using an internal proximal femoral replacement prosthesis

Chinyelu Menakaya, Matthieu Durand-Hill, Richard Carrington, Robin Pollock, Alister Hart, James Donaldson, Jonathan Miles, Timothy Briggs, John Skinner

Royal National Orthopaedic Hospital, Stanmore, London, United Kingdom

Background: The management of femoral bone loss is challenging during revision hip arthroplasty. In patients with Paprosky grade IIIB and IV defects, obtaining fixation and rotational stability using traditional surgical constructs is difficult. The use of custom-made “internal proximal femoral replacement” prostheses has been proposed as a solution in patients, with severe femoral bone stock loss. However, there is a paucity in the literature on their use and long-term outcomes. We report on the clinical and radiological results of our cohort.

Methods: We retrospectively reviewed all patients who underwent internal proximal femoral replacement for revision hip arthroplasty between April 1996 and April 2019. All patients had at least 2 years of follow-up time.

Results: 160 patients had undergone limb salvage at our institution using internal proximal femoral replacement. The mean follow-up was 60 months (25 to 192). Indications for revision included periprosthetic fractures, aseptic loosening, and deep infection. The mean Oxford hip score increased from 13.8 (0-22) to 31.5 (18-43) (paired t-test, p < 0.001) and the mean Harris Hip score increased from 30.4 (3 to 57.7) to 71.7 (44 to 99.7) (paired t-test, p < 0.001). Kaplan-Meier prosthesis survival analysis with revision as the endpoint was 87% at 5 years. None required revision of the femoral stem. There were four dislocations (5%) and there was failure to eradicate the deep infection in four. 

Conclusion: This technique allows instant distal fixation, allowing for early mobilisation. Long-term clinical and radiological outcomes are encouraging and the complication rates are acceptable for this patient group.

185 - Obesity does not adversely impact the outcome of unicompartmental knee arthroplasty for osteoarthritis: a meta-analysis of 80,798 subjects

Nikhil Agarwal¹, Kendrick To², Bridget Zhang³, Wasim Khan⁴

¹University of Aberdeen, Aberdeen, United Kingdom; ²Addenbrooke's Hospital, Cambridge, United Kingdom; ³University of Cambridge, Cambridge, United Kingdom; ⁴Addenbrooke's hospital, Cambridge, United Kingdom

Background: Patients with end-stage single compartment osteoarthritis benefit from the less invasive unicompartmental knee arthroplasty (UKA). With increasing financial restraints, some healthcare services have set specific BMI cut-offs when determining patient eligibility for knee arthroplasty due to perceived obesity-related complications. The aim of this systematic review is to determine the effect obesity has on outcomes following UKA, and thus elucidate whether obesity should be a contraindication for UKA. 

Methods: A PRISMA systematic review was conducted using five databases (MEDLINE, EMBASE, Cochrane, PubMed and Web of Science) to identify all clinical studies that examined the effect of obesity on outcomes following UKA. Quantitative meta-analysis was carried out using RevMan 5.3 software. Quality assessment was carried out using the Critical Appraisal Skills Programme (CASP) checklist.  

Results: Thirty studies, including a total of 80,798 patients were analysed. The mean follow- up duration was 5.42 years. Subgroup meta-analyses showed no statistically significant difference following UKA between patients cohorts with and without obesity in overall complication rates (95% CI, P = 0.52), infection rates (95% CI, P = 0.81), and revision surgeries (95% CI, P = 0.06). When further analysing complications, no differences were identified in minor (95% CI, P = 0.23) and major complications (95% CI, P = 0.68), or venous thromboembolism rates (95% CI, P = 0.06). When further analysing revision surgeries, no differences were identified for revisions specifically for infection (95% CI, P = 0.71) or aseptic loosening (95% CI, P = 0.75). 

Conclusion: This meta-analysis shows that obesity does not result in poorer post-operative outcomes following UKA and should not be considered a contraindication for UKA. Future studies, including long-term follow-up RCTs and registry-level analyses, should examine factors associated with obesity and consider stratifying obesity to better delineate any potential differences in outcomes. 

257 - An analysis of national variance in coding for patellofemoral instability

Jatin Mistry¹, Morgan Bailey², Caroline Hing³, Andy Metcalfe⁴

¹St George's University of London, London, United Kingdom; ²Hampshire Hospitals Foundation Trust, Hampshire and West Berkshire, United Kingdom; ³Institute of Medical and Biomedical Education, St George’s University of London, London, United Kingdom; ⁴University Hospital Coventry and Warwick, Coventry, United Kingdom

Background: Patellofemoral instability (PFI) is a common presentation to emergency departments, trauma clinics and elective knee clinics with an incidence rate between 5.8 – 23.2 per 100,000. However, there is limited robust evidence on the management of acute or chronic dislocation. Accurate coding of patellofemoral dislocation and its management in the UK is therefore important to allow data analysis of PFI patients in trust databases and ensure correct remuneration of procedures. 

Methods: All acute NHS Trusts in England were sent freedom of information (FOI) requests regarding their use of International Statistical Classification of Diseases and Related Health Problems version 10 (ICD-10) codes for the diagnoses related to PFI, and Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures 4th revision (OPCS-4) codes for surgical management of PFI. 

Results: 106 of 132 (80%) relevant trusts responded with information. Coding for diagnosis of patellar dislocation and recurrent dislocation were largely consistent with 96% of the trusts using the same code. However, coding of patellar instability varied widely with 10 different codes being used, the most common of which was being used by only 34% of trusts. Coding for operative management exhibited greater variety with the number of different codes being used by trusts for each of the eight surgical treatments ranging from 11 to 19 and the range for the most common code being used by trusts ranging from 34% to 64%. Furthermore, a large number of trusts used multiple different codes for the same diagnose or treatment of patellofemoral instability. 

Conclusions: There is a lack of uniformity in how trusts code PFI diagnosis and treatment and standardisation will enable further research involving focused analysis of trust databases to facilitate a better understanding of the epidemiology of this condition. 

280 - Diabesity is associated with a worse functional outcome and a higher risk of superficial and deep wound infection after total primary hip replacement

Jack Lovie¹, Nicholas D Clement², Deborah Macdonald², Issaq Ahmed²

¹Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom; ²Department of Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background: Although the independent effects of diabetes mellitus and obesity on total hip replacement (THR) outcomes have been widely studied, their combined effect remains uncharacterised. This study aimed to assess the influence of diabesity on post-operative primary THR outcomes.

Methods: A retrospective study was performed comparing the outcomes of patients with diabesity (diabetes mellitus and obesity [BMI ≥30]) with a control cohort after primary THR using an established arthroplasty database. Data were collected pre-operatively and 12 months post-operatively, including Oxford Hip Score (OHS), EuroQol 5-dimensions (EQ5D), post-operative satisfaction and complication rates.

Results: 2323 THRs were analysed, of which 94 (4%) had diabesity. Diabesity was associated with significantly worse OHS improvement post-operatively (-1.85 points, 95% CI -2.93 to -0.76, p=0.001). This reduction in addition to the independent effect of obesity (-0.69 points, 95% CI -1.18 to -0.21, p=0.005) resulted in an overall 2.54 point OHS reduction for patients with diabesity. Diabesity was not associated with EQ5D score change or post-operative satisfaction. Diabesity was associated with a worse pre-operative EQ5D score (-0.08 points, 95% CI -0.12 to -0.03, p=0.002). When combining the associated risk of obesity (Odds Ratio (OR) 1.71, 95% CI 1.15 to 2.54, p=0.008) with the superadded effect of diabesity (OR 2.37, 95% CI 1.19 to 4.71, p=0.014) the rate of superficial wound infection post-operatively was significantly increased (OR 4.05, 95% CI 1.38 to 11.95). Obesity was associated with significantly increased risk of deep infection (OR 3.67, p=0.008), but no additive effect of diabetes was found.

Conclusion: Diabesity was associated with worse improvement in hip-specific functional outcome, worse post-operative quality of life, and an increased risk of superficial and deep wound infection following THR.  

Implications: Understanding the interaction between diabetes mellitus and obesity facilitates better counselling of patients regarding post-operative expectations and increased risk of post-operative superficial and deep infection.

305 - Intraoperative communication is associated with lower anxiety levels in fathers of pediatric patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis

Kevin Bondar¹, Jeff Kessler²

¹Miami, Florida, USA; ²Kaiser Permanente, Los Angeles, USA

Background:  The purpose of the present study is to assess parental anxiety before and during posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), and to determine whether communication with parents during PSIF decreases parental anxiety.

Methods: A randomized prospective study was done over a 2-year period on 50 consecutive patients with AIS undergoing PSIF. The state portion of the State-Trait Anxiety Inventory was administered to the parents of these patients immediately preoperatively, and at the end of surgery. Parents were randomized to either have no communication during surgery, or to have communication via a standardized phone script at the time of the incision and every 90 minutes thereafter. 25 patients were in each group. Anxiety scores were compared between the 2 groups. 

Results:  There were no statistical differences between the 2 groups in patient age, surgery time, and number of levels fused. There were no differences in preop anxiety score between the communication and non-communication group. Fathers had a statistically significant higher anxiety score intraoperatively in the non-communication group versus the communication group (43.0 vs 32.7, p=.02). Significantly higher preoperative scores versus intraoperative scores for both mothers (p=0.0275) and fathers (p=0.0098) for the combined NC and C groups.  There was no significant association between length of surgery and parental intraoperative anxiety scores. 

Conclusions:  Multilevel PSIF for AIS is associated with pre-operative and intra-operative parental anxiety.  Communication from the OR nursing staff can reduce this anxiety, particularly in fathers of these pediatric patients. 

432 - Crash course in orthopaedics: Lessons from a 12-week webinar series for medical students

Catherine James¹, Edwin Jesudason²

¹Cardiff University Medical School, Cardiff, Wales, United Kingdom; ²Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, Wales, United Kingdom

Background: As a result of the COVID-19 pandemic, many medical students have had their orthopaedic placements disrupted or cancelled. Using the British Orthopaedic Association (BOA) Undergraduate Syllabus, a 12-week online teaching programme was designed to supplement and enhance orthopaedic teaching for medical students across the UK.

Methods: The “CRASH COURSE IN ORTHOPAEDICS” consisted of 12 webinars, with each lasting 45 minutes. Topics ranged from ‘The Limping Child’ to Orthopaedic Emergencies. The teaching was delivered using the online platform Zoom. Feedback questionnaires were created using Google forms. Attendees were invited to complete the feedback questionnaire. Qualitative data was assessed using thematic analysis (Braun & Clarke).

Results: The webinar series was attended by approximately 3800 participants, with the largest demographic group being clinical medical students (51%). The majority of attendees (82%) discovered the webinar series through social media, in particularly Facebook.

Broad themes from the feedback questionnaire included:

1) Interactivity: question + answer (Q+A), polls, single best answer questions (SBA’s)

2) Content: case examples, orthopaedic examinations, OSCE tips  

3) Accessibility: slides, recordings, duration of the session, time of session

A guide on “How to Run a Successful Webinar Series” was also created based on student feedback and the organiser’s experiences.

Conclusion: Online webinars can effectively improve orthopaedic knowledge for medical students’ whose orthopaedic teaching may have been disrupted due to the COVID-19 Pandemic. From feedback, students particularly enjoyed interactivity through the use of polls and the chat function on Zoom, and learning by case examples, with a focus on content relevant to Objective Structured Clinical Examinations (OSCEs). The guide on “How to Run a Successful Webinar Series” will be useful to anyone who is hoping to host future webinars.

461 - Epidemiology and long-term outcomes of lateral end clavicle fractures in an adolescent population

Rory Teed¹, Jamie Nicholson^1,2, Nathan Ng³

¹The University of Edinburgh, Edinburgh, United Kingdom; ²The Royal College of Surgeons of Edinburgh, Edinburgh, United Kingdom; ³NHS Lothian, Edinburgh, United Kingdom

Background: Displaced lateral-end clavicle fractures in adolescents are uncommon injuries. It is unclear if this injury has a risk of nonunion comparable to that in the adult population. 

The primary aim of this study was to determine the epidemiology of lateral-end clavicle fractures in the adolescent population. The secondary aim was to assess outcome following non-operative management. 

Methods: A retrospective review of all adolescent clavicle fractures (aged 13-17) that presented to our region over a 10-year period was undertaken. Fracture classification, patient demographics, management and complications were analysed. Long-term outcomes of non-operatively managed displaced Neer type IIA and IIB fractures were obtained using the QuickDASH and EQ-5D. 

Results: 677 clavicle fractures occurred over the study period but only 8.7% were lateral-end fractures (n=59/677). The median age was 14.6 (range 13-17) and 92% were male (n=54/59). The most common fractures were undisplaced (Neer 1 n=28), physeal (Neer type IV n=14) and intra-articular minimally displaced (V n=2). Fifteen fractures were completely displaced with no cortical contact (Neer IIA n=8 and IIB n=7).  

The incidence of displaced lateral-end fractures in adolescents was approximately 0.17 per 100,000 population per year. Approximately one third of the displaced fractures underwent acute fixation and united without complications (n=5/15). Of the non-operatively managed displaced fractures (n=10/15) there was one case of nonunion in a malnourished patient with systemic co-morbidities (10%). Mean age (15.3 vs 14.7, p=0.21) and overall fracture displacement (16.7mm vs 14.8mm, p=0.34) was comparable between operative and non-operative groups.

Long-term follow-up was undertaken at 8.7 years post-injury in the non-operative displaced fractures that united (n=5/9). The mean QuickDASH was 3.2 and EQ-5D was 1.0. 

Conclusion: Displaced lateral-end clavicle fractures are rare injuries in the adolescent population. Nonunion is rare and would appear to be less than the adult variant of these injuries.

538 - Use of Pre-Operative EuroQol Five-Dimension (EQ-5D) to Prioritise Patients for Elective Hip and Knee Arthroplasty in the Aftermath of the COVID-19 Pandemic

James Redmore^1,2, Partha Talukdar², George P Ashcroft^1,2, Luke Farrow^1,2

¹University of Aberdeen, Aberdeen, United Kingdom; ²NHS Grampian, Aberdeen, United Kingdom

Background: The COVID-19 pandemic has led to unprecedented delays for those awaiting elective hip and knee arthroplasty, with significant associated detriment to patient health. One potential approach to addressing this backlog is via adoption of surgical prioritisation methods, such as use of pre-operative health related quality of life (HRQOL) assessment. We set out to determine whether dichotomization using a previously identified bimodal EuroQol Five-Dimension (EQ-5D) distribution could be used to triage arthroplasty waiting lists. 

Methods: Data regarding demographics, perioperative variables and patient reported outcome measures (pre-operative & 1-year post-operative EQ-5D-3L and Oxford Hip and Knee Scores (OHS/OKS) were retrospectively extracted from electronic patient health records at a large university teaching hospital. Patients were split into two equal groups based on pre-operative EQ-5D Time Trade-Off (TTO) scores and compared (Group1 [worse HRQOL] = -0.239 to 0.487; Group2 [better HRQOL] = 0.516 to 1 (best)). The EQ5D TTO is a widely used and validated HRQOL measure that generates single values for different combinations of health-states based upon how individuals compare x years of healthy living to x years of illness.

Results: This study included 513 patients. Those in Group1 had significantly greater improvement in post-operative EQ-5D TTO valuation scores compared to Group2 (Median 0.67vs.0.19; p<0.0001 respectively), plus greater improvement in OHS/OKS (Mean 22.4vs16.4; p<0.0001 respectively). Patients in Group2 were significantly less likely to achieve EQ-5D MCID attainment (OR 0.13, 95%CI 0.07-0.23; p<0.0001) with a trend towards lower OHS/OKS MCID attainment (OR 0.66, 95%CI 0.37-1.19; p=0.168). There was no clinically significant difference in length of stay (Median 3-days both groups), and no statistically significant difference in adverse events (30 day&1year readmission/reoperation). 

Conclusions: A pre-operative EQ-5D cut-off of ≤0.487 for hip and knee arthroplasty prioritisation may help to maximise clinical utility and cost-effectiveness in a limited resource setting post COVID-19. 

638 - Outcome comparison of Superior Capsule Reconstruction and Subacromial Balloon Spacers for the treatment of massive rotator cuff tears: A systematic review

Ciarán O'Hanlon¹, Karam Al-Tawil², Sobha Singh¹, Joydeep Sinha²

¹GKT School of Medical Education, King's College London, London, United Kingdom; ²Department of Orthopaedic Surgery, King's College Hospital NHS Trust, London, United Kingdom

Background: Superior Capsule Reconstruction (SCR) and Subacromial Balloon Spacers (SBS) are novel treatments with similar biomechanical principles used in patients with massive rotator cuff tears (MRCT). Medium term outcomes and indications for use in both SCR and SBS remain uncertain. This review aimed to summarise the evidence available for both interventions in the context of MRCT and narrowly characterise patient populations who may benefit from each procedure. 

Methods: A systematic review was performed by searching Embase, Medline, PubMed and the Cochrane Library on 28 June 2020. Inclusion and exclusion criteria were applied to retrieve all records investigating SCR and SBS use in patients with MRCT. MINORS criteria were used to assess risk of bias. 

Results: 26 Studies were included in this review. There were 442 shoulders in 13 SCR studies and 300 shoulders in 13 SBS studies. Mean follow up was 31.35 and 30.58 months respectively. Mean participant age was 62.90 in SCR and 65.87 in SBS. Both patient groups had medium to high grade fatty infiltration and minimal degenerative changes. Greater mean difference in ASES score at final follow was observed in SCR: 44.19 (10/13, n= 321) vs 36.46 (5/13, n=86) in SBS. Mean difference in Constant Murley score (CMS) of 30.02 observed in SBS (10/13, n=306). SBS had lower complication rates (3.5% vs 6.42%) and revision rates (4.21% vs 7.54%). Greater improvement in pain, strength and return to activity was observed following SCR. Both interventions significantly improved ROM and had high rates of patient satisfaction. 

Conclusion: SCR demonstrates superior outcomes in younger, high demand populations. SBS can restore functionality in low demand patients or those not suitable for invasive surgery. Both interventions demonstrate outcomes comparable with established treatments at 5 years. Well-designed RCTs are required to improve an evidence base consisting of only non-randomised studies. 

648 - The Incidence of Major Complications Following Per-Acetabular Osteotomy (PAO)

Benjamin Rouse¹, Sanjeev Madan², Nitish Gogi², Reza Saatchi³, Grace Scaplehorn¹

¹The University of Sheffield, Sheffield, United Kingdom; ²Sheffield Children's Hospital, Sheffield, United Kingdom; ³Sheffield Hallam University, Sheffield, United Kingdom

A retrospective single surgeon cohort of 243 PAOs were performed on 220 patients between 2006 and 2020 across 2 hospital sites in England. There was a female predominance of 74.4% within the cohort, 56.6% of PAOs were performed on the right side, and the mean age at the time of surgery was 26.4±1.5 years (9-55 years). The most common primary diagnosis was developmental dysplasia of the hip (DDH) which represented 68.6% of all patients within the cohort, followed by Perthe’s disease (9.5%). Complications were recorded over the follow-up period and categorised using the modified Clavien-Dindo criteria, and further subdivided into major and minor complications. Those with a grade of III, IV or V were considered major complications. 19 major complications were reported, affecting 18 patients (7.4%) involved, and there were no grade V complications reported within this study. The most common major complication was acetabular migration, occurring in 2.1% of all patients. Other major complications included posterior column non-union requiring fixation (1.6%), penetration of screws into the joint space (0.8%), iliopsoas pain requiring exploration (0.8%) and deep infection requiring washout (0.8%). Also present were major nerve injury, recurrent subluxation and acetabular lateral rim fracture each evident in 1 patient (0.4%). Minor complications classified as grades I or II were also recorded, including superior pubic ramus non-union (9.1%), inferior pubic ramus stress fractures (6.6%) and infection not requiring washout (2.9%). The results of this study are consistent with that seen in the available literature, comparable to the 9% rate of major complications described by Wells et al (2018) and 7% reported by Clohisy et al (1999). This demonstrates a low rate of major complications following PAO, confirming that it is a safe procedure for the treatment of acetabular dysplasia within a select cohort of patients.

864 - Evaluation of Low-Intensity Pulsed Ultrasound usage and outcomes in bone healing- a retrospective audit

Rosalind Walsh

Swansea Medical School, Swansea, United Kingdom. Swansea Bay University Health Board, Swansea, United Kingdom

Background: Low-Intensity Pulsed Ultrasound (LIPUS) is used to promote healing in non-union and delayed union fractures, its mechanism is attributed to a local increase in cytokines and growth factors, stimulated by micromechanical stress. 

Currently, two sets of NICE guidance apply to LIPUS which overlap and complicate prescribing. IPG623 applies to LIPUS generally, whilst MTG12 is EXOGEN® specific (the LIPUS device used in this patient group).

Aims: To establish whether LIPUS is being prescribed in accordance with NICE guidance and to evaluate outcomes following LIPUS therapy.

Methods: A retrospective audit of cases prescribed LIPUS from 2013-2018 was performed. Each case and their outcomes were assessed against the standards below and whether they met predetermined definitions for non-union and delayed union.

NICE Standards

IPG623- LIPUS must only be used as part of clinical audit/research to promote healing of non-union and delayed-union fractures.

MTG12- supports use of EXOGEN® in management of long bone fractures with non-union but not delayed union.

Results: 99 patients were treated with LIPUS therapy. Use was in accordance with guidance in 42% of cases, 21% of cases lacked sufficient documentation to assess. 33% of fractures went on to unite, 48% of which met the definition for delayed union with only 9% defined as non-union. 43% of fractures did not go on to unite- 88% of which required surgery.

Conclusion: The majority of LIPUS use was either not in accordance with guidance or lacked documentation for assessment. Progression to union rates were low in the non-union group and though better in delayed unions, 38% of cases treated with LIPUS required further surgery. In light of this and the cost of LIPUS, it is recommended that its use should be an MDT decision. The findings also emphasise the importance of a general consensus on the definitions non-union and delayed union.

874 - Manipulation of severely displaced distal tibial Salter Harris type 2 fractures in paediatric population using intranasal morphine and Entonox in ED

Ravinder Kaur, Jaimin Bhanderi, Ben A. Marson, Dominik Lawniczak

University of Nottingham, Nottingham, United Kingdom

Purpose: Distal tibial Salter Harris type 2 (SH2) fractures are uncommon childhood injuries that have previously been associated with high rates of growth arrest. Management of displaced fractures requires reduction, either following a general anaesthetic, sedation, or analgesia. Reduction following analgesia (nitrous oxide and diamorphine) has been shown to be effective for upper limb injuries, reducing the hospitalisation duration compared to surgical procedures under general anaesthetic. 

This investigation sought to evaluate patient satisfaction and assess the patient experience following reduction with analgesia to evaluate the acceptability of this procedure in the Emergency Department.

Methods: 12 paediatric patients who underwent closed manipulation of SH2 distal tibial fractures were identified from a prospective database. Children were treated with intranasal diamorphine (0.1mg kg^-1) and 50% oxygen and nitrous oxide (Entonox) according to an established pathway in the Emergence Department at a UK trauma centre.

A patient satisfaction questionnaire to evaluate procedural experience and acceptance was developed and telephone follow-up was conducted. Pre- and post-manipulation and the final radiographs were also reviewed.

Results: Of the 12-patient cohort, there was significant improvement in AP angulation after manipulation from 17.8° to 3.8° (Wilcoxon signed-rank p<0.001). Fracture position was maintained.  

There were no negative reported experiences at the time of manipulation. There was only 1 reported case of ongoing moderate discomfort >6 months post-manipulation. All the subjects stated they would be willing to undergo the same management again with none reporting any suggestions for changes regarding the procedure. The mean level of satisfaction with pain management was 9.5±1.2 and overall satisfaction with the experience was 9.8±0.6 (0-10, 10 fully satisfied).

Conclusions: Closed reduction in ED is safe and effective management strategy, eradicating the necessity for overnight admission and treatment in theatre. The high satisfaction rate recommends the procedure facilitates same-day discharge and highly benefits patient’s experience.

925 - Intra-articular steroid injections and COVID19: Balancing the risks and rewards

Kira Faircloth¹, William Garland¹, Jonathan Coorsh², An Murty², David Townshend², Rajesh Kakwani²

¹Newcastle University, Newcastle, United Kingdom; ²Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom

Background: During the SARS-CoV-2 pandemic intra-articular steroid injections, commonly used in musculoskeletal pain management, were withheld. This was due to the concern of an immunosuppressive response following the procedure, subsequently increasing the risk of COVID19 infection. Most guidance given over this time only states to weigh risk and benefit when considering the procedures. We intend to assess the risks involved in our present cohort of patients.

Method: Prospective data was collected for 167 patients who underwent fluoroscopy guided foot and ankle steroid injections in the operating theatres at our unit between Aug 2020 and Apr 2021. 57.5% of the cohort were female and 42.5% were male with an age range of 19 to 90 years. The safety protocol involved pre-screening of each patient with a negative COVID19 swab within 3 days of attending theatres alongside self-isolating for these 3 days prior to the procedure. Most patients underwent a telephone consultation between 2 to 3 weeks post injection, where patients were asked if they had experienced common COVID19 symptoms or had a positive test during this period.

Results: Of our patients, only 2 had experienced common symptoms of COVID19, both of which proceeded to have negative swabs. No patients in the study tested positive within the review period in which the expected immunosuppressive risk would be highest.

Conclusion: In conclusion, from our study it can be inferred that if pre-assessment screening protocol is followed, there is no increased risk of COVID19 infection with intra-articular steroid injections performed in theatres. As long as a shared decision-making process is followed when enlisting these patients for the injections, we can avoid delay in their care whilst ensuring their safety from this deadly pandemic.

Implications: We believe that during outbreaks of COVID19, we can safely continue intra-articular steroid injections with diligent pre-operative testing and self-isolation.

929 - Outcomes and complication rates of joint arthroplasty in Ehlers-Danlos Syndrome patients: The first systematic review to date

Catrin Sohrabi¹, Salah Hammouche²

¹Barts and The London School of Medicine and Dentistry, London, United Kingdom; ²Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Background: Ehlers-Danlos Syndrome (EDS) is an inherited group of connective tissue disorders that cause defects in collagen synthesis or processing. This leads to appendicular skeleton joint hypermobility and ligamentous laxity, which may affect patient outcomes following joint arthroplasty. This is the first systematic review to evaluate outcomes and complication rates of joint arthroplasty (hips, knees, shoulder, elbow, ankle, digits) in EDS patients.

Methods: In line with PRISMA guidelines and Cochrane PICO ontology, PubMed, Medline, EMBASE, and Web of Science databases were searched. A total of 85 articles were evaluated and 15 duplicates were removed. Full-text evaluation of the remaining 70 articles identified six eligible studies.

Results: Data from a total of 42 patients was analysed. Two studies assessed post-hip arthroplasty (one cohort study and one case report), and four assessed post-total knee arthroplasty outcomes (two cohort studies and two case reports). There were no studies reporting outcomes after shoulder, elbow, ankle, digit, or any other joint arthroplasty. Subjective (satisfaction, joint stability, pain levels) and objective (Harris Hip Score, Knee Society Score) patient outcomes were significantly improved following total hip arthroplasty (THA) and total knee arthroplasty (TKA) compared with pre-operative status. Following hip and knee arthroplasty, the incidence of postoperative complication rates was similar between EDS and non-EDS matched controls. The dislocation rate was 6.9% vs. 6.9%, the reoperation rate was 10.3% vs. 24.1%, and the revision rate was 3.4% vs. 13.8%, respectively, at >3-year follow-up.

Conclusions: Outcomes after hip or knee arthroplasty in EDS patients may be similar to the general population. However, current literature on joint arthroplasty in EDS patients is very scarce (none on shoulder, elbow, ankle, or digit arthroplasty). Assessment of large-scale regional and national joint registries are required to accurately assess long-term outcomes and complication rates in this unique patient population.

989 - Determining key factors and predictors of 30-day mortality in pelvic ring fracture patients

Guandayi Qiao, Douglas Evans, Angus Lewis, Chris Jordan, Jasvinder Daurka

Imperial College Healthcare NHS Trust, London, United Kingdom

Background: Pelvic ring fractures are relatively uncommon injuries, however, due to the fact that they are greatly associated with polytraumatised patients, pelvic ring fractures are associated with a high mortality rate. The aim is to identify key factors which may affect 30-day mortality in pelvic ring fracture patients.

Methods: 1000 patients with pelvic ring fractures were chosen within the Trauma Audit and Research Network database for St Mary’s Hospital, London, between 2012 and 2020. Patients with acetabular-only fractures were excluded. The primary outcome was 30-day mortality, variables included the Glasgow Coma Score (GCS), gender and age, as well as any additional injuries. A multiple logistic regression was conducted, with backwards elimination to establish significant variables and demography of patients who did not survive.

Results: 5.2% of patients died within 30-days. Increasing age (p<0.001), Glasgow Coma Score ≤8 (p<0.001), the presence of a chest injury (p<0.01) and an AO foundation/Orthopaedic Trauma Association Tile classification Type-C (p<0.001) are found to be significant contributors to 30-day mortality. 

Conclusion/Findings: Increasing age, Glasgow Coma Score ≤8, presence of a chest injury and Type-C fractures are all significant predictors of 30-day mortality in pelvic ring fracture patients.

Implications: Further research is needed to validate the results and create a new scoring system which may be used to help guide clinical decisions.

1008 - Evaluating student perspectives on current orthopaedic teaching in undergraduate medicine

Chirag Rao¹, Ciarán O'Hanlon²

¹University College London Medical School, London, United Kingdom; ²GKT School of Medical Education, King's College London, London, United Kingdom

Background: Trauma and Orthopaedics (T&O) is an underrepresented speciality in the UK undergraduate medical curriculum (1). This study aimed to evaluate the standard of T&O education in a cohort of UK undergraduates. 

Methods: A modified version of a previously validated survey instrument (1) was sent to students who registered to attend a T&O finals revision event. The 28 item instrument collected demographics, quantified T&O teaching and assessments and explored student attitudes to education delivery. A subgroup analysis of final year students was also performed. 

Results: 507/918 participants responded to the survey, giving a 55.32% response rate. Subgroup analysis found 24.9% (43/173) of final year medical students had not undergone a specific T&O placement. 48.8% (21/43) of these disagreed that they could safely perform their first postgraduate T&O job compared to 21% in those who had. The majority of final years had not received a T&O specific OSCE (52%) or written assessment (53.8%). Self-reporting of T&O exposure demonstrates a lack of standardisation in teaching. When asked whether they preferred virtual or face-to-face (F2F) modalities, 90% would prefer to attend F2F clinics and 62% preferred F2F small-group tutorials. 70% of students preferred to attend lectures virtually and the independent use of external virtual resources has increased in 80.1% of participants since the COVID-19 pandemic began. 

Conclusion: Large proportions of students feel underprepared following current undergraduate T&O education with evident non-uniformity in teaching. 

1. Malik-Tabassum et al., 2020.

1013 - The effect of the use of navigated and manual technology in total knee replacements on patient reported outcome measurements

Charlotte Jones¹, Amr Mohsen^1,2

¹Hull York Medical School, Hull, United Kingdom; ²Hull University Teaching Hospitals Trust, Hull, United Kingdom

Background: Total Knee Replacements (TKRs) are one of the most common surgical procedures carried out in the UK. Age and obesity, current challenges faced by society, are risk factors for osteoarthritis (OA). OA is the most common indication for TKRs. Therefore, as obesity levels rise and society continues to age, the importance of successful TKRs becomes clear. The field has seen recent advancements with regards to the use of navigated technology in TKRs. Current literature falls short in establishing whether navigated technology is beneficial with regards to patient outcomes. This study aims to address this shortfall. 

Methods:  PROMs data was anonymised for six surgeons currently performing TKRs in the Hull region. Three of these surgeons used navigated technology, the other three performed the procedure manually. IBM SPSS Statistics 26 (SPSS Inc, Chicago, Illinois) was used to perform an independent t-test to determine if there were any significant differences between the average health gain in PROMS data of the navigated and manual group. 

Results: The total number of TKRs performed using the manual technology was 694, whilst 680 were performed using navigated technology. There were no statistically significant differences in health gain scores reported by patients between those that had a navigated TKR and those that had a manual TKR. This was true for all three scoring questionnaires: the Oxford Knee Score (average manual health gain (MHG) = 15.60, average navigated health gain (NHG) 16.23, p=0.41, -2.56 to 1.29), the EQ-5D Score (MHG = 0.31, NHG=0.32, p=0.46, -0.46 to -0.03) and the EQ-VAS Score (MHG = 4.82, NHG = 5.50, p=0.59, -2.3 to 0.97). 

Conclusion: The results of this study support the null hypothesis, suggesting that the use of navigated technology does not improve PROMs data compared to the use of manual technology.

1049 - Delayed ACJ Reconstruction does not increase the risk of fixation failure or major complications

Hattie Pleasant¹, CM Robinson², JA Nicholson²

¹University of Edinburgh, Edinburgh, United Kingdom; ²Department of Trauma and Orthopaedics, Royal Infirmary Edinburgh, Edinburgh, United Kingdom

Background: Management of displaced ACJ injuries remains contentious; evidence suggests routine acute operative reconstruction does not improve long-term functional outcome. It is unclear if delayed reconstruction has increased complications and requirements for revision surgery. 

The primary aim of this study was comparing complications of early versus delayed reconstruction and secondly to compare modes of failure of ACJ reconstruction requiring revision surgery. 

Methods: A retrospective comparative study of tertiary unit patients who had undergone operative reconstruction of ACJ injuries over a 10-year period was performed. Reconstructions were classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method and post-operative complications were noted, with one-year follow-up a minimum requirement for inclusion. Fixation failure was defined as loss of reduction requiring revision surgery.

Results: 104 patients were analysed (n=60 early reconstruction and n=44 delayed reconstruction). Mean age was 42.0 (SD 11.2, 17-70 years), 84.6% male and 16/104 were smokers. Most injuries were Rockwood Grade III/IV (n=86/104), the remainder were Grade V (n=18/104). There was no difference in acute versus delayed reconstruction concerning grading (p=0.17).

The delayed group were older (p<0.001), with more smokers (p=0.02) and a higher ASA (p=0.04). No difference was observed between fixation failure (p=0.39) or deep infection (p=0.13). 

Deep infection occurred in three patients requiring surgical debridement. Overall, eleven patients underwent revision surgery for loss of reduction and implant failure (n=6 suture fatigue, n=3 endo-button escape and n=2 coracoid stress fracture). No patient demographic factor nor timing of surgery was predictive of fixation failure on regression modelling.

Conclusion: Delayed ACJ reconstruction does not have a higher incidence of fixation failure or major complications. Given sparse evidence justifying acute ACJ fixation and the difficulty in predicting late instability, results suggest delayed intervention in symptomatic patients following a trial of non-operative management is a safe approach.

1110 - 98% union rate in long-bone fracture non-unions treated in the absence of supplementary biological therapies: a retrospective cohort study

Connor Togher¹, Faiz Shivji², Alex Trompeter³

¹St. George's, University of London, London, United Kingdom; ²Nottingham University Hospitals Trust, Nottingham, United Kingdom; ³St George's University Hospitals NHS Foundation Trust and St. George's, University of London, London, United Kingdom

Non-union is often agonising for patients, complex for surgeons and a costly burden to our healthcare service; as such, its management must be well defined. There is debate as to the requirements for the successful treatment of such patients, particularly the need for additional biological therapies to ensure union. This study's primary aim was to determine if operative treatment alone was an effective treatment for the non-union of long bones in the upper and lower limbs.

A single-centre retrospective cohort study using prospectively collected data was performed. Inclusion was defined as patients 16 years or older with a radiologically confirmed non-union of the upper or lower limb long bones managed with surgical treatment alone between 2014-2019, with at least a 12 month follow up. Patients with bone defects or whose non-unions were treated with biological therapies were excluded from this study. The primary outcome was union rate and time to union assessed via the RUST score.

82 patients were included and received 94 intervention between them. Overall, 97.56% of the 82 patients achieved union in 6.43 months since the first intervention. The mean RUST score increased from 6.09 at diagnosis to a final RUST score of 11.36 (p < 0.0001). Of the 94 interventions, 85.11% went on to union.  Surgical factors showed that percutaneous exchange of an implant for an alternative type was most successful with a union rate of 100.00% and a mean time to union of 7.35 months from first intervention or 5.22 months from the final intervention. Augmentation surgery was associated with the shortest time to union of 3.51 months from final intervention and open exchange for an alternative implant type was shortest from first intervention, with 5.42 months. 

The continued use of biological therapies as a first-line treatment should be questioned. 

1188 - A robust treatment algorithm for pilon fractures: Our management and outcomes

Victor Lu¹, James Zhang¹, Matija Krkovic²

¹University of Cambridge, School of Clinical Medicine, Cambridge, United Kingdom; ²Department of Trauma and Orthopaedics, Cambridge University Hospitals, Cambridge, United Kingdom

Background: Current literature on pilon fracture includes a range of different management strategies, however there is no universal treatment algorithm.

Aim: Determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm applied consistently over the span of this study.

Methods: 135 patients over a 6-year period were included. Primary outcome was AOFAS score at 6, 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB), full weight-bear (FWB), bone union time, follow-up time. AO/OTA classification was used (43A: n=23, 43B: n=30, 43C: n=82).

Treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis (MIO) was performed in combination with FWF to improve joint congruency.

Results: Mean AOFAS score 6, and 12 months post-treatment for open and closed fracture patients were 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of 141 fractures healed without further intervention (84.4%). Average time to union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). On average, open and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively.

Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042;OR=2.558,95% CI 1.016-6.441), bone defect (p=0.001;OR=5.973,95% CI 1.986-17.967), and superficial infection (p<0.001;OR=4.167,95% CI 1.978-8.781).

Conclusion: FWF with MIO, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery.

928 - Is Primary ACL Repair a Credible Alternative to ACL Reconstruction in the Treatment of ACL Injuries?

Harry Ashton^1,2, Phillip Walmsley¹

¹University of St Andrews, St Andrews, United Kingdom; ²University of Edinburgh, Edinburgh, United Kingdom

Background: Anterior cruciate ligament (ACL) injuries have significant effects on knee function and increase the risk of longer-term complications due to poor healing characteristics. Historically, ACL injuries were treated by open suture repair. Due to high failure rates and poor mid-term outcomes, open repair was replaced by autologous ACL reconstruction (ACLR). With advances in surgical techniques, there has been renewed interest in primary repair due to its potential to avoid the drawbacks of ACLR, such as weakness and loss of joint proprioception. This review compared the published outcomes of current primary repair techniques with those of ACLR to determine if repair is an acceptable alternative treatment for ACL injuries.

Methods: A literature search was performed on OVID Medline. Using PRISMA guidelines, 11 papers were identified which matched the search criteria. Exclusion criteria specified against non-clinical research, multi-ligament injuries, paediatric cases, traditional open repair, and papers published before 01/01/2002. The papers were assessed for risk of bias and quality. The results of the 11 articles (n=765 cases) were divided into tables displaying demographics, study characteristics, and results. The outcomes assessed whether ACL repair and ACLR are comparable in terms of functional tests and physical examinations; patient outcomes; and failure and complication rates.

Results: Concerning functional testing, primary repair showed a slightly improved range of motion but increased joint instability when compared to ACLR. There was no significant disparity found in physical examination grading. Patient outcomes were assessed using subjective questionnaires; primary repair decreased daily joint awareness overall. There were no significant differences between the two regarding failure or complication rates in the mid-term.

Conclusion: The current evidence suggests that primary repair is comparable to ACL reconstruction in the three outcomes assessed. However, this review highlights the need for larger, longer-term studies to further compare these treatment methods.

46 - Leg length difference in Legg-Calvé-Perthes disease; changes in femoral morphology and the role of contralateral epiphysiodesis

Jaap Tolk^1,2, Deborah Eastwood^1,3, Aresh Hashemi-Nejad¹

¹Royal National Orthopaedic Hospital, Stanmore, United Kingdom; ²Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; ³Great Ormond Street Hospital for Children, London, United Kingdom

Background: Legg-Calvé-Perthes disease (LCPD) often results in femoral head deformity and leg length discrepancy (LLD). Objective of this study was to analyse femoral morphology in LCPD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalisation on proximal and subtrochanteric femoral lengths. 

Methods: All patients treated for LCPD in our institution between January 2013 and June 2020 were retrospectively reviewed. Patients with unilateral LCPD, LLD of ≥5mm and long leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD) and subtrochanteric femoral length were compared between LCPD side and unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis. 

Results: 79 patients were included, 21/79 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort the average LLD was 1.8cm (95% CI 1.5 – 2.0), average ATD difference was 1.8cm (95% CI -2.1 – -1.9) and average subtrochanteric difference was -0.2cm (95% CI -0.4 – 0.1). In the epiphysiodesis group the average LLD before epiphysiodesis was 2.7 (1.3 – 3.4) cm and 1.3 (-0.5 – 3.8) cm at skeletal maturity.  In the non-epiphysiodesis group the average LLD was 2.0 (0.5 – 5.1), p=0.016. The subtrochanteric region on the LCPD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the non-epiphysiodesis group: -1.0 (-2.4 – 0.6) versus 0.1 (-1.0 – 2.1), p<0.001. 

Conclusion: This study concludes that LLD after LCPD originates from the proximal segment only. In patients who had had a contralateral epiphysiodesis, the subtrochanteric femoral region was significantly longer on the LCPD side. These anatomical changes need to be considered by paediatric surgeons when advising leg length equalisation procedures, and by arthroplasty surgeons when LCPD patients present for hip arthroplasty.

346 - Can the Physiological Vulnerability Score predict outcomes of hip reconstruction in children with severe neuromuscular disability?

Alistair Bevan¹, Alexander Aarvold², Caroline Edwards², Simon Bennet², Stephanie Buchan³

¹University of Southampton, Southampton, United Kingdom; ²Southampton General Hospital, Department of Paediatric Trauma and Orthopaedics, Southampton, United Kingdom, ³Southampton Children’s Hospital, United Kingdom

Background: Children with a severe neuromuscular disability frequently undergo hip reconstruction surgery to prevent migration and chronic pain. These patients often have complex co-morbidities, meaning surgery carries a high risk of severe complications. It can be difficult to know when the risk outweighs the benefit. This study looked to correlate the Physiological Vulnerability Score (PVS) with outcomes of hip reconstruction surgery in children with a severe neurodisability.  

Methods: For this service evaluation, pre-operative physiological vulnerability scores were correlated against length of stay (LOS) and postoperative complications. Regression analysis was used to substratify patients undergoing femoral versus femoral and pelvic osteotomies. 

Results: There were 68 patients included, with a PVS of 0 to 21. Increased PVS had no correlation with either LOS (p=0.169) or severity of complications (p=0.981) for patients that underwent VDRO’s (n=48). However, for patients who also had a pelvic osteotomy (n=20), higher PVS was associated with increased LOS (p=0.009) and severity of complications (p=0.0002). 

Conclusion: For patients with significant medical vulnerability, the PVS was associated with a higher rate of postoperative complications and longer LOS following femoral and pelvic hip reconstruction, but not following isolated bilateral femoral osteotomies. The results support early intervention before significant acetabular changes occur. 

Implications:  The physiological vulnerability score can be used to augment clinical decision-making and enable a more informed surgical consent by the child’s parents.    

434 - Dynamic supination in congenital clubfoot: A Delphi Panel approach to standardizing definitions and indications for treatment

Deborah Eastwood¹, Danika Baskar², Steve Frick²

¹Great Ormond St Hospital for Children, London, United Kingdom; ²Stanford University School of Medicine, Stanford, USA

Background: Dynamic supination is a well-recognized cause of relapse following treatment of congenital clubfoot deformity. To date, there have been no published reports of efforts to define dynamic supination or develop consensus on its treatment, and the need for targeted work to better describe this concept has been referenced in clubfoot literature.

Methods: An international panel of 15 paediatric orthopaedic surgeons with clinical and research expertise in childhood foot disorders participated in a modified Delphi Panel on dynamic supination in congenital clubfoot. Panelists voted on 51 statements related to defining dynamic supination, clinical indications for treatment, operative techniques, and post-operative casting/bracing in two rounds, with an interim meeting for discussion. Responses were classified as unanimous consensus (100%), consensus (80% or above), near-consensus (70%-79%), and indeterminate (69% or less). 

Results: Consensus was achieved for 34 out of 51 statements. Panelists agreed dynamic supination is a result of muscle imbalance, and is present when the forefoot is supinated during both active ankle dorsiflexion and swing phase of gait. Consequently, initial contact occurs on the lateral border of the foot, leading to increased callus formation under the base of the fifth metatarsal. There was no consensus on observation of hindfoot varus in dynamic supination, operative indications for posterior release of the ankle joint to improve dorsiflexion, or the incisional approach for tibialis anterior tendon transfer. 

Conclusion/Findings: Reference to planes of movement, the calcaneopedal unit concept, and phases of gait were deemed important factors when evaluating dynamic supination. Adapting standardized terminology will promote future collaborations addressing dynamic supination and the treatment of clubfoot deformity relapse. 

Implications: Consensus statements from the expert panel can guide diagnosis and clinical decision-making related to preoperative casting, surgical intervention, and postoperative immobilization. Near-consensus and indeterminate statements can direct further areas of research.

452 - The functional mobility of patients with cerebral palsy at long-term follow-up after single-event multilevel surgery

Tomos Edwards¹, Robin Prescott², Julie Stebbins¹, James Wright³, Tim Theologis¹

¹Oxford Gait Laboratory, Oxford, United Kingdom; ²Centre for Population Health Sciences, Edinburgh, United Kingdom; ³The Hospital for Sick Children, Toronto, Canada

Background: Single-event multilevel surgery (SEMLS) is the standard orthopaedic treatment for gait abnormalities in children with diplegic cerebral palsy (CP). The primary aim of this study was to report the long-term functional mobility of these patients after surgery. The secondary aim was to assess the relationship between functional mobility and quality of life (QoL).

Methods: Patients were included if they met the following criteria: 1) diplegic CP; 2) Gross Motor Function Classifica­tion System (GMFCS) I to III; 3) SEMLS at age ≤ 18. A total of 61 patients, mean age at surgery 11 years eight months (SD 2y 5m), were included. A mean of eight years (SD 3y 10m) af­ter SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online ver­sion of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%).

Results: Of patients graded GMFCS I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients grad­ed GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respec­tively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better ‘feelings about function’ in patients with better home FMS scores (r=0.55; 95% confi­dence interval 0.15 to 0.79; p=0.01).

Conclusion: The majority of children maintained their preop­erative level of functional mobility at long-term follow-up af­ter SEMLS. Despite the favourable functional mobility, there was little evidence to establish a link between functional status and QoL.

901 - Prophylactic pinning in Slipped Upper Femoral Epiphysis – a closed loop audit of 25 years practice

Ewan Semple, Abdel Bakhiet, Stephen Dalgleish, Donald Campbell, Jamie MacLean

NHS Tayside, Dundee, United Kingdom

Background: Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip.

Methods: Universal prophylactic pinning was introduced in our health region in 2005 after an audit of ten years local practice identified one in four unilateral cases presented with a subsequent slip. This study reports our experience between 2005 and 2020 and as such constitutes a closed loop audit of 25 years practice.

Results: We observed a reduction in the overall incidence of cases. In this prospective study 44 patients presented with 55 affected hips compared with 60 patients with 67 affected hips in the original study. Two patients were excluded as their initial slip had not been treated in our unit.

Of the 42 hips seven were bilateral, 34 of the 35 unilateral hips underwent prophylactic pinning the one exception presented as the policy was introduced and subsequently underwent prophylactic pinning due to developing pain in the unpinned hip.

At a minimum follow up of 13m there have been no complications subsequent to prophylactic pinning in the form of wound infection, fracture, chondrolysis or avascular necrosis. This is consistent with the 36 cases who underwent prophylactic pinning in our original series.

Conclusion/findings: In our population over 25 years 70 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 17 subsequent slips over 25 years including the consequences which can be significant.

Implications: We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE.

1026 - Is Gallows traction effective before open reduction surgery for hip dysplasia?

Nicholas Uren¹, Julia Judd², Ed Lindisfarne², Kirsten Elliott², Alex Aarvold², Stephanie Buchan³

¹Southampton University, Southampton, United Kingdom; ²University Hospital Southampton, Southampton, United Kingdom; ³Southampton Children’s Hospital, United Kingdom

Background: Gallows traction is overhead traction used before the surgical reduction of dislocated hips on infants with Developmental Dysplasia of the Hip (DDH). It is safe but requires nursing expertise and a longer hospital stay. The evidence base is scant.  Theoretically, it reduces soft tissue tension, allowing a more straightforward surgical reduction and fewer complications including re-dislocation and avascular necrosis. This study aims to quantify the effectiveness of Gallows traction by assessing whether resting hip position is affected post-traction. 

Methods: Infants treated at our institution with hip open reduction surgery, undergo one week of pre-operative gallows traction if less than 12kg at the time of surgery. All routinely have a pre-traction radiograph, repeated pre-operatively in theatre with traction removed. The pre-and post-traction imaging of eighty consecutive patients who had this treatment regime, excluding those with missing images, were analysed for hip position using the IHDI classification system. 

Results: Eighty hips from 80 patients (48F, 32M) at a mean age of 16 months (Range: 8-30) were analysed. Prior to commencing traction, 51 hips were IHDI grade IV, 24 hips were grade III, and 5 hips were grade II. Following traction, 17 hips were grade IV, 44 hips were grade III, and 19 hips were grade II. There was a significant improvement in hip position according to IHDI classification (P < 0.001, Wilcoxon signed-rank test): The longer-term outcomes (minimum four years follow up) of this cohort of patients are a 0% re-dislocation rate and a 94% Severin 1 or 2 outcome (i.e. good or excellent.)

Conclusion: This study found that one week of pre-operative Gallows traction decreases the degree of hip displacement. Despite the practicalities of the regime, this study supports its use ahead of hip open reduction surgery.

1187 - Correlating Patient-Reported Outcome Measures with Radiographic Hip Shape in Perthes' Disease

Mohammed Ali^1,2, Mohammed Khattak³, Daniel Perry^3,1

¹University of Liverpool Institute of Translational Medicine, Liverpool, United Kingdom; ²University of Liverpool School of Medicine, Liverpool, United Kingdom; ³Trauma and Orthopaedics Department, Alder Hey Children’s Hospital, Liverpool, United Kingdom

Background: The relationship between radiographic outcome and patient self-reported outcome is unclear in Legg-Calvé-Perthes disease (LCPD). We aimed to delineate this by evaluating the relationship between radiographic hip shape (Stulberg class) with patient-reported outcome measures (PROMs), for LCPD in the long-term. We hypothesised that spherical hip shapes would correspond to the highest PROM function scores, aspherical hips would correspond to the lowest scores, whilst PROM function scores would decrease with increasing age.

Method: 136 participants with LCPD completed the PROMIS Mobility score, nonarthritic hip score (NAHS), EQ-5D-5L score, and the numeric rating scale for pain (NRS). The Stulberg class of the participants' hip radiographs were evaluated by a team of paediatric orthopaedic surgeons, according to the consensus from Neyt et al. on the classification. The corresponding PROMs of these patients were then categorised into these groups and differences were compared.

Results: The results showed that those with a spherical hip shape were associated with the highest PROM scores for function and quality of life, as well as lowest pain. Conversely, aspherical hips exhibited the lowest functional scores and highest pain, which was also true for increasing age within the same hip shape. There were statistically significant differences in the PROMs of spherical hips and aspherical hips (PROMIS p=0.002, NAHS p=0.000, EQ-5D-5L p=0.017, NRS p=0.001), Stulberg Class II and Class IV/V (NAHS p=0.005, EQ-5D-5L p=0.005), and PROM scores between the age groups of 12-16 and 26+ (PROMIS p=0.010, NAHS p=0.000, EQ-5D-5L p=0.002, NRS p=0.000). 

Conclusion: We show that PROM scores report lower function, quality of life, and higher pain in aspherical hips, and older age. The apparent radiographic indicator which largely affects patient outcomes was shape of the hip. Within the same hip shape, there did not appear to be a step-wise deterioration in PROM scores between individual Stulberg classes.

324 - Evaluation of PROMIS CAT Mobility Physical Function Score in the follow up of Perthes’ disease and Slipped Capital Femoral Epiphysis

Mohammed Ali^1,2, Weisang Luo³, Richard Limb⁴, Daniel Perry^3,1

¹University of Liverpool Institute of Translational Medicine, Liverpool, United Kingdom; ²University of Liverpool School of Medicine, Liverpool, United Kingdom; ³Trauma and Orthopaedics Department, Alder Hey Children’s Hospital, Liverpool, United Kingdom; ⁴Trauma and Orthopaedics Department, Aintree University Hospital, Liverpool, United Kingdom

Background: The Patient Reported Outcomes Measurement Information System (PROMIS) has demonstrated faster administration, lower burden of data capture and reduced floor and ceiling effects compared to legacy Patient-Reported Outcomes Measurements (PROMs). We investigated the suitability of PROMIS Mobility in assessing physical function in the long term follow up of Perthes’ disease and Slipped Capital Femoral Epiphyses (SCFE).

Methods: 291 young people (12 years+) and adults with a prior diagnosis of Perthes’ disease or SCFE were included from the Alder Hey Children’s Hospital Perthes’ Register and SCFE database. Participants were asked to complete the PROMIS Mobility Computer Adaptive Test (CAT), Non-Arthritic Hip Score (NAHS) (the legacy PROM), EQ-5D-5L, and Numeric Rating Scale for Pain (NRS). We compared these instruments to (1) measure the strength of correlation via Spearman's rank correlation coefficient and (2) assess floor and ceiling effects.

Results: The results showed a strong correlation between the PROMIS Mobility CAT and the legacy PROM; NAHS (r_s=0.8, <0.01). There were notable ceiling effects in PROMIS (41%), with less when using the NAHS (19.6%). The ceiling for EQ-5D-5L was 28.2%, and the NRS showed a floor effect in 28.5%, with no ceiling effects.

Conclusion: We find that PROMIS Mobility was highly correlated with other tools in this population, though had a marked ceiling effect. Whilst the PROMIS Mobility tool appears to be reliable in measuring physical function in this population, there were elements of hip disease not captured in PROMIS Mobility alone. This knowledge is helpful in planning clinical trials in this group of patients, where combinations of instruments relevant to the Core Outcome Sets should be used.

728 - Biomechanical assessment of paediatric supracondylar humeral fracture fixation constructs; posterolateral Gartland 3 fractures require special consideration

Peter S E Davies¹, Rachel Pennington¹, Alasdair Macinnes¹, Joseph Littlechild², Jamie Deyell¹, Nicole Robin¹, Michael Reidy³, Donald Campbell¹

¹Ninewells Hospital, Dundee, United Kingdom; ²Ninewells Hospital, Dundee, United Kingdom; ³Royal Aberdeen Children's Hospital & Woodend Hospital, Aberdeen, United Kingdom

Introduction: BOAST recommends lateral wiring for supracondylar fractures to avoid iatrogenic ulnar nerve injuries. The aims of this study were to review fixation constructs assessing for mechanical failure.

Methods: An OPERA search identified all paediatric supracondylar humeral fractures fixed between 2012 and 2020.  Caldicott approval was obtained. Radiographs were classified by 3 surgeons using the posterolateral or posteromedial modifier (Rockwood and Wilkins). Primary outcome was defined as an obvious malrotation on follow up radiograph. Fishers exact test was used for statistical analysis.

Results: 153 cases were included. There were 41 Gartland 3A fractures; 21 posterolateral and 19 posteromedial.  Mechanical failure occurred in 73% of posterolateral fractures treated with lateral wires and 10% treated with crossed wires (p=0.0037). In posteromedial fractures, the rate of malrotation with lateral wires was 40% and crossed wires 0% (p<0.0909). 46 fractures were Gartland 3B, associated with 64% malrotation rate with lateral only wires and 9% with crossed constructs (p<0.0003).

Discussion: With posterolateral type 3A and 3B fractures, the medial periosteum is damaged mandating fixation of the medial column. In this cohort, lateral only wires were associated with a high rate of mechanical failure. Stability can be achieved with optimal lateral wiring configurations, or with the addition of a medial wire. One of two lateral wires should be low and have good cortical purchase medially. Use of a third lateral wire should be considered if intraoperative screening demonstrates ongoing instability. A medial wire is likely to confer stability but may risk iatrogenic ulnar nerve injury.

865 - Tibialis anterior transfer for dynamic supination in club foot treatment using a bone anchor: short term follow-up

Anouska Ayub, Gemma Green, Dimitrios Manoukian, Paulien Bijlsma, Gregory Firth, Manoj Ramachandran

The Royal London Hospital, London, United Kingdom

Background: Affecting 1.2 per 1000 live births, Congenital Talipes Equinovarus is a common condition, which is treated successfully using the Ponseti technique in most cases. Tibialis Anterior Tendon Transfer has been widely used in CTEV for dynamic supination.  Several techniques are described, the most widespread being that described by Garceau and Palmer in 1967, the so-called pull through method. Other methods of anchorage of the transferred tendon are described though all methods involve breaching the plantar skin either temporarily or more long term. This may have implications with skin irritation and infection and pressure sores as well as posing risk to plantar nerves.  

Method: We present a case series of 81 feet in 68 patients utilising a Mitek anchor (Johnson & Johnson, New jersey, USA) to dock the whole tibialis anterior tendon, which is transferred to the lateral cuneiform under the extensor retinaculum. This technique negates breaching the plantar skin with sutures thus eliminating plantar skin complications.   

Results: The average age at surgery was 5.8 years (SD 2.1 years). The average follow up was 5.5 years with a minimum follow up of 2 years. No tendon transfer in this multi-surgeon series failed, there was no cases of pull out of the anchor and only 1 transfer complicated with a superficial wound infection, which was at the harvest site, not the anchorage site.  

Conclusion: This is the largest series of tibialis anterior transfer using any technique in the literature to date. Although bone-tendon anchor fixation is widespread in orthopaedic surgery, it is novel for this indication. It is simpler, and less traumatic for the bone than a bone tunnel and less traumatic for the plantar skin than transcutaneous anchorage, with a very low complication rate. 

1007 - MRI for paediatric flat foot: Is it justified?

Caroline Bagley, Sean McIlhone, Nehal Singla, Paul O'Donnell, Sally Tennant, Asif Saifuddin

Royal National Orthopaedic Hospital, Stanmore, United Kingdom

Background: The Radiological assessment of paediatric flat foot deformity may include AP, lateral and oblique plain radiographs. Computed Tomography may be useful for assessing tarsal-coalition but the role of Magnetic Resonance Imaging (MRI) imaging is unclear. This study aimed to determine whether MRI adds value to standard radiography in the assessment of paediatric flat-foot deformity. 

Methods: 81 feet in 57 patients who had undergone MRI following a clinical diagnosis of flat-foot were included. Notes were analysed for the presence, nature and severity of pain, clinical examination findings (flexible/rigid) and the suspected clinical diagnosis. A single Orthopaedic surgeon, measured talo-calcaneal and talo-metatarsal angles on AP standing radiographs, and Meary’s angle and Calcaneal-Pitch on standing lateral radiographs. A Musculoskeletal Radiologist then classified radiographs into either showing no underlying abnormality, talo-calcaneal coalition, calcaneo-navicular coalition, os-naviculare or other. MRI studies were classified in the same way by a different radiologist blinded to radiographic findings. 

Results: Pain was present in 87.7% of feet. Most clinically-diagnosed talo-calcaneal and half of calcaneo-navicular coalitions had rigid flatfoot; most other clinical diagnoses had a flexible flatfoot.       

Plain Radiographs showed no abnormality in 63%, talo-calcaneal coalition in 7.4%, and calcaneo-navicular coalition in 3.7%. MRI found no abnormality in 49.4%, talo-calcaneal coalition in 12.3%, calcaneo-navicular coalition in 6.2%.  

MRI provided additional relevant diagnostic information in 23.5% cases, either identifying a lesion not seen radiographically or correcting a radiographic diagnosis. This was the case for 14.6% of patients with flexible flatfoot and 38.5% with rigid flatfoot.

Conclusion: MRI is a valuable adjunct to weight bearing radiography for the investigation of paediatric flatfoot deformity.

102 - Improving care for patients on growing waiting lists for planned care: What can we learn from the experiences and expectations of patients in the COVID-19 pandemic?

Kunal Kulkarni¹, Rohi Shah¹, Maria Armaou¹, Paul Leighton², Joseph Dias¹

¹University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; ²University of Nottingham, Nottingham, United Kingdom

Background: COVID-19 has compounded a growing waiting list problem, with 4.5 million patients waiting for consultant-led elective care. Waiting list patient views are rarely considered in prioritisation. Our aim was to 1) understand their experiences, concerns, and expectations, and 2) develop and operationalise pragmatic solutions to address identified issues. 

Methods: Prospective cross-sectional study. Questionnaires sent to a randomised sample of patients on the elective orthopaedic waiting list of a teaching hospital with their planned intervention paused due to COVID-19. Collected baseline health data, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, objective quality of life status (EQ-5D, GAD-2). Sampling stratified by body region and duration on waiting list. Quantitative analysis based upon minimum sample size calculation to ensure representative responses ((824 patients, 3% margin of error). Qualitative analysis via Normalisation Process Theory.  

Results: 888 responses. Minimum sample sizes met. No significant differences in baseline demographics and mood scores between cohorts. Better health, pain, and mood reported by upper limb patients (vs lower limb/spine). Longest waiters reported better health but poorer mood and anxiety scores. 81.9% had tried self-help measures to ease symptoms. 94.4% wished to proceed with intervention, despite 65.8% expressing anxiety about COVID-19 risks. Only 20.8% sought deferral.  Overall mood represented by ‘understandable’, ‘frustrated’, ‘pain’, ‘disappointed’, and ‘not happy/depressed’. COVID-19 mandated health and safety measures and technology solutions implemented well. Patients struggled with access to doctors/pain management, quality of life (physical and psychosocial) deterioration, delay updates, and points of contact. 

Conclusion: Largest study to hear the views of this ‘hidden’ cohort. We developed a structured ladder of support and ‘3Cs’ action plan (hear Concerns, help Cope, better engaged Catch-up) to operationalise solutions. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within current resources.

169 - Total hip arthroplasty - The consequences of not templating

Benjamin Kapur, Stylianos Papalexandris, Gunasekaran Kumar

Liverpool University NHS Teaching Hospitals Foundation Trust, Liverpool, United Kingdom

Introduction: Documentation of pre-operative templating is recommended by the BOA. Digital templating accurately predicts implant size in total hip replacement (THR). Templating allows the surgeon to identify variation and potential need for procuring implants at the extremes of size. 

Methods: Patient records and radiographs were reviewed at two trusts who merged – trust A didn't use templating and trust B did.

During the period 2015 to 2019 we retrospectively examined the records of THR for osteoarthritis.  Data collected included demographics, cemented or uncemented implants, digital template implant size and actual implant size. In trust A radiograph magnification was set at 120% as hip radiographs were performed. A Tolerance of +/- 1implant size was deemed to be acceptable. Analysis was performed to assess accuracy of implant position and accuracy of templating. In trust B Marker ball radiographs were performed.

Results: In trust A there were 336 THRs. The individual components were templated to within +/-1 size as follows; Stem 87% and acetabulum 62%. Overall accuracy in one patient was 47%. Accuracy in cemented implants was 45%, uncemented 64%, Hybrid 45%, Reverse Hybrid 17%. The accuracy of templating female hips was 47% and males 49%.

In trust B, 201 THRs were used for comparison – comparable patient numbers, demographics and implants were used. Digital templating revealed an accuracy of 90% for a complete hip system to within +/- 1 size. Accuracy in cemented implants was 86%, uncemented 91%, Hybrid 90%, Reverse Hybrid 91%. The accuracy of templating female hips was 85% and males 88%.

Conclusion: Templating for elective THR is not accurate enough without the use of marker balls. Caution must be used in templating the acetabular component with this being the least accurately templated component. 

529 - National Joint Registry recorded untoward intraoperative events during primary total hip arthroplasty: An investigation into the data accuracy, causal mechanisms and attributability

Rohit Singhal, Justin Leong, Asim Rajpura, Martyn Porter, Tim Board

Wrightington Hospital, Wigan, United Kingdom

Introduction: Untoward intraoperative events occurring during total hip arthroplasty are recorded by the National Joint Registry through Minimum Data Set (MDS) forms. This data may be used to assess the safety of implants. The aim of this study is to evaluate the accuracy of the untoward intraoperative events recorded by the NJR, assess the mechanism of these events and ascertain whether these are attributable to the implants inserted.

Methods: A retrospective analysis was undertaken of 12,802 consecutive primary total hip arthroplasties performed at a single centre between 2005 and 2018. Operation notes, electronic patient records and radiographs of all the cases where an untoward intraoperative event was recorded were reviewed.

Results: From the 12,802 primary hip replacements, 64 patients (0.5%) had untoward intraoperative events recorded on the MDS form. In 43 out of 64 cases the intraoperative untoward event recorded on the MDS form matched the operations notes. Amongst these 43 cases, the intraoperative events for 30 (69%) patients could be attributable to the implant inserted. In the remaining 13 (31%) cases, the events recorded could not be attributed to the implant. In 6 cases, the NJR records attributed the untoward events to the implants which were used to manage the complication rather than the implants which caused them.

Conclusions: Our analysis highlights that all untoward intraoperative events recorded on the NJR form are not implant related or could be attributed to the implant inserted. Assessment of implants based on these untoward events is unreliable at present as only 46.8% (30 out of 64) of the cases were related to the recorded implant and 9% (6 out of 64) relate to an implant that was not inserted.

Implications: Provisions should be made on the MDS form to clarify whether a particular untoward intraoperative event was related to the implant inserted.

586 - Introduction of an Intranasal Diamorphine pathway for manipulation of paediatric forearm and distal radius fractures in the Emergency Department

Tomos Richards, Ashish Khurana, Robert Stafford, Alexander Beveridge

¹Royal Gwent Hospital, Newport, United Kingdom

Paediatric forearm and wrist fractures are common injuries which often require gross alignment only due to the remodelling capacity in the young. By retrospective audit we identified an opportunity to improve patient satisfaction and save cost and theatre capacity in our department. We present our results of management of these injuries immediately following the introduction of an Emergency Department Manipulation protocol.

A retrospective review was performed of all paediatric patients undergoing forearm or wrist manipulation in theatres between 01/05/20 and 30/09/20. Following local presentation of these results a protocol was developed to allow manipulation of simple injuries with intranasal diamorphine and entanox in conjunction with departmental leads. Following introduction of this protocol on 15/11/20 prospective data was collected in all patients undergoing the procedure.

Initial audit identified 63 cases undergoing operative treatment of which 42 cases were felt to be amenable to manipulation in the Emergency Department on review of the initial radiographs. This translated to a potential cost saving of £4200 and theatre time saving of 12.5 hours per month. Following the introduction of the protocol 21 Emergency Department Manipulations were undertaken between 15/11/20 and 26/04/21. Median age was 10 and all cases had an adequate reduction with no reoperations. The median VAS pain score was 3.5 out of 10 and 91% of parents were “very satisfied” with the remaining 9% being “somewhat satisfied”.

The introduction of this protocol had high success and patient and parent satisfaction. It has led to large cost savings and freeing of theatre time. We would recommend utilisation of similar protocols in other departments.

621 - Improving Humeral Shaft Fracture Management: Implementation of a new clinical pathway

Sammie Jo Arnold, Andrew Dekker, David Clark, Amol Tambe, Marius Espag

Royal Derby Hospital, Derby, United Kingdom

Background: Humeral shaft fractures have traditionally been treated using functional braces with perceived low costs and high union rates whilst avoiding the risks of surgery.  The Radiographic Union Score for HUmeral fractures (RUSHU) and fracture mobility at 6 weeks have recently been shown to predict union by 6 months in patients treated conservatively.

This study assesses the effectiveness of a new clinical pathway which incorporates the RUSHU score and fracture mobility implemented in our department.

Methods: An audit of consecutive conservatively managed humeral shaft fractures was identified prior to implementation of the pathway (Sept-Nov 2019) was undertaken.  A new management pathway for humeral shaft fractures was created stipulating review in an upper limb specific fracture clinic at 6 weeks for assessment of RUSHU score and fracture mobility. A decision should then be made whether to proceed with conservative management or consider ORIF if the patient is at risk of non union (RUSHU<8, fracture mobile). This pathway was presented at the departmental audit meeting prior to implementation. Following implementation a re-audit has been performed to assess compliance.

Results: The implementation of our management pathway has reduced the number of X-Rays (Mean 6.2 vs 5.1), fracture clinic appointments (mean 5.3 vs 3.4) and occupational therapy appointments (mean 12.4 vs 10.1) that the patient has to attend. All humeral shaft fractures are seen in an upper limb fracture clinic. Examination for fracture mobility at 6 weeks increased from 33% to 64%, RUSHU score was calculated in 46% of patients, helping to reduce time to definitive decision making from a mean of 11.3 weeks to 6 weeks.

Conclusions: Implementation of a new clinical pathway has initially improved practice; reducing patient attendances to hospital, earlier definitive management decisions and therefore avoidance of prolonged unsuccessful conservative treatment in patients likely to go on to non union. 

624 - Service development in response to Coronavirus pandemic: Setting up the Aberdeen Virtual Hand Service

Katharine Hamlin, Yasmeen Khan, Alexandra Haddon, Clare Miller, David Lawrie

Woodend Hospital, Aberdeen, United Kingdom

We present our experience of setting up the virtual hand clinic in Aberdeen. Following the successful implementation of the local virtual fracture clinic and the virtual hand clinic model established in Fife we have developed a sister service in Aberdeen.  The advantage of a virtual service includes; providing patients with immediate access to information and conservative measures, patients who are better informed for discussion in clinic, reducing footfall in clinic in the COVID era, promotion of utilisation of digital platforms in patient led care and improving optimisation of resources.

We detail our experience during the initial set up and first 4 months of establishing a virtual hand service. The Aberdeen hand service currently sees 2,500 new patients a year across the multidisciplinary team (MDT). In 2019 10% of new patients in Aberdeen were discharged without receiving any treatment, however, it is possible that the very act of coming to clinic encourages the offer and acceptance of treatments which may not be required. The newly established service hopes to reduce face to face appointments by 25% in those suitable for virtual review as achieved in Fife.  

Each GP referral is reviewed by the MDT vetting team and patients entering the virtual pathway will be sent be a letter directing them to information via our website aberdeenvirtualhandclinic.co.uk and then, following the opt-in model for face to face appointments already in use by Jane MacEachern, patients contact the department if they desire review.  

Successful implementation of this model in a different setting shows the applicability of a virtual hand clinic across different departments.

455 - The Mass Knee Clinic – a cost-benefit analysis

Lily Li¹, Haddon Paul Lionel Ganippa², Rajarshi Bhattacharya¹, Dinesh Nathwani¹

¹St Mary's Hospital Paddington, London, United Kingdom; ²Imperial College, London, United Kingdom

Background: The Mass Knee Clinic is an innovative new clinic concept. It involves seeing high numbers of new elective orthopaedic patient referrals every six weeks. The success of the clinic is multifactorial but involves focused multidisciplinary consultant-led care in every case, training opportunities for junior doctors, a “one-stop shop” for patients allowing them to commence definitive management plans in a single day, and subspeciality consultant presence, preventing multiple clinic attendances. 

Methods: A cost-benefit analysis was performed to assess the overall financial and operational efficiency gains and losses resulting from the implementation of the Mass Knee Clinic concept at the authors’ trust from both the patient and provider perspectives. 

Results: The Mass Knee Clinic model is a profitable and effective model from both the patient and provider perspectives: prior to the implementation of the Mass Clinic model, patients attended hospital a mean 4.57 times before being discharged, which dropped to 2.41 times after implementation. Compared to the traditional model, the Mass Knee Clinic also generated savings of £264,018.89 per year for the department.

Conclusion: Building on work previously presented at this Congress, compared with traditional outpatient models, this disruptive outpatient model not only offers patients a genuine consultant-led service, but its “one-stop shop” nature also minimises trips to hospital for the patient. This becomes even more relevant in the post-Covid world where efforts are concentrated to reduce unnecessary hospital touch-points for patients. 

The Mass Knee Clinic model can generate significant financial savings as well: around £264,000 per year. By improving resource allocation, the provider can realise both operational efficiency gains and financial savings, in the process helping to manage waiting lists and bringing departments in line with Government-mandated targets. This concept can be easily transferred across Orthopaedics and throughout hospital specialties.

475 - Trauma and Orthopaedic community's perspective of barriers to participation in research activity - A survey of 146 consultants and junior doctors in Wales

Prashanth D'sa¹, Hamid Daud², Aurelia Vas³, Avadhut Kulkarni⁴, Claire Carpenter⁴

¹Glangwili General Hospital, Carmarthen, United Kingdom; ²Withybush General Hospital, Haverford West, United Kingdom; ³Princess of Wales Hospital, Bridgend, United Kingdom; ⁴University Hospital of Wales, Cardiff, United Kingdom

Background: Research has led to substantial improvement in health and quality of life. It is pertinent for doctors to participate in research to keep up with the advances of modern medicine, and forms one of the seven pillars of clinical governance defined by GMC. However, clinicians face multiple barriers to participate in research. 

Aim: Identifying barriers that prevent trauma & orthopaedic (T&O) surgeons from participating in research and recognising measures to improve their engagement.

Methodology: T&O consultants & junior doctors in Wales were asked to complete a web-based survey with 15 questions about barriers to participation and what would encourage them to take part in research.

Results: A total of 146 completed forms were received with response rate (RR) of 84%, which included 59 consultants (RR-78%) and 87 junior doctors [59 registrars (RR-91%) and 28 senior house officers (RR-85%)].

40% juniors and 20% consultants were not aware of any ongoing research studies. 47% juniors and 15% consultants were unfamiliar with the process of taking part in research. Majority acknowledged they have time constraints (70%) and there is too much paperwork involved (62%). However, many agree that taking part in research is worth the effort (59%), and are still interested in participating in research (75%). 

Majority responded that they would more likely take part in research activity if there were formal training sessions (85% juniors, 60% consultants), more dedicated research sessions scheduled into their timetable (85% juniors, 71% consultants), more rewards/recognition for participation (70%), and if there was a peer/research officer who could motivate and guide them (70%). Majority (72%) believe that taking part in research was relevant for their job role & training. 

Conclusion: Majority of T&O community is interested in participating in research, however face multiple hurdles. Some of these could be mitigated by implementing simple interventions.

554 - Evaluating the Measures in Patient Reported Outcomes, Values and Experiences (EMPROVE) - A Multi-Network Multi-Centre National Collaborative Audit

Alex Matthews¹, EMPROVE Collaborative², Jonathan Evans¹

¹University of Exeter, Exeter, United Kingdom; ²South West Orthopaedic Club, Exeter, United Kingdom

Introduction: Societies advocate the standardisation of Patient Reported Outcome Measures (PROMs) in elective practice. PROMs are also increasingly embedded within national registries. The National PROMs network conducted a pilot review of a small number of NHS trusts, identifying broad variation in PROMs. To provide a national insight into this variation we utilised a collaborative methodology to perform the largest audit into PROMs practice within elective orthopaedics in the United Kingdom (UK). 

Methods: A national data collection form was hosted on the Research Electronic Data Capture (REDCap) management platform. Data collection was centrally coordinated with participants within each NHS trust conducting a standardised audit. Data was collected for each elective subspecialty on PROMs used, collection methods and administration intervals. National society guidelines were used for our audit standard. 

Results: 39 participants submitted data representing 33 NHS trusts across all 9 UK regions. Ten (25.6%) have a designated PROMs manager and 19 (67.9%) thought consultants were responsible for PROMs. The most commonly collected PROMs were for shoulder (28 or 77.8%), hip (25 or 73.5%) and knee (24 or 70.6%) arthritis. Interestingly PROMs for hand and spinal conditions were the most underrepresented with the most variation in collection despite national society guidelines. There was no clear standardisation of data collection interval outside of registry collection and a wide variety of PROMs were employed. The preferred method of collection remains paper and pen.  

Conclusion: The integration of PROMs within national registries has influenced the frequency and standardisation of PROMs collection. Procedures outside the scope of registries are under-represented and poorly standardised. In line with national societies we echo the call for expansion of this practice to all orthopaedic procedures. This audit of practice exemplifies the need for a national forum to simplify PROMs collection and encourage standardisation. This approach will enrich future patient-focused research. 

596 - Check X-rays in Paediatric Orthopaedic trauma: is it a redundant practice?

Jacques Davis, Scott Wilson, Innes Smith

Greater Glasgow and Clyde, Royal Hospital for Children, Paediatric Orthopaedics, Glasgow, United Kingdom

Introduction/Background: Modern trauma practise usually involves the repeat of radiographs following any intervention including the applications of casts or back slabs. Most decision making with regards to orthopaedic surgical intervention can be made on the initial presenting X-ray and a thorough neurovascular examination alone. All healthcare staff have a duty to minimise exposure to ionizing radiation as far as clinically possibly, and more so in a paediatric cohort. 

Method: Retrospective review of all patients attending RHC emergency department between 01/08/20 - 31/10/20 with upper limb trauma that clearly required operative intervention based on initial radiographs. We used an exclusion criteria of the following requirements:  

• Need for surgical intervention unclear on initial imaging 
• Manipulation undertaken in Emergency Department 
• Application of full-Plaster of Paris 

After establishing that there is a significant amount of redundant repeat x-rays we implemented a departmental wide QI request (28/02/2021 - 22/04/2021) to halt repeat x-rays being performed for all traumatic forearm fractures, including Monteggias, Galeazzis, off-ended distal radius fractures and displaced supracondylar humerus fractures. We repeated a similar audit months after to establish if there were any significant clinical outcomes. 

Results: 

Audit 1:  

• 18 Supracondylar humeral fractures 
• 47 Forearm Fractures (both bone, distal radius, Galleazzi, Monteggia 
• 30 of 65 patients (46%) unnecessarily re-imaged following backslab application in the knowledge that they required surgical intervention! 

Audit 2:  

• 28 Cases including aforementioned upper limb traumatic cases 
• 26 of 28 patients did not receive a repeat x-ray 
• 2 of 28 received a repeat x-rays 

Outcomes/Conclusion: After implementation of QI – there was no difference in outcome of whether patients required surgical intervention. Audit 1 presented us with data to establish that repeat x-rays were performed on those intended for theatre. Audit 2 proved that repeat x-rays provided no difference in clinical outcomes. Are repeat x-rays outdated, necessary and possibly harmful? On average it takes between 20-30 mins from request in an acute setting to receive an X-ray, these implementation could possibly lead to reduced waiting times in A/E. Implementation of these findings possibly have the potential to reduce total ionizing radiation and faster turn-over rates in an acute setting. Question remains, is this applicable to more trauma?

705 - Can multidisciplinary coding meetings improve the accuracy of coding orthopaedic operations and provide economic value to the hospital?

Caroline Bagley, Benan Dala-Ali, Alicja Dziadul, Aresh Hashemi-Nejad

Royal National Orthopaedic Hospital, Stanmore, United Kingdom

Background: ‘Payment by Results’ translates clinical activity into codes which determine the tariff reimbursed to NHS Trusts. Trusts are reliant on accurate coding to ensure appropriate financial remuneration and to audit clinical activity which aids effective service-planning.

Coding is carried out by non-clinical, professionally-trained Clinical Coders whilst operation notes are written by surgeons not trained in coding. This mismatch makes it challenging for Coders to decipher operation notes and match them to ambiguous clinical codes. Inaccuracies are common within Orthopaedics due to the wide-range of subtly-different procedures, the complexities of which are hard to appreciate from documentation.

This study assesses whether clinician-involvement in coding of orthopaedic operations increases accuracy and economic gain for the Trust.

Methods: A single-centre retrospective study within a tertiary orthopaedic hospital.  60 complex operation notes were selected by the Coding-Validation Lead over a 3-month period (ten notes from each sub-specialty – Joint-Reconstruction, Sarcoma, Spinal, Paediatrics, Foot and Ankle, and Upper-Limb) and coded by a Coder alone. Meetings were then held between the Coder and each sub-specialty Consultant, and subsequently between the Coder and each sub-specialty SpR, and the notes blindly re-coded again. Tariffs were compared.

Results: Tariffs changed in 5 out of 10 cases for each specialty (48% operations coded with an SpR, 65% with a Consultant). The total tariff from 10 operations in each sub-specialty increased by £6,102 following a meeting with an SpR and £7,718 with a Consultant compared to Coder alone (mean £2,303/month). Whilst these figures represent complex procedures requiring clinical clarification, financial implications are substantial.

Conclusions: This study highlights that coding by Coders alone and ambiguity of documentation produces inaccuracies with significant financial ramifications to Trusts. Whilst reasons for errors are multifactorial we suggest an effective and simple way to improve accuracy is through regular meetings between Orthopaedic Surgeons and Coders.

908 - Efficacy of telephone consultations for new elective orthopaedic patients during COVID-19 pandemic

Muhammad Usman¹, Sean Garcia¹, Saman Horriat²

¹East Kent Hospitals University NHS Trust, Margate, United Kingdom; ²East Kent Hospitals University NHS Trust, Margate, United Kingdom

Background: With the advent of Covid-19 Pandemic, telephonic consultations were instituted as a measure of safety for both patients and healthcare professionals. These newly devised consultations were in line with the clinical guidelines of NHS England, NHS Improvement and British Orthopaedic Association. Using a retrospective analysis, we analysed how effective these consultations were at achieving an outcome for new orthopaedic patients.

Methods: Data was collected retrospectively from electronic clinic templates at a NHS DGH Hospital over 3 months period (August-October 2020). All Telephone consultations for new orthopaedic patients during study time were included. Fracture clinic appointments, face-to-face, follow-up and spine patients were excluded.

Results: 519 Telephone consultations were made for new patients referred from Primary care and orthopaedic assessment services. 67 (13%) patients were from Shoulder and Elbow clinics, 182 (36%) from Hip and Knee clinics, 175 (34%) from Hand and 95 (18%) from Foot and Ankle Clinics.

52% patients were requested  to attend face to face clinics, 14% patients were sent for further investigations(CT,MRI, Bone Scan, Nerve Conduction Studies), 1% patients were referred to physio and only 15% patients received a definite management plan( added to the list)on these telephonic consultations. 18% patients clinic outcome was categorized as other (Discharge, telephone follow up, referred to other organization or clinician).

Conclusion: Telephone consultations often provide insufficient information to make a clinical decision. Patients added to lists are invariably invited for face to face consultations which remain the preferred choice to make a clinical decision.

Implications: It was recommended after the study that consultants should triage their new patients before clinics and if any work up needed will be organised before their clinic appointments. Pre Assessment clinics were instituted for face to face consultations for patients added to elective lists.

992 - The use of magnetic resonance imaging (MRI) of the knee in current clinical practice. A retrospective evaluation of the MRI reports within a large NHS Trust

Imran Ahmed¹, Haseeb Moiz², William Carlos², Claire Edwin², Sophie Staniszewska¹, Nick Parson¹, Andrew Price³, Charles Hutchinson¹, Andrew Metcalfe¹

¹University of Warwick, Coventry, United Kingdom; ²University Hospital Coventry and Warwickshire, Coventry, United Kingdom; ³NDORMS, Oxford, United Kingdom

Introduction: Magnetic resonance imaging (MRI) is one of the most widely used investigations for knee pain as it provides detailed assessment of the bone and soft tissues. The aim of this study is to report the frequency of each diagnosis identified on MRI scans of the knee and explore the relationship between MRI results and onward treatment. 

Methods: Consecutive MRI reports from a large NHS trust performed in 2017 were included in this study. The hospital electronic system was consulted to identify whether a patient underwent x-ray prior to the MRI, attended an outpatient appointment or underwent surgery. 

Results: 4466 MRI knees were performed in 2017 with 71.2% requested in primary care and 28.1% requested in secondary care. The most common diagnosis was signs of arthritis (55.2%), followed by meniscal tears (42.8%) and ACL tears (8.3%). 49.4% of patients who had an MRI attended outpatients and 15.6% underwent surgery. 

The rate of knee surgery was significantly higher for patients who had their scans requested in secondary care (32.9% vs 8.9%, p<0.001).

Conclusion: The rate of surgical intervention following MRI is low and given these results it seems unlikely that the scan changes practice in most cases. The rate of surgery and outpatient follow up was significantly higher in scans requested by secondary care. We urge clinicians avoid wasteful use of MRI and recommend the use of plain radiography prior to MRI where arthritis may be present. 

Disclosures: Presenting author declares funding from NIHR doctoral research fellowship programme.

1069 - Burnout in the workplace: A national survey of British Trauma and Orthopaedic Surgeons

Christopher Jukes, James Nutt, Callum Counihan, William Butler-Manuel, Maryam Ahmed, Ben Caesar

Brighton & Sussex University Hospitals NHS Trust, Brighton, United Kingdom

Background: Work-related burnout was officially recognised as a syndrome by the World Health Organisation in 2019 and added to the International Classification of Disease. Studies have reported rates as high as 40-60% in certain medical specialties. We aim to investigate to what extent burnout is affecting the British orthopaedic community.

Methods: In collaboration with the British Orthopaedic Association (BOA), self-reported surveys were distributed amongst the BOA membership. Burnout scores were calculated using the Copenhagen Burnout Inventory. Demographic data of respondents was collected, as well as qualitative information about respondents’ primary stressors at work and at home. All responses were anonymous.

Results: Between January and February 2021, 1,298 responses were received. Burnout rates were reported as: severe 4%; moderate 36%; mild 50%; and nil 10%. Consultants comprised 70% of respondents, with a further 12% fellows/associate specialists and 15% specialty registrars. 83% were male and 15% female (2% undisclosed). Regarding ethnicity, 67% were white, 22% Asian/Asian British, 2.5% mixed ethnicity, 2% Black/African/Caribbean, and 6% ‘other’. Sexual orientation was 95% heterosexual, and 79% of respondents were married. There was a direct correlation between workplace dissatisfaction and high burnout scores. Burnout scores were lower in white, married, heterosexual men compared with other demographic groups.

Conclusions: We have identified that 40% of the surveyed orthopaedic population are experiencing significant levels of burnout. Many pressures were directly related to the COVID-19 pandemic. 

Implications: As a community it is important to appreciate that if left unresolved, chronic burnout can lead to not only personal illness but financial costs for hospitals and institutions. Strategies to manage burnout should not only be tailored to each individual, but also implemented and spearheaded from a senior institutional level.

Disclosure: Survey was carried out as a collaboration between the authors and the BOA. 

89 - A quality improvement project to improve induction of new SHOs into orthopaedic surgery

Sarah Easby

York Teaching Hospitals NHS Foundation Trust, York, United Kingdom

Background: NHS employers state that all doctors should receive a formal induction. This is to ensure they have the knowledge and support needed to perform their role and deliver safe and effective care. It allows available learning opportunities to be highlighted and ensures a smooth transition to working in an unfamiliar environment. The aim is to introduce a clinical handbook to help trainees feel more confident on starting their new role. 

Methods: We aimed for 80% of trainees to feel confident on starting their rotation. An online survey was sent in January 2020 to gather thoughts about induction, seventeen responded. A handbook of common orthopaedic presentations and emergencies was produced and proof read by registrars for accuracy. We completed two PDSA cycles. In December 2020, the handbook was distributed to six incoming trainees and the survey was resent, all trainees replied. The coronavirus pandemic limited the number of rotations therefore respondents in further cycles.

Results: Prior to the introduction of the handbook 65% did not feel confident starting orthopaedics, which decreased to 16% following its introduction, 23% then 17% felt neutral, meaning confidence increased from 12% to 67%. 23% felt confident managing emergencies which increased to 50% after handbook distribution. 67% agreed the handbook managed expectations of the role. A comment box allowed respondents to leave suggestions for amendments or additional content which will be used to refine future editions.

Conclusion: The induction handbook is successful in increasing confidence on starting orthopaedics however did not reach the target of 80%. These findings highlight the importance of a good induction process.  

Implications: The handbook is now given in conjunction to a departmental induction and is available to access from a centralised intranet location for future reference. The handbook will be refined by future trainees to meet ongoing needs. 

173 - England’s first national weekly diabetic foot virtual multidisciplinary team meeting – the King’s Collage Hospital experience

Basil Budair, Razi Zaidi, Venu Kavarthapu

King's College Hospital NHS Foundation Trust, London, United Kingdom

Introduction: Complex diabetic foot problems managed in multi-disciplinary team (MDT) setting are associated with lower amputation rate and mortality. Our diabetic foot service (DFS) holds a weekly MDT and routinely receives referrals and treats patients from various parts of England. These meetings are attended by foot and ankle surgeons, diabetologists and podiatrist with further input from vascular and plastic surgeons. As part of our continuous service improvement endeavours, we present our experience of running the first national weekly virtual MDT meeting to manage complex diabetic foot cases.

Methods: Analysis of prospectively collected data over the period from 1st September 2020 to 31^st December 2021. This date range was chosen as during the pandemic this period was most representative of the normal volume of referrals seen by our DFS. External referrals were vetted by the senior author and referring clinicians were invited to attend the meeting virtually and discuss patient management at the MDT. Attendance compliance and outcomes of the MDT discussions were also recorded.

Results: 10 virtual MDTs took place each running for 45 minutes. 27 patients were discussed (17 local and 9 national cases). Attendance compliance was 100%. All external case discussions were attended via a video link by a senior member of the referring team. 8 of these were offered clinic appointments for assessment and 1 was advised for local treatment. Following the discussions, 6 patients had further investigations organised locally prior to their clinic visit and a management plan was formulated on the initial visit. Of the total referrals, 15 patients were listed for Charcot reconstruction, 2 for amputation, 2 for debridement and exostectomy and 8 for total contact casting and podiatric care. 

Conclusion: Virtual platforms are valuable tools that should be capitalised on for MDT management of complex conditions on a local, regional & national levels.

178 - Setting a standard for post-operative care documentation in orthopaedic polytrauma at a major trauma centre (MTC)

Cieran McGrory¹, William Giles², Kay Wynn¹, Raveen Jayasuriya¹

¹Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; ²University of Sheffield, The Medical School, Sheffield, United Kingdom

Background: All healthcare professionals are involved in cross-covering teams to deliver patient care. No detailed audit standard has been established for post-operative care documentation in orthopaedic polytrauma, which is vital for patient safety and early rehabilitation.

 Methods:

1) Stakeholder analysis, consultation and consensus from the major trauma MDT for evidence-based auditable criteria.

2) Audit completeness of post-operative care documentation for the first 50 patients undergoing orthopaedic polytrauma surgery in 2020, identified using the TARN database.

3) Staff survey focussed on exploring the most significant deficiencies identified in the audit.

4) Stakeholder group to plan intervention.

Results: MDT identified 13 mandatory criteria for complete post-operative documentation in orthopaedic polytrauma, including important negative fields. 

Audit revealed the following compliance; need for VTE prophylaxis 72%, post-operative bloods 50%, check x-rays 69%, follow-up plans 74%, and weight-bearing status was documented in 91% of operated injuries, but only 42% of conservatively managed orthopaedic injuries. Trauma conference dictations detailed weight-bearing status of conservatively managed orthopaedic injuries in 35% of cases. 

Survey received 87 responses, representative of the whole ward team at this MTC. Of the non-orthopaedic surgeons (n=67), 62% were less than confident in determining the weight-bearing status for patients with multiple orthopaedic injuries, when not explicitly documented. When weight-bearing status is unknown staff check the operation note first, followed by the ward round note and trauma conference dictation. When not documented, 15% of staff reported it took >24 hours or until the next day to ascertain a patient’s weight-bearing status. 

Conclusion and implications: Weight-bearing status of non-operated polytrauma injuries is poorly documented and the majority of healthcare professionals are uncertain in determining this independently. We are implementing a “delete as appropriate” style, suffixed electronic post-operative care template embedded within existing software, based on the 13 criteria established by MDT consensus.

362 - The use of opioid analgesia following ambulatory orthopaedic trauma in Scotland: A national cohort study

Tim Gardner^1,2, David MacDonald¹, Matthew Kennedy³, Alastair Faulkner⁴, Joshua McIntyre⁵, Patrice Forget², Stuart Aitken⁶, Iain Stevenson¹

¹Department of Trauma & Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, United Kingdom. ²University of Aberdeen, Aberdeen, United Kingdom; ³Department of Trauma & Orthopaedics, QEUH, Glasgow, United Kingdom; ⁴Department of Trauma & Orthopaedics, Ninewells Hospital, Dundee, United Kingdom; ⁵Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ⁶MaineGeneral Hospital, Augusta, USA

Background: The Opioid crisis faced by the USA is rapidly spreading into Europe. Perioperative opioid use increases the risk of long-term opioid use. This study reviews opioid use following wrist and ankle fracture fixation across Scotland, to establish prescribing patterns and associations with patient, injury or peri-operative factors.

Methods: 6 Orthopaedic Units across Scotland contributed. Inclusion criteria: >16 years of age, isolated fracture of distal radius/ankle managed surgically. A retrospective Electronic Health Records review and regression analysis was performed to gather patient, injury and peri-operative factors that may influence discharge opioid prescription rates. 

Results: 598 (298 distal radius, 300 ankle) patients were included in this retrospective cohort study. Patient Demographics for each group were similar across all sites, although there was significant variation in anaesthetic practice, length of stay and AO fracture type (p<0.01).

For distal radius fractures, 85.6% of patients received an opioid prescription on discharge, of which 5.0% contained a strong opioid. There was no significant variation across the 6 units in prescribing practice.

For ankle fractures, 82.7% of patients received a prescription for opioids on discharge, of which 17% contained a strong opioid. Dundee and Edinburgh using significantly more strong opioids; Inverness and Paisley gave the least opioid prescriptions overall (p<0.01). Younger patient age, location and length of stay were independent predictors of increased opioid prescription on binary regression.

Conclusions: There remains significant variability in the perioperative practices across Scotland. Despite this, opioid analgesic prescription on discharge remains overwhelmingly consistent.

We believe that the biggest influence on prescription practices lies with the prescriber rather than the patient - institutional ‘standard practice’.

Implications: Education of healthcare staff and patients is key to reducing the use of opioids following surgery, and thus lowering long term opioid dependence.

Disclosure: Nothing to Disclose. Performed as part of the SCORE collaborative.

540 - Edmonton Frail Scale in elective total hip and knee arthroplasty: a predictor for increased length of stay

Kevin Syam, Gopikanthan Manoharan, Salam Ismael, Srinath Anand, Kahlan Al Kaisi, Ben Burston

The Robert Jones and Agnes Hunt Hospital, Oswestry, United Kingdom

Background: The Edmonton Frail Scale (EFS) is a valid and reliable tool for defining frailty. EFS has been used to predict increased LOS and morbidity in elective cardiac and colorectal surgery. This study aimed to evaluate EFS as a predictor for increased post-operative LOS and complications in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods: Consecutive patients with completed EFS scores who underwent elective THA and TKA between October 2016 to March 2017 were retrospectively reviewed. Following power analysis, EFS score, ASA grade, co-morbidities, LOS, high dependency unit (HDU) admission and post-operative complications were collected. SPSS software was used for statistical analysis. 

Results: Two-hundred patients (94 frail and 106 non-frail) were included. The median LOS was 4 days. The mean LOS for frail patients (8.4 days) was significantly longer than the non-frail patients (3.7 days). There were significantly higher post-operative complications and HDU admissions in the frail group (p<0.05).   Receiver operator characteristic (ROC) curve analysis showed that EFS was an acceptable predictor for increased LOS (>4 days) with an EFS score of 6 or more being associated with greater LOS (ROC 0.753). Logistic regression analysis did not show any association between EFS score and post-operative complications.  

Conclusions: EFS is an acceptable predictor for increased LOS, but not for post-operative complications in elective hip and knee arthroplasty. The use of EFS should be considered in pre-operative clinics for elective THA and TKA. A score of 6 or more should trigger pre-operative interventions to optimise these patients.

Implications: To the best of our knowledge this is the first study to look at EFS as a predictor for increased LOS in elective THA and TKA patients. This could be used to target pre-operative patient optimisation, better discharge planning and more accurate bed modelling.

657 - The changing face of orthopaedic trauma services: A city wide experience

James Chapman, Chirag Manwani, Daniel Fletcher, Gavin Heyes, Neil Walker

Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

Background: In the last decade, the demand on UK trauma services has changed with the introduction of major trauma networks and specialist management pathways. We are seeing an increased demand on tertiary centres to accommodate management of patients sustaining major trauma and open fractures, alongside ‘routine’ admissions. In our city, NHS services continue to be reorganised; two major hospitals have merged and orthopaedic trauma services are delivered from a single site. The ‘one size fits all’ traditional junior rota pattern no longer meets the demands of the service.

Methods: We conducted a retrospective review of all acute referral times and trauma calls during January 2020 following the department merger. Patients were identified using the acute take database. Diagnostic x-ray and ED attendance time were used as a surrogate marker for referral time; ward referrals were recorded to monitor workload. Significance was calculated using 2-sample t-tests.

Results: 314 patients were identified. There were 183 A&E referrals (mean=5.9/day, range 3-12), 79 trauma calls (mean=2.55/day, range 0-8) and 52 ward referrals (mean=1.68/day, range 0-6). Peak times for A&E referrals were between 15:00-16:00, with 47.5% being made between 15:00-00:00; 58.2% of trauma calls occurred over the same time period. There was no significant difference between weekend and weekday A&E referrals (p=0.65) and trauma calls (p=0.91), but there was a significant difference in weekend ward referrals (p=0.025).

Conclusion/Findings: The biggest burden on the on-call team occurs in the afternoon and into the traditional handover period and night shift, with a large variation in daily activity. Weekends show little change in intensity of the workload.

Implications: Rotas should be organised to cover service demands, and additional ‘twilight’ junior cover during the whole week and at traditional handover periods in busier centres should be considered to ensure continuity of safe patient care.

804 - Can a patient focussed, and procedure specific risk calculator predict complications post total knee arthroplasty?

Helen Jones¹, Andrew Brunt², Adeel Akhtar^2,3, Phil Walmsley^2,4

¹School of Medicine, University of Edinburgh, Edinburgh, United Kingdom; ²Victoria Hospital, Kirkcaldy, United Kingdom; ³School of Medicine, University of St Andrews, St Andrews, United Kingdom; ⁴School of Medicine, University of St Andrews, Kirkcaldy, United Kingdom

Introduction: The number of primary total knee arthroplasty (TKR) performed in Scotland almost doubled between 2001 to 2018, and is predicted to increase. TKR comes with risks of complications, including Venous Thromboembolism and Cerebrovascular insult. Informing patients of potential risks from surgery, is now a legal requirement and a crucial part of the shared decision making process between clinician and patient. The American College of Surgeon’s Surgical Risk Calculator is a tool that attempts to predict post-operative complications following surgery. Several issues have been identified with this, namely there are no large scale studies which externally validate its efficacy and even fewer studies that aim to do this with orthopaedic procedures

Methods: Prospective data was collected on 66 patients undergoing TKR in our unit. For each patient, data was entered into the surgical risk calculator, allowing risk predictions to be compared to the overall event occurrence compared to those from the Scottish Arthroplasty Project for our unit and Scotland. A one sample t test was used to evaluate the ability of the surgical risk calculator to predict the occurrence of selected post-operative outcomes.

Results: The most common post-operative complication was ARF, followed by wound infection, VTE and lastly Myocardial Infarction (MI). This mirrors national data. There was a statistically significant difference for the post-operative complications Surgical Site Infection, VTE and ARF for our unit and Scotland against their predicted outcomes. Only MI showed no statistically significant difference between predicted outcome and actual outcome, locally and across Scotland.

Conclusion: The only post-operative complication showing no statistically significant difference between actual and predicted outcome was MI. All other complications showed a statistically significant difference between event occurrence and predicted. To our knowledge this is the first study to evaluate this surgical risk calculator in the UK, but further development is required.

839 - Implementation of a Complex Revision Hip Proforma at a District General Hospital in London reduces outpatient clinic appointment time

Sarkhell Radha^1,2, Irrum Afzal³

¹Croydon University Hospital, London, United Kingdom; ²South West London Elective Orthopaedic Centre, London, United Kingdom; ³South West London Elective Orthopaedic Centre, London, United Kingdom

Although revision total hip arthroplasty (THA) is an established procedure, some cases still remain complex. Careful attention to detail regarding the primary procedure and the techniques involved and imaging should be reviewed by orthopaedic surgeons and in a Multi-Disciplinary Team (MDT) meeting in order to identify the failure mechanism for the primary THA.

There is substantial variation across facilities in adherence to evidence-based care processes and information provided to the orthopaedic surgeon when a patient is first referred from the General Practitioner (GP) or another orthopaedic surgeon for review of a potential failed THA.

In September 2019, a new complex revision arthroplasty referral proforma was put into the place at our District General Hospital. The complex arthroplasty referral proforma requested all referring doctors include information on patient demographics including primary operative details, imaging and pathology. We report results from two study periods; the control period (1^st July 2019 –31^st July 2019) and following the introduction of the Complex Arthroplasty proforma (6^th January 2020 – 31^st January 2020). 

Upon implementation of the complex revision arthroplasty referral proforma, there was improvement in all three domains. There was a 14.29% improvement in primary operation details being provided to the orthopaedic surgeon, a 9.52% improvement in clinical examination findings being provided. In addition, there was 77.35% improvement in imaging being provided and readily available to view by the orthopaedic surgeon. There was 56.25% improvement in Blood results being accessible. Furthermore, implementation of this complex revision arthroplasty referral proforma reduced outpatient clinic appointments by 7 minutes. 

In conclusion, to provide optimal clinical care to patients with complex needs, all information should be readily available to surgeons. Awareness and implementation of our complex revision arthroplasty referral proforma could be a useful tool for surgeons when undertaking an outpatient clinic or reviewing the patient in an MDT meeting.

840 - Cost analysis and outcomes of management of 5th metatarsal base fractures in a Virtual Fracture Clinic Model

Amit Patel, Nusrat Zahan, Kate Atkinson, Isabella Drummond, Alexandros Vris, Francesc Malagelada, Lee Parker, Lucky Jeyaseelan

Barts Health NHS Trust, London, United Kingdom

Introduction: Virtual fracture clinics (VFCs) have been shown to be safe and cost-effective in orthopaedics. Optimal treatment of 5^thmetatarsal base (MB) fractures remains controversial. Complications of these fractures includes delayed union and painful mal/non-union. Surgical fixation demonstrates faster union times and lower non-union rates than conservative management. The aims of this study were to assess if management of 5th MB fractures using a VFC model is safe, cost effective and avoids adverse outcomes.

Methods: All patients presenting to the VFC with a 5th MB fracture between January 2019 and December 2019 were included in the study. Minimum follow-up was one year. Retrospective case review for baseline demographic data, complication rates, as well as operative intervention rates were noted. A cost analysis was also performed to evaluate cost saving to the unit.

Results: One hundred and thirty-six patients were identified. The mean age was 41.6 years (Range: 18-92). Fractures were classified according to the Torg Classification with 106 (78%) Type 1 fractures, 15 (11%) Type 2 fractures and 15 (11%) Type 3 fractures. At VFC, 135/136 (99.2%) were discharged with the appropriate 5^th MB fracture protocol. Twelve patients (8.8%) arranged further follow-up after initial discharge. The most common reason for return was ongoing pain (6/8 - 75.0%). This subgroup of the patients required an average of 3 (1-6) further appointments. There was one non-union during the study period. Based on two face to face visits on a traditional pathway, 248 clinic visits were saved with an approximate cost saving of £40,000. 

Conclusion: Our study supports, that management of 5th MB base fractures in the VFC model with a defined protocol, is both safe and cost effective. Fifth MB fractures have good outcomes with conservative management, removing the traditional need to have in-person clinic visits.

859 - Length of Stay for Elective Arthroplasty: A comparison of clinician gathered data with data submitted to the Model Hospital (MH) and the Getting It Right First Time (GIRFT) programme

Eleanor Kissin¹, Joon Ha², Teniola Adeboye¹, Jacinda Chahal², Tolu Akande¹, Thomas White¹, Jonathan Bird¹

¹University Hospital Lewisham, London, United Kingdom; ²Queen Elizabeth Hospital, London, United Kingdom

Background: The MH is a digital tool used to support efficiency within NHS trusts. Information is used to address variations in performance on peer and national levels and submitted to GIRFT. Reliability of data is essential as it is a reflection on trust performance and used by GIRFT to plan services nationally. The 2019 Lewisham and Greenwich Model Hospital Report showed the length of stay for arthroplasty was longer than the GIRFT average. We believed this metric and the numbers to be inaccurate and therefore performed our own audit.

Methods: Trust data on every operation in 2019 was reviewed and all knee, hip and shoulder arthroplasty selected using Excel. We are confident of inclusion of all elective arthroplasty. The date and time of admission and discharge on the discharge summary on iCare was used to calculate the length of stay in days.

Results: 539 cases were identified. Results show a median length of stay of 3.3days for hips compared to the MH data of 4.0days, 4.1days for knees compared to the MH data of 4.6days and 2.4days for shoulders compared to the MH data of 4.1days.

Conclusions: Our audit demonstrated improved results to those published by the MH and submitted to GIRFT, and show that we are performing better than the GIRFT average. This is an audit that can be readily replicated at different trusts.

Implications: MH data is collected by Business Intelligence teams and is not reviewed by clinicians before publication. The data is used internally but also submitted to GIRFT and has implications on a much wider scale. We need to ensure that accurate data is being used to make decisions about future services. Clinicians need to work closely with management to review parameters and methods for data collection to ensure that accurate data is published regarding performance.

1112 - Scoring of peri-operative radiographs in trauma surgery. An important quality assurance tool and call for national standards on scoring

Adam Smith, Matthew Flintoftburt, Jemma Rooker, Sunny Deo, Ian Lowdon

Great Western Hospital, Swindon, United Kingdom

Background: Reviewing the quality of fracture reduction and fixation in trauma surgery is a valuable learning experience and forms an important part of clinical governance. We have developed a new departmental process for quality control of patients undergoing orthopaedic trauma surgery requiring peri-operative check x-rays. 

Methods: As the first QI cycle in March 2020 we augmented our trauma database (Access, Microsoft). This enabled all cases requiring peri-operative radiographs to be automatically added to a review list. Each patients’ radiographs were then scored by a panel of senior orthopaedic trauma surgeons during the daily trauma meeting assessing the radiographic quality of fixation. X-rays were rated as “Good”, “Acceptable”, “Poor” or “Inadequate”. Additional comments could be added. Data prospectively collated within the database was analysed. The second QI cycle identified the named surgeon for each case allowing surgeon specific constructive feedback. 

Results: All trauma cases requiring peri-operative radiographs (March 2020 - March 2021) were included with a total of 1,154 patients. The X-ray review rate was 98% and the mean time to X-ray review was 3 days. In total 83% of cases were scored “Good”, 13% “Acceptable” and just 0.95% scored as “poor”. The remainder were scored “Inadequate” and so further imaging was arranged. Interestingly there was a 64% reduction in “poor” scores when comparing the first and second 6 months of this study. 

Conclusion: The process of closely reviewing intra-operative radiographs allows early identification of potential problems, encourages discussions of useful learning points and real time teaching. An annual report of an individual surgeon’s scores can be produced, providing valuable feedback for reflection and appraisal. 

Implications: This system allows continued prospective analysis of fixation quality in trauma surgery. We would support the development of national standards on reviewing trauma fixation and standardisation of scoring for common trauma procedures.

18 - Anterior instability of the sternoclavicular joint: Long term results from a Tertiary Center in the United Kingdom

Lambros Athanatos, Kunal Kulkarni, Michail Samaras, Helen Tunnicliffe, Alison Armstrong

University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Background: Anterior sternoclavicular joint (SCJ) instability is a rare condition that can cause discomfort if treated inadequately. The study aimed to present patients' long-term outcomes with anterior instability of the SCJ managed at a tertiary centre with a tailored treatment algorithm. 

Methods: Patients with anterior SCJ dislocation treated between 2007 and 2019 were included in this prospective study. Patients were divided into two groups–‘atraumatic with or without hypermobility’ (assigned to physiotherapy) and ‘traumatic with or without hypermobility’ (offered surgery, primarily sternocleidomastoid tendon autograft reconstruction). Patients were evaluated clinically via a postal questionnaire to determine subjective SCJ instability, Visual Analog Scale (VAS) for pain, and Oxford Shoulder Instability Score (OSIS, adapted for SCJ). 

Results: 48 patients (51 SCJs, 3 bilateral dislocations) responded; 30 SCJs were treated with physiotherapy [median follow-up 5.1 years (range, 0.9-8.3 years)] and 21 SCJs with surgery [median follow-up 8.7 years (range, 0.5-12 years)]. 

94% (48/51) of the total cohort achieved a stable SCJ, with 59% (30/51) achieving unrestricted function. 80% (41/51) recorded good-to-excellent OSIS (80% physiotherapy, 81% surgery) and 75% (38/51) reported low (0-4) pain VAS scores at final follow up.

95% (18/19) of patients who were compliant with their physiotherapy programme had a stable SCJ [median OSIS 39 (range, 18-48) and pain VAS 1 (range, 0-7)] compared to 91% (10/11) of patients who were non-compliant [median OSIS 26 (range, 3-47) (p=0.007) and pain VAS 5 (range, 0-9) (p=0.008)]. Surgical complications included 19% revision rate, 11% frozen shoulder, and 4% scar sensitivity.  

Conclusion: The presented treatment algorithm emphasises the importance of appropriate patient selection for either physiotherapy or surgery based on trauma and hypermobility. Compliance with the physiotherapy programme was essential in ensuring good outcomes. All but 3 joints achieved a stable SCJ after treatment, with stability maintained at 5.1 years (physiotherapy) and 8.7 years (surgery).

31 - Clinical results and 10-year survivorship of the Synthes Epoca Resurfacing Head Total Shoulder Arthroplasty

Timothy Karssiens, Rui Zhou, James Gill, Christopher Roberts

East Suffolk and North Essex NHS Foundation Trust, Ipswich, United Kingdom

Background: The purpose of this prospective cohort study is to report the 10 year survivorship, medium to long term patient reported outcome measures (PROMs) and radiographic outcomes of the first series of the Epoca Resurfacing Head Total Shoulder Arthroplasty (TSA). 

Methods: From July 2008 to July 2014, a total of 59 Epoca RH TSAs were implanted in 50 patients by a single surgeon. Mean age at time of operation was 69 years old (range 38 to 87). Minimum 4.8 year and maximum 11.3 year follow-up (mean 7.9 years) was analysed using the Oxford Shoulder Score (OSS) at latest follow-up. Kaplan Meier survivorship analysis was performed with implant revision as the end point. Most recently performed radiographs were reviewed for component radiolucency, osteolysis and proximal humeral migration. 

Results: Two shoulders underwent revision surgery (3.4%); one for pain with posterior subluxation following a fall and the other for pain with evidence of failure of the glenoid. 10-year survivorship of the implant was 98.2% (95% confidence intervals, 87.99 to 99.75%). Mean OSS improved significantly compared to preoperative values from 18.2 (5 to 45) to 46.6 (36 to 48) (p < 0.001). Radiographic analysis was undertaken for 53 shoulders (89.8%). This revealed humeral radiolucency in two cases (3.8%), glenoid radiolucency in 3 cases (5.7%) and radiographic rotator cuff failure in 8 cases (15.1%). 

Conclusion: This prospective cohort study shows excellent 10-year survivorship, medium to long-term clinical and radiological results and for the Synthes Epoca Resurfacing Head TSA. 

162 - Clinical effectiveness of intra-operative tranexamic acid use in shoulder surgery: a systematic review and meta-analysis

Alexander Hartland¹, Kar Teoh², Mustafa Rashid³

¹Broomfield Hospital, Chelmsford, United Kingdom; ²Princess Alexandra Hospital, Harlow, United Kingdom; ³Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Oxford, United Kingdom

Background: Tranexamic acid (TXA) has been shown to be effective in trauma, spinal surgery, and lower limb arthroplasty. The aim of this study is to investigate the clinical effectiveness of TXA in all types of shoulder surgery on bleeding and non-bleeding related outcomes.

Methods: This study was registered on the PROSPERO database (ref: CRD42020185482). A systematic review and meta-analysis of randomised controlled trials (RCTs) investigating intra-operative use of TXA versus placebo in any type of shoulder surgery. Electronic databases searched included MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and Jadad score. Certainty of findings were reported using the GRADE approach. The primary outcome was total blood loss. Secondary outcomes included patient reported outcome measures, adverse events, and rate of blood transfusion.

Results: Eight RCTs were included in the systematic review and data from 7 of these studies pooled in the meta-analysis. A total of 708 patients were randomised across the studies (406 received TXA, 302 received placebo). Pooled analysis demonstrated significant reduction in peri-operative bleeding with TXA compared to controls; estimated total blood loss (mean difference [MD], -209.66; 95% CI -389.11 to -30.21; p=0.02), and post-operative blood loss (via drain output) (MD, -84.8ml; 95% CI, -140.04 to -29.56; p=0.003). A mean difference in Visual Analogue Scale (VAS) of 2.93 was noted in favour of TXA (95% CI 0.2 to 5.66; p=0.04).

Conclusion: Whilst noting some risk of bias within studies, TXA was effective in reducing blood loss and pain in shoulder surgery. There may be a benefit of TXA use in both open and arthroscopic shoulder procedures. Larger, low risk of bias, RCTs for specific surgical shoulder procedures are required.

Implications: TXA can be used across shoulder surgery to reduce peri-operative blood loss.

163 - Outcomes of long head of biceps tenotomy are comparable to tenodesis: A systematic review and meta-analysis

Alexander Hartland¹, Raisa Islam², Kar Teoh², Mustafa Rashid³

¹Broomfield Hospital, Chelmsford, United Kingdom; ²Princess Alexandra Hospital, Harlow, United Kingdom; ³University of Oxford, Oxford, United Kingdom

Background: There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. 

Methods: This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomised controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardised mean difference (SMD) and a random effects model. Secondary outcome measures included visual analogue scale (VAS), rate of cosmetic deformity (Popeye sign), range of motion, operative time, and elbow flexion strength.

Results: 751 patients from 10 RCTs demonstrated (369 tenotomy vs 382 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.17 95% CI -0.02 to 0.36, p=0.09). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. Secondary outcomes including VAS, shoulder external rotation, and elbow flexion strength did not reveal any significant difference. Tenodesis resulted in a lower rate of Popeye deformity (OR 0.27 95% CI 0.16 to 0.45, p<0.00001).

Conclusion/Findings: Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. This finding was irrespective of the whether the rotator cuff was intact.

Implications: Surgeons should weigh up the additional time and cost required to perform a long head of biceps tenodesis against the lower rate of cosmetic deformity in light of lack of functional superiority to tenotomy.

181 - Diabetes and outcomes following reverse polarity shoulder arthroplasty- a single centre experience

Zakk Borton, Hasan Daoud, Chris Smalley, Marie Morgan, Tim Cresswell, Marius Espag, Amol Tambe, David Clark

Royal Derby Hospital, Derby, United Kingdom

Background: The effects of diabetes mellitus on outcomes following shoulder arthroplasty have not yet been fully elucidated. Large registry-based studies have suggested associations with increased length-of-stay, perioperative morbidity, and mortality. We aim to present retrospective review of a consecutive series of reverse polarity shoulder arthroplasties (rTSAs) and evaluate the presence of diabetes upon survivorship and clinical outcomes.

Methods: A prospectively maintained local joint registry was queried to identify primary rTSAs performed at a single UK centre. Minimum follow-up was 12 months. The primary outcome was the effect of diabetes on implant survivorship, complication rate, range-of-motion and patient-reported outcomes. 

Results: 407 shoulders in 386 patients were identified at median 43 months from surgery (interquartile range [IQR] 27-67). Median age was 76 years (IQR 70-80) and 294 (72.2%) female. 48 (11.8%) were implanted in diabetics. There was no significant difference in revision rate (0 vs 2.6%, p=1), all-cause complication (2.1% vs 3.7%, p=1), or mortality (22.9% vs 12.8%, p=0.059) between diabetic and non-diabetic cohorts.  Similarly, no differences were identified in flexion (115° vs 120°, p=0.455), abduction (100° vs 110°, p=0.535), external rotation (30° vs 30°, p=0.695), or patient reported outcomes (Oxford Shoulder Score 39 vs 40.5, p=0.772; Constant-Murley score 62 vs 62, 0.919).

Conclusions: Though a number of ‘big data’ studies have highlighted deleterious consequences of diabetes upon outcomes following shoulder arthroplasty, we were not able to demonstrate an appreciable clinical impact of diabetes on outcome in a large consecutive single-centre series of rTSAs.

Implications: Though surgeons should be cognisant of the findings of population-level studies, it should be borne in mind that further work is required to elucidate and quantify the effect of glycaemic control upon the risks conferred by diabetes and provide the granularity required to apply the association at the single-patient level.  

228 - Elbow hemiarthroplasty has equivalent functional outcomes and a lower early complication rate compared to open reduction internal fixation for treatment of multi-fragmentary distal humeral fracture in patients >60 years of age

Anand Tathgar¹, Humaid Ghori¹, Mina Derias², Robert Moverley², Joideep Phadnis²

¹Brighton and Sussex Medical School, Brighton, United Kingdom; ²Brighton and Sussex University Hospital, Brighton, United Kingdom

Background: Open Reduction Internal Fixation (ORIF) and elbow Hemiarthroplasty (HA) can both be used to treat multi-fragmentary distal humeral fractures in older patients, however to date there are no comparative studies evaluating outcomes of the two techniques.  

Objectives: To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or HA for a multi-fragmentary distal humerus fracture. 

Methods: 41 patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of 34 months (12-73 months). There were 20 patients in the HA group and 21 in the ORIF group. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes.

Results: Patients in the HA group had a higher mean OES (42.5 vs 39.6, p=0.28) and lower VAS (0.5 vs 1.7, p=0.08) although the difference was below the minimally important clinical difference for the Oxford Score. There was no difference in ROM between the two groups: mean flexion-extension arc (123° vs 112°, p=0.12). There were fewer complications (6% vs 39%, p=0.04), re-operations (6% vs 33%, p=0.09) and radiographic outcomes (22% vs 33%, p=0.71) in the HA group. Two patients had failed ORIF, requiring conversion to total elbow replacement. There were no revisions in the HA group. 

Conclusion: This cohort study demonstrated similar functional outcomes between ORIF and HA for treatment of multi-fragmentary distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group although longer term arthroplasty surveillance is required.   

379 - Radial head arthroplasty for trauma: Medium to long term outcomes of press-fit radial head arthroplasty

Pradeep Kankanalu, Alistair Eyre-Brook, Lawrence Majkowski, Valarie Jones, David Thyagarajan, Amjid Ali, Simon Booker

Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Aim: To evaluate the long-term survival of radial head arthroplasty (RHA) for unreconstructable radial head fractures and to report on the clinical, radiological, and patient-reported outcomes.

Methods: Retrospective review of consecutive primary RHA’s for trauma at a single trauma centre between 2007 and 2020. The primary outcome was survivorship of the implant. Secondary outcomes were clinical, radiographic, and patient-reported outcomes; Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS). 

Results: One hundred RHA’s in 63 men and 37 women with a mean age of 44 years (SD15) were included. 

Indications for RHA were unreconstructable radial head fractures with concomitant elbow instability (39); terrible triad injury (32); complex proximal ulna fracture-dislocations (25) and Essex-Lopresti injury (4).

Eight patients subsequently underwent RHA excision. An additional 15 patients underwent a further procedure. Kaplan-Meier cumulative survival was 90.1% at 10-years.

Seventy-five patients were available for review. Median time of review was 80-months (range 13 to 164) from injury. Mean flexion arc was 98⁰(5 to 140), supination 69⁰ and pronation 74⁰. The mean OES was 36.1 (7 to 48) and mean MEPS was 82.4(15 to 100). 72% of patients reported full and 13% partial return to their pre-injury activity level.

Mean time from injury to last radiographic assessment was 17 months (SD 23.1). Capitellar erosion was noted in 16; Radiographic loosening of stem in 32; Bone resorption around the neck of the prosthesis in 43; heterotrophic ossification in 15. The stem position in the canal was central in 80 patients. There was no statistically significant difference in OES or MEPS in patients with and without radiological loosening (p=0.221).

Conclusion: Our series has demonstrated that despite high incidence of clinical and radiological complications, press-fit RHA for unreconstructable radial head fractures yields a 10 year survival of 90.1% with good patient-reported outcomes. 

405 - Patient-specific instrumentation versus standard surgical instruments in primary reverse total shoulder arthroplasty: A retrospective clinical comparative study

Ahmed Elsheikh¹, Mohamed Galhoum², Margaret Roebuck³, Amanda Wood³, Qi Yin⁴, Simon Frostick³

¹Department of Orthopaedic Surgery, Faculty of Medicine, Benha University, Benha, Egypt; ²Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Shebin ElKoum, Egypt; ³Musculoskeletal Science Research Group, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom; ⁴Department of Orthopaedic Surgery, Royal Liverpool University Hospital, Liverpool, United Kingdom

Aims: Patients specific instrumentation (PSI) in shoulder arthroplasty has been theoretically and clinically studied, most of the results supported the positive impact of the PSI on the position of the glenoid component. Yet no clinical outcomes have been investigated. We compare the clinical outcomes of primary reverse total shoulder arthroplasty between two groups: PSI versus the standard methods. 

Methods: 53 patients were available to review, 35 patients (66%) received a primary standard RSTA and 18 patients (34%) received primary PSI RSTA. All patients were operated in a single centre and received the same prosthesis. The full record of preoperative and postoperative scores was analysed. 

Results: There was an overall significant postoperative improvement in the whole cohort (P < 0.05). The standard group had a significantly inferior preoperative constant score, forward flexion, lateral elevation (p = 0.02 and 0.034) respectively. Though, in comparison to the PSI group, both groups have no statistically significant differences in any clinical outcome postoperatively. PSI neither prolonged the waiting time to have the surgery (p = 0.693) nor the intraoperative surgical time (P 0.962). The median satisfaction level was 10 out of 10 with no difference between groups (p = 0.192).  Radiologically, PSI secured a higher percentage of optimum baseplate position and screw anchorage than the standard group, however, no statistical correlation was found. 

Conclusion: PSI did not achieve a better clinical outcome after primary RSTA in this series. Both groups achieved comparable good outcomes. Importantly, PSI did not negatively impact the waiting time or the surgical time. 

516 - Does the addition of cross-element fixation prevent locking screw subsidence following plate fixation of proximal humerus fractures?

Priyadarshi Amit, Kalpesh Vaghela, Ahmed Elkewey, Zahra Jaffry, Livio Di Mascio

Barts Health NHS Trust, London, United Kingdom

Purpose: The aim of this study to assess screw subsidence and screw penetration in proximal humerus fracture fixation with the PANTERA (Toby Orthopaedics, Miami, FL, USA) plate using cross-element fixation in comparison to the PHILOS (Synthes, West Chester, PA, USA) plate.

Methods: Fifteen consecutive patients who underwent proximal humerus fracture fixation with PANTERA plate system using cross elements (PANTERA group) between January 2019 and September 2020 were matched in 1:1 model based on age and Neer’s fracture classification with 15 patients who underwent fixation with PHILOS plate system (PHILOS group). Intraoperative and post-operative radiographs (after fracture union) were assessed for screw subsidence.  The Screw Subsidence Index (SSI) was calculated as a difference in screw-head ratio (ratio of screw length to the width of the head along the screw) between final radiograph and intraoperative radiograph on both coronal (Cor-SSI) and axial (Ax-SSI) view [SSI = postoperative screw-head ratio – intraoperative screw-head ratio]. 

Results: The mean age of patients in both group was 53.6±10.4 years. There were 66.7% and 53.3% male patients in the PANTERA and the PHILOS groups respectively. There were three patients with Neer’s two-part, six three-part and six four-part fractures in both groups. Seven patients in the PHILOS group were noted to have screw subsidence with mean Cor-SSI of 0.046±0.059mm and Ax-SSI of 0.045±0.059mm, while in the PANTERA group, mean Cor-SSI and Ax-SSI were zero with no difference in intraoperative and postoperative screw-head ratio (p = 0.005 and 0.028 for Cor-SSI and Ax-SSI respectively). Four patients in PHILOS group had screw penetration in comparison to none in PANTERA group (p = 0.09). 

Conclusion: The cross-elements in the PANTERA plate system significantly reduces screw subsidence following fixation as compared to PHILOS plate system. It may be effective in avoiding the screw penetration.

610 - Validation of the Radiographic Union Score for HUmeral fractures (RUSHU): a retrospective study in an independent centre

William Fordyce¹, Jonathan T Evans^2,3, Grace Kennedy¹, James Allen¹, Mohamed Abdelmonem¹, Jonathan P Evans^1,4, Paul Guyver¹

¹University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom; ²Torbay and South Devon NHS Foundation Trust, Torquay, United Kingdom; ³University of Bristol, Bristol, United Kingdom. ⁴University of Exeter, Exeter, United Kingdom

Background: Early diagnosis and fixations of fractures unlikely to unite can prevent months of pain and reduced function for patients. The Radiographic Union Score for Humeral fractures (RUSHU) has been suggested as a tool for predicting patients at high risk of developing non-union of humeral shaft fractures from a radiograph taken at six weeks. The RUSHU is summative scoring system based on signs of union on plain radiographs to give a score between 4 and 12.

Our aim was to externally validate the RUSHU system using a previously collected database of midshaft humeral fractures in our local population.

Methods: Fifty-seven patients were identified from our database who would have met the inclusion criteria of the original RUSHU study with radiographs taken six weeks after their injury. Three reviewers (blinded to patient outcome) independently scored the radiographs using the RUSHU tool and interobserver intraclass correlation (ICC) was calculated.

Results: Of the 57 patients, six progressed to non-union after six months. We observed an ICC co-efficient of 0.89 (95%CI.0.84,0.93) in the RUSHU score at six weeks indicating “near perfect” agreement. Median score at six weeks was higher in the group of patients that went on to union (10v5,p<0.001).  Of the six fractures that went on to non-union, none had a score of eight or more. Using the suggested score of <8 to predict non-union gave an area under the ROC curve of 0.87 (95%CI.0.83,0.90), positive predictive value 31% (95%CI.19.5,44.5), and negative predictive value of 100% (95%CI.96.8,100).

Conclusions: In this retrospective single-centre study, we have observed good inter-reviewer reliability and thus external validity of RUSHU. We suggest that the generalisability of RUSHU could be further assessed in a multi-centre prospective study. We agree with the statement of the initial paper, that RUSHU could potentially reduce morbidity of delayed treatment of non-union.

933 - Long-term outcomes following manipulation under anaesthetic for patients with frozen shoulder

Anna Fairclough¹, Christopher Waters¹, Thomas Davies², Peter Dacombe¹, David Woods^1,3

¹Great Western Hospital, Swindon, United Kingdom; ²Aintree University Hospital, Liverpool, United Kingdom; ³Ridgeway Hospital, Swindon, United Kingdom

Objectives: To evaluate the long-term (>10 years) outcomes of Frozen Shoulder (FS) post Manipulation Under Anaesthetic (MUA). FS is a common, debilitating condition for which MUA is a non-invasive and effective treatment option. Current literature has looked at short to medium-term outcomes, but there are no studies of long-term outcomes published. The long-term prognosis of this condition is therefore currently unknown. Knowledge of longer term outcomes is also vital if there is evidence that either frozen shoulder or its treatment with MUA pre-disposes to other shoulder pathology in the long term.

Methods: We conducted a retrospective analysis of 398 shoulders undergoing MUA for FS between Jan 1999 and Jan 2010; a complete data was obtained for 240 shoulders. Outcomes were Oxford Shoulder Score (OSS), recurrence rate and development of other shoulder pathology (arthritis or rotator cuff tear).

Results: At a mean follow-up of 13.2 years (10-20 years) 71.3% had no symptoms (OSS > 48), 16.6% had minor symptoms (OSS 42-47) and 12.1% had significant symptoms (OSS<42). There were 14 (5.8%) self-reported recurrences of FS >1 year (11 non-diabetic, 3 T1DM), of these only 4 (1.6%) occurred > 5 years after initial MUA, all in non-diabetic patients. Development of other shoulder pathology was not above the expected rate in a population of this age; 3.7% developed OA of the same shoulder and 6.7% a proven rotator cuff tear.

Conclusions: This study suggests that long-term outcome after MUA for FS is favourable. True late recurrence of FS is uncommon and the development of OA or rotator cuff pathology is no greater than that of the general population.

Implications: This study offers the first evidence that MUA for FS can offer patients a safe, effective and minimally invasive treatment in the long-term.

422 - Superior Capsular Reconstruction Versus Bridging Graft: A Prospective Randomised Controlled Trial

Tanujan Thangarajah, Saho Tsuchiya, Yohei Ono, Kristie More, Ian Lo

University of Calgary, Calgary, Canada

Background: The purpose of this study was to compare arthroscopic superior capsular reconstruction (SCR) to bridging grafting for massive irreparable rotator cuff tears. 

Methods: A prospective double-blind randomised study was conducted to compare SCR versus bridging graft for massive irreparable rotator cuff tears. Fifty patients (mean age: 60.2 +/- 6.0 years) with chronic tears (mean duration of symptoms: 5 +/- 5.2 years) were intra-operatively randomised following partial repair, to either bridging graft or SCR using human dermal allograft. All patients were followed-up at 3, 6, 12 and 24 months clinically and radiographically. Graft integrity was assessed at 12 months using magnetic resonance imaging (MRI). 

Results: Forty-six patients were available for follow-up at 2-years. The SCR group demonstrated significantly greater abduction (p<0.044) and forward flexion (p<0.020) at 3 months. At 24 months, the mean American Shoulder and Elbow Surgeons (ASES), Western Ontario Rotator Cuff (WORC) Index and Disabilities of the Arm, Shoulder and Hand (DASH) scores were 77.9, 69.5 and 25.0 for the bridging group and 74.8, 66.0, and 24.7 for the SCR group respectively. No significant differences were noted between groups. MRI demonstrated 16 of 25 (64%) in the bridging group and 18 of 24 (75%) in the SCR group were intact at 12 months. Compared to ruptured grafts, intact grafts (both bridging and SCR) were associated with significantly higher WORC (53.7 vs 72.3; p<0.040) and ASES (65.7 vs 81.0; p<0.021) scores at 24 months. Compared to baseline measurements, intact grafts were associated with a significantly higher acromiohumeral interval at 12 (p<0.033) and 24 months (p<0.008). 

Conclusion: At 2 years follow-up, functional outcome was not significantly different between groups. Compared to ruptured grafts though, intact grafts were associated with superior functional outcome scores and a higher acromiohumeral interval. 

Disclosure: IKL receives funding from Smith & Nephew. The remaining authors have nothing to declare. 

774 - Hip fracture surgery performed by cadaveric simulation-trained versus standard-trained residents: a pragmatic multicentre randomised controlled trial

Hannah James^1,2, Giles Pattison¹, James Griffin², Joanne Fisher², Damian Griffin^1,2

Abstract not available online

1197 - Who learns best: The tortoise or the hare? A randomised controlled trial of spaced practice versus intense training in immersive virtual reality

Thomas Edwards, Sikandar Khan, Arjun Patel, Shubham Gupta, Daniella Soussi, Alexander Liddle, Justin Cobb, Kartik Logishetty

Imperial, London, United Kingdom

Background: Evidence supporting the use of immersive virtual reality (iVR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. We aimed to investigate whether spaced iVR training is more effective than intense iVR training for novices learning hip arthroplasty.

Methods: 24 medical students with no hip arthroplasty experience were randomised to learning total hip arthroplasty using the same iVR simulation training either once-weekly or once-daily for four sessions. Participants underwent a baseline real-world assessment to orientate an acetabular component on a saw bone pelvis, and a baseline knowledge test. In iVR, we recorded procedural errors, time, numbers of assistive prompts required and path lengths of the hands and head across 4 sessions. To assess retention of the learnt skills, the iVR and baseline physical world assessments were repeated at one-week and one-month.

Results: Baseline characteristics were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the mean number of procedural errors from 76.8±37.5 (S1) to 11.1±10.1 (S4), compared to the weekly group improvement from 71.1±19.1 (S1) to 17.2±10.6 (S4), p < 0.001. The weekly group error count plateaued remaining at 16±6.7 at 1-week and 17.5±8.5 at one-month, the daily group however, showed poor retention with error counts rising to 17.8±10.5 at 1 week and becoming higher than the weekly group at one-month to (23.2±13.0 vs 17.5±10.5). A similar effect was noted for procedural time and the number of assistive prompts. In the real-world assessment, both groups significantly improved the accuracy of their acetabular component positioning, these improvements were equally maintained.

Conclusions: Daily iVR training facilitates faster skills acquisition, however weekly practice has superior skills retention. Skills learnt using both regimes demonstrate sustained transfer to the real-world.

79 - Long term core outcomes in Cauda Equina Syndrome

Thomas Barker^1,2, Lennel Lutchman², Nick Steele², Girish Swamy², Andrew Cook², Am Rai², Robert Crawford²

¹Colchester General Hospital, Colchester, United Kingdom; ²Norfolk and Norwich University Hospital, Norwich, United Kingdom

Introduction: Cauda Equina Syndrome (CES) can be associated with long-term autonomic dysfunction and chronic severe lower back pain. This study assesses the recently defined core outcome set for CES, in a cohort of patients, using validated questionnaires.

Material and Methods: 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our institution between January 2005 and December 2019. After review of patient records, patients were included only if they presented with clinical and radiological features of CES. Patients were classified as CES incomplete (CESI) or with retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. All patients provided written consent and completed a series of questionnaires.

Results: 61 of the 82 patients returned completed surveys. The mean age at presentation was 43 years and the mean duration of follow up was 58.2 months. Autonomic dysfunction was frequent with 33% of patients reporting bladder dysfunction, 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction respectively, 47% reported genital numbness, 67% reported significant back pain, 44% required further investigations and 10% required additional interventions for back pain. Quality of life was lower than expected when corrected for age and sex. Half of patients reported moderate or worse depression. 40% of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were statistically significantly more common in patients with CESR.

Conclusion: This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the Core Outcome Set for CES. Persistent severe back pain and on-going autonomic dysfunction was frequent in this cohort of patients at a mean follow-up of five years.

180 - Routine in-hospital radiographs following anterior cervical discectomy and fusion surgery:  neither necessary nor cost-effective?

Rory McCabe, James Davis, Melvin Grainger

Queen Elizabeth Hospital, Birmingham, United Kingdom

Purpose: To evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging. 

Design: A retrospective review of 101 consecutive ACDF patients of radiographs performed before discharge, associated length of inpatient stay and any complications involved. 

Methods: A retrospective review of 101 ACDF patients from a single neurosurgical centre. 78 had an in-hospital post-operative radiograph, 23 did not. In 95 of these, it was documented that there was ‘satisfactory intra-operative imaging’. All patients had intra-operative imaging of completed instrumentation. Any post-operative complications were noted, and the length of hospital stay (LOS) recorded. Study parameters also included: levels operated on, whether or not a plate was used with a cage, additional costings to the hospital.   

Results: There was one post-operative complication relating to the metalwork in the 101 patients. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR’s, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year.

Conclusion: In patients who undergo ACDF surgery with an uneventful post-operative course and satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace. 

232 - Histopathological and microbiological assessment of Paraspinal muscle tissue following spine surgery at a tertiary care centre

Sudeep Date^1,2, Nandan Marathe²

¹Cumberland infirmary, Carlisle, United Kingdom. ²Seth G.S. Medical College, K.E.M Hospital, Mumbai, India

Introduction: Spine surgery inherently causes damage to surrounding muscles. Injury is greatest when using midline posterior approach with multifidus being the most commonly injured muscle. Muscle atrophy coincides with decreased cross-sectional area which in turn co-relates with decreased force production capacity of the muscle. Aim of this study was to evaluate histological and microbiological changes in paraspinal muscles following long term retraction.

Materials and methods: Study was carried out at a tertiary care centre with a sample size of 150 subjects and study period of 2 years. 

All patients were operated by a single surgeon. 

Patients were classified on the basis of diagnosis, duration of surgery and the spinal level of surgery. 

Intra-operative muscle biopsies were taken from devitalized muscle tissue at the end of surgery and were analyzed for histological changes and microbiological growth.

Results:

90 patients showed ischemic necrosis changes on histopathological report.

17 patients showed a positive culture on microbiological examination.

7 patients had soakage at surgical site.

2 patients required wound wash.

Out of 17, the duration of surgery exceeded 10 hours in 12 cases.

Discussion: Direct injury to muscles occurs by dissection and stripping of attachments from the posterior elements of the spine. Electro-cautery leads to local thermal injury and necrosis. Long standing Self-retaining retractors cause muscle injury by mechanism similar to crush syndrome caused by pneumatic tourniquet.

Snipping off the devitalized muscle tissue, intermittent release of retractors, shorter surgery duration, relatively longer incision are measures advised to minimize paraspinal muscle injury following spinal surgeries and in turn reduce the wound dehiscence and infection rate.

274 - Decompression alone versus decompression with fusion for treatment of degenerative spinal foraminal stenosis: A systematic review

Pratik Shah, Duncan Whittaker, Tristan McMillan, Andrew Frost, Santosh Baliga

Aberdeen Royal Infirmary, Aberdeen, United Kingdom

Lumbar foraminal stenosis is a debilitating condition that requires consideration of surgical intervention in patients with refractory pain despite conservative treatments. However, there is no clear consensus on the specifics of surgical intervention, particularly whether a decompression is performed with or without fusion. 

A systematic review of the literature was performed and data collected using the PRISMA protocol. Databases searched were Pubmed, Embase and Medline. The search terms were decompression, fusion, posterolateral, foramina, random and fusion. The Boolean operators AND/OR were used. Studies reporting on decompression alone (DA) or decompression with fusion (DF) were included in the review. Primary outcomes were leg pain. Secondary outcomes were complications including re-operation, dural tear and recurrence.

9 studies (1 RCT and 8 Observational) were included in the final analysis, yielding a total of 331 patients. 228 patients had DA and 103 patients had DF. For leg pain, there was no statistically significant (P<0.05) difference in VAS, ODI when comparing DA with DF. For complications, odds ratio calculation yielded a value of 0.53 in favour of DA, however CHI-squared test for association revealed no difference in complications between DA or DF.

This review demonstrates no significant difference in outcomes and complication between DA and DF for treatment of lumbar foramina stenosis. However, this review also demonstrates the paucity of good quality evidence on this topic. The authors, therefore, recommend that treatment decisions should be patient specific and depend on the focus of compression, whether the compression is focal to foramen or there is co-existing compression of the nerve elsewhere and finally whether there is co-existing spinal deformity. To assist with this consideration and to aid the information gathering in future research we propose a new classification system for foraminal stenosis.

301 - Creation of an Osteoporotic Vertebral Fracture Pathway

Louis Hainsworth, Oliver Beaumont, Dushan Thavarajah, Yee Leung, Ashok Subramanian, Paul Thorpe, Pradeep Madhavan

Musgrove Park Hospital, Taunton, United Kingdom

Introduction: Osteoporotic vertebral fractures are a frequent source of referral to the spinal department at Musgrove Park Hospital. Out project aimed to identify the current workload of osteoporotic vertebral fractures in spinal emergency clinics and review how these fractures are investigated and managed.  

Methods: A notes review was undertaken of all patients seen in clinic between August 2020 and January 2021. For those who presented with an osteoporotic vertebral fracture we reviewed the investigations and management they underwent.

Results: 17% of all spinal emergency clinic appointments were for osteoporotic vertebral fractures. All patients were managed conservatively with 50% using a TLSO. All TLSO treatment had been started prior to clinic. 76% were discharged or given a patient initiated follow up after their first appointment, the remaining 23% were seen once more and then discharged. 

Discussion: The results showed that we make no changes to the management plan in clinic. Therefore, we have created an osteoporotic vertebral fracture pathway in which patients are given a patient information leaflet and a patient initiated follow up appointment from the time of referral.

Conclusion: We have developed an osteoporotic vertebral fracture pathway which will reduce clinic appointment and unnecessary XR’s while maintaining patient care.

344 - Standardising post-operative care documentation in spinal surgery through a simple, innovative, quality improvement process

Callum Edmonds¹, Siddharth Komperla¹, Lucy Amos², Rye Yap¹, Amy Neal², Natalie Mallinder², James Tomlinson², Raveen Jayasuriya²

¹Sheffield Medical School, Sheffield, United Kingdom; ²Sheffield Teaching Hospital, Sheffield, United Kingdom

Background: The NHS has increasing numbers of junior doctors, nurses, and therapists cross-covering speciality teams. Comprehensive post-operative care documentation is essential to reduce information clarification requests, ensure patient safety, and shorten length of stay. This project demonstrates how an iterative process brings quality improvement through simple effective innovation. 

Aim: To improve post-operative care documentation practices in spinal surgery.

Methods: 1) Stakeholder analysis, consultation and consensus from 7 spinal surgeons and wider MDT to generate evidence-based auditable criteria, 2) Audit baseline completeness of post-operative care documentation, 3) Stakeholder group to plan intervention, 4) Longitudinal monitoring and an iterative process to refine.

Results: Below summarises five audit cycles, over three years, and includes 283 major spinal operative notes.

Stage 1: A consensus was achieved on 15 essential criteria for complete documentation, including important negative fields.

Stage 2: Baseline audit demonstrated unexpectedly poor documentation: >75% compliance in four criteria, and <50% compliance for 10 criteria. 

Stage 3: A post-operative instruction template based on the 15 criteria was embedded within the existing IT software. It allowed continued use of existing operative templates, with the addition of a non-overwriting suffix requiring only two mouse clicks. 

Stage 4: Re-audit at 3 and 12 months showed improved and sustained compliance. At 24 months compliance had declined. Questionnaire of template usage identified problems of criteria response options, and lack of awareness of template by newly appointed consultants and registrars. Template updated and compliance over the next 4 months improved further (>75% compliance in 11 criteria).

Conclusion: Simple innovation changed documentation practices by 1) achieving a consensus from stakeholders, 2) a “shock and awe” moment to highlight existing poor documentation, 3) implementing change which fit easily into existing systems, 4) respecting autonomy rather than enforcing change and 5) an iterative process to ensure template was fit for purpose.

354 - Impact of a local pathway on the waiting time for MRI in patients presenting to a district general hospital with suspected Cauda Equina Syndrome

Hossam Fraig, DMR Gibbs, G Lloyd-Jones, NR Evans, GS Barham, HV Dabke

Salisbury District Hospital NHS Foundation Trust, Salisbury, United Kingdom

Aim: To assess the impact of the Salisbury Protocol for Assessment of Cauda Equina Syndrome (SPACES) on the waiting time for MRI in patients presenting with suspected CES in a UK district general hospital.

Patients and Methods: All consecutive patients undergoing an MRI scan in our hospital, for suspected CES (sCES), over a 12 month period, prior to and following the introduction of SPACES, were identified. Patient gender, age, MRI diagnosis, time from MRI request to imaging and outcome were recorded. 

Results: In the year prior to the introduction of SPACES, there were 66 patients (71% female, mean age of 48 years) with sCES. MRI confirmed cauda equina compression (CEC) in 15%, other spinal pathology in 58% and normal appearances in 27%. In the year following the introduction of SPACES, 160 patients (71% female, mean age of 50 years) with sCES underwent MRI which confirmed CEC in 6.2%, other spinal pathology in 70.8% and normal appearances in 23%. Referrals for MRI for sCES increased more than 2-fold following the introduction of SPACES, despite which there was substantial reduction in the median time from MRI request to scan from 9.1 to 4.2 hours (p=0.106, Mann-Whitney-U). Following introduction of SPACES, the number of patients transferred to the regional hub hospital annually, decreased from 7 to 3. 

Conclusion: The implementation of SPACES for patients with sCES results in a substantial reduction in waiting time for MRI and decreases the number of transfers to the regional hub hospital. Based on our early experience, we encourage other centres within the UK to introduce such a pathway locally, to improve the management of patients with sCES.

402 - Pedicle Screw Insertion - an Educational Assessment of Accelerated Learning

Darren Lui, Bisola Ajayi, Benjamin Barkham, Timothy Bishop, Jason Bernard

St George's Hospital, London, United Kingdom

Background: The correct placement of pedicle screws is a major part of spine fusion and it requires experienced trained spinal surgeons. In the era of European Working Time Directive (EWTD), surgical trainees have less opportunity to acquire skills. Josh Kauffman (Author of The First 20 Hours) examined the K.Anders-Ericsson study that 10,000 hours is required to be an expert. This study was done to show the use of accelerated learning in trainees to achieve competency and confidence on the insertion of pedicle screws.

Methods Data was collected using 3 experienced spine surgeons, 8 trainees and 1 novice (control) on the cadaveric insertion of pedicle screws over a 4 day didactic lecture in the cadaver lab. Each candidate had 2 cadavers and 156 screw placements over 4 hour shifts. Data was collected for time of pedicle screw insertion for each level on the left and right side. A pre-course and post-course questionnaire (Likert scale) was conducted. 

Results: 8 surgeons were involved. 1 spinal SpR, 6 spine fellows and 1 junior consultant. A physiotherapist was the control novice. The surgeons and the control got significantly faster over time. The control made significantly more errors than the surgeons. Surgeons were significantly faster by the end (p value < 0.05). The control got faster over time and by the end, was no longer significantly slower than the surgeon when they first started.

Conclusion: Pedicle screw insertion can cause significant morbidity, which includes paralysis. As a trainee, this is not an easy skill to acquire or practice. This focused pedicle screw course shows that a junior spinal surgeon can achieve improved competency and confidence in 20 hours but furthermore a complete novice can learn to insert pedicle screws and reach a level of competence almost at the level of the trainee in 20 hours as well. 

444 - The Effects of the Covid-19 Pandemic on Cauda Equina Syndrome Referrals in the Scottish Highlands

Iuliana Kanya¹, Jennifer Dunn², Gerard Cousins²

¹Ninewells Hospital, Dundee, United Kingdom. ²Raigmore Hospital, Inverness, United Kingdom

Cauda equina syndrome (CES) is regarded as an emergency due to the devastating implications for the patient and significant medico-legal consequences a missed diagnosis can have. The aim of our research was to evaluate whether the Covid-19 pandemic altered the threshold for presentation with suspected CES. We expected the conditions during lockdown between April and June 2020 to deter patients with CES symptoms from seeking medical attention. .

This was a retrospective single-centre study based in a district general hospital. We collected CES referral data between April 1^stto June 30^th, in 2019 and 2020. Our on-call daily trauma work-list was used, and this was cross-referenced to PACS imaging for both time-frames.

22 referrals were made in 2019 and 23 in 2020. 6 patients were referred by their GPs in 2019 and 12 in 2020. All referrals underwent an MRI assessment: there were 7 confirmed cases in 2019 and 2 confirmed cases in 2020 (p=0.07 using Fisher’s Exact). Therefore, the number of CES referrals and true positive cases was unaffected by the Covid-19 pandemic. As yet no missed cases of CES have been reported locally.

To our knowledge this is the only study to assess the impact of Covid-19 on CES presentation. We found that, unlike other critical conditions where the Covid-19 pandemic has led to a substantial delay in diagnosis, CES is still recognized by patients and primary care physicians and investigated promptly. Further work is necessary to determine the full extent of the Covid-19 pandemic on CES referrals and presentations in wider geographical areas.

587 - The impact of the COVID-19 pandemic first national lockdown on emergency referrals to a tertiary referral spine centre

Daniel Tadross, Antonia Isaacson, Neil Chiverton, James Tomlinson

Sheffield Teaching Hospitals, Sheffield, United Kingdom

Introduction: The novel virus SARS-COV-2 has had a profound worldwide impact, causing over 2 million deaths worldwide and unprecedented healthcare pressures. This study aimed to establish the effect of a national lockdown on rates and types of referral to a tertiary emergency spinal surgery service.

Method: All emergency referrals to Sheffield’s adult spine centre (direct emergency referrals and tertiary emergency referrals from 5 surrounding hospitals) over a six-month period were analysed (Jan 6th 2020 to July 26th 2020). Data collected included demographics, pathology being referred, mechanism of injury (where relevant), and treatment. 

Results: A total of 1156 patients were referred during the period studied. (680 direct and 411 indirect referrals, and 65 indirectly assessed and transferred to the spinal centre). Referrals were 21% lower across the lockdown, with a 58% reduction in atraumatic self-presentation in particular. Mean referrals were 43.3 patients per week (p/w) pre-lockdown, 34.2 p/w during lockdown, 45 p/w post lockdown.  

Statistically significant reductions (p<0.01) were seen in both direct and tertiary referrals made during the first month of lockdown. Referral patterns changed within the lockdown period with a mean of 17.75 referrals p/w during the first 4 weeks, returning to 38.3 p/w referrals during the second month. 

A ‘rebound’ increase was seen in each type of pathology presenting from 2 weeks post lockdown commencement. There was no change in the rate of tertiary referral with emergency transfer across the study period.

Conclusion: Referral patterns changed dramatically during the initial stages of lockdown, before recovering to normal levels. This emphasises the need for clear communication with both patients and colleagues that emergency spinal services are available during lockdown. Without this, there is a risk that patients with treatable pathology may come to unnecessary harm.

589 - Assessing the validity of a temperature sensor to monitor patient adherence to cervical spine orthosis wear time

Elizabeth Headon¹, Raveen Jayasuriya^2,3, Nikki Totton², Dominic Wardell⁴, James Tomlinson³

¹Lewisham & Greenwich Trust, London, United Kingdom; ²University of Sheffield, Sheffield, United Kingdom; ³Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom; ⁴University of Sheffield, Sheffield, United Kingdom

Keywords: Temperature Sensor, Validation, C-Spine, Immobilisation, Orthoses

Introduction: Cervical spine (c-spine) orthoses, also known as semi-rigid neck collars, offer conservative treatment for c-spine injuries. For many patients the orthosis is prescribed for full-time wear. In some cases these orthoses fail to manage the injury, and it is unclear whether this is a failure in the mechanical properties of the orthosis or patient compliance. 

Aim: To evaluate the validity of a generic orthosis temperature sensor to monitor compliance with a cervical orthosis. 

Methods: This observational study involved healthy participants, wearing a cervical orthosis according to a 150 minute protocol (n=8), tested at threshold temperatures of 22-31degrees, sampling every 15 minutes. 

Primary outcome: agreement of temperature sensor with digital camera to determine collar on versus collar off. 

Secondary outcome: validity of mean wear time. 

Results: The mean temperature whilst collar off was 22 degrees (SD=5.0) and whilst collar on was 28 degrees (SD=4.2). The highest agreement of the 160 data-points was demonstrated at a threshold of 25-27 degrees, which showed moderate agreement between sensor and camera for collar on time and collar off time. (Kappa =0.60, p value <0.001). These analyses are adversely affected by warm-up and cool-down lag. 

The mean warm-up of 16.8 minutes and cool-down time of 13.2 minutes were similar (p value>0.05), thus negating one another in wear time analysis. Mean detected wear time ranged from 189-90 minutes for thresholds 22-31degrees. A threshold of 25.5 degrees gives optimum correlation between sensor detected wear time and true wear time. 

Conclusion: This novel study demonstrates a widely available temperature sensor can be used to accurately and objectively measure patients’ compliance with cervical orthoses wear time. This has important implications for both clinical practice and research studies such as the forthcoming NIHR DENS study.

University of Sheffield ethical approval reference: 031694.

618 - Optimisation and validation of a new low profile adherence sensor for monitoring spinal orthosis wear-time

Dominic J Wardell¹, Raveen L Jayasuriya², Nikki Totton³, Andrew J Mills⁴, Lee M Breakwell², Ashley A Cole²

¹The Medical School, University of Sheffield, Sheffield, United Kingdom; ²Spinal Service, Sheffield Children's Hospital, Sheffield, United Kingdom; ³Clinical Research Trials Unit, University of Sheffield, Sheffield, United Kingdom; ⁴Spine Corporation, Chesterfield, United Kingdom

Background: Self-reported adherence to bracing in adolescent idiopathic scoliosis is unreliable. Thermal sensors have been trialled to objectively measure adherence in bracing research. Little is known about new low-profile sensors, optimal location within a brace, thermal micro-climate at a specific location and effect of brace lining thickness.

Aims:

1. Calculate optimal threshold for agreement between measured and true wear-time
2. Identify optimal sensor position
3. Quantify warm-up and cool-down time

Outcomes will inform the NIHR Bracing AdoleScent Idiopathic Scoliosis (BASIS) multicentre RCT evaluating full-time versus night-time bracing.

Methods: Seven Orthotimer and five iButton (DS1925L) sensors were synced to record temperature at five-minute intervals. Three healthy participants donned a rigid spinal brace, embedded with sensors at four anatomical locations. Experiments were conducted both in and outdoors according to four strict don/doff timed periods; 180-minute (9 repeats), 240-minute (3 repeats), 300-minute (3 repeats), 120-minute (6 repeats). In 300/120-minute repeats, 6mm foam lining separated one Orthotimer and skin in abdominal/axilla locations.

Intraclass correlation coefficient (ICC) assessed agreement between measured and true wear-time at threshold temperatures 15-36^oC.

Results:

Optimal threshold (indicated by greatest ICC>0.9):

Orthotimer: Abdomen=26^oC, axilla=27 ^oC, lateral-gluteal=24.5 ^oC, sacral=22.5 ^oC.

6mm foam: Abdomen=23.5 ^oC, axilla=24.5 ^oC.

iButton: Abdomen=26 ^oC, axilla=27 ^oC, lateral-gluteal=23.5 ^oC, sacral=23.5 ^oC.

Mean warm-up and cool-down time to threshold temperature (minutes):

Orthotimer: Abdomen=12, axilla=13, lateral-gluteal=12, sacral=12.

6mm foam: Abdomen=19, axilla=21.

iButton: Abdomen=6, axilla=6, lateral-gluteal=7, sacral=9.

Conclusion: Abdominal/axilla positions demonstrated higher optimised brace-on thresholds of 26/27 ^oC. Mean warm-up and cool-down times were similar and suitably low to avoid large error in clinical wear-time measurement. However, abdominal is most practical for fitting a sensor. Foam lining thickness must also be accounted for when setting thresholds.

Lateral-gluteal/sacral demonstrated lower peak temperatures, likely to fall below ambient temperature in warmer seasons.

Both sensors are clinically appropriate but custom position-specific thresholds are critical for reliable brace adherence monitoring.

721 - Comparative Study of PELD Percutaneous Endoscopic Lumbar Discectomy versus Traditional Surgical Discectomy Treatment Lumbar Disc Herniation

Ahmed Alkhuzai

Sulaimani University/ Faculty of Medicine, Sulaymaniyah, Iraq

Objective: Lumbar disc prolapse for long time treated by traditional Surgical Discectomy with rate of complications (Failed Back Syndrome). In this study we evaluated (PELD) Percutaneous Endoscopic Lumbar Discectomy, as minimal invasive technique, solve the disc prolapse, plus evaluation of this techniques in general.

Methods: From January of 2018 to January of 2020, 108 patients with symptomatic LDH, post failure of nonsurgical treatment were involved in this study. Classify into two groups after inclusion-exclusion criteria. Group A 56 patients used the PELD procedure assisted by fluoroscope plus Endoscopic techniques compared to. Group B 52 patients were traditional surgical discectomy of (LDH) lumbar disc herniation used fluoroscope alone for primary identification of the lumbar disc herniation level. Depend on (VAS) visual analog scale (VAS), (ODI) (Oswestry low back disability score), and Stanford scoring index for assessment of the results.  

Results; The PELD techniques using for lumbar disc herniation in group A patients, were noticed significant improvement in the mean of Stanford score and ODI (Oswestry low back disability index score) from baseline were at all follow up visit at 12, 24 Months according to sciatica pain Functional outcome, with the general satisfaction rate. Compare to group B 52 patients were traditional surgical discectomy of (LDH) lumbar disc herniation. Also there were significant statistical differences at 12, 24 Months follow up for both Stanford and ODI Oswestry index, revealed high outcome results for group A was treated by (PELD) Percutaneous Endoscopic Lumbar Discectomy Herniation (P- value <0.001), compared to group B were treated by classical lumbar Discectomy. With minimal complications rate in group A compared to group B.

Conclusion. This study indicated that PELD assisted by fluoroscope plus Endoscopic techniques is safe, accurate, simple, minimally invasive, rapid relief from pain, little scarring and efficient  in Compare to traditional surgical discectomy for the treatment of lumbar intervertebral disc herniation. 

937 - Fusion and Subsidence in Cervical Disc Replacements - A Retrospective Cohort Study

Oliver Beaumont, Louis Hainsworth, Ashok Subramanian

Musgrove Park Hospital, Taunton, United Kingdom

Background: Anterior cervical decompression is a well established operation for treatment of cervical myelopathy with good outcomes. Subsequent stabilisation with disc replacement rather than fusion has been shown to provide improved mobility in the neck and reduce further canal stenosis at adjacent levels. This study evaluates the rates of prosthesis subsidence and fusion in the disc replacement population, seeking to evaluate the true long term risks and benefits of disc replacements and therefore whether the increase cost and complications verses cervical decompression and primary fusion are justified. 

Methods: Retrospective review of 100 consecutive Mobi-C cervical disc replacements performed in a single centre by 3 independent reviewers (2 surgeons and 1 radiologist). Follow-up radiographs were reviewed up to 2 years for all patients by assessing range of movement on flexion/extension lateral views and osteophyte formation. Inter-observer reliability was calculated to ensure accurate reporting of results.

Conclusion/Findings: Patients received Mobi-C disc replacements at between 1 and 3 cervical levels. Some received a hybrid of replacement and fusion at adjacent levels. We found a high rate of fusion, compared to that reported in the literature. Rates of subsidence were low. We performed secondary analyses looking at the impact of age, sex, number of levels replaced and concurrent adjacent level fusion.

Implications: Spinal surgeons must consider that there is a significant rate of fusion in the mobi-C cervical disc replacement cohort and weight up the cost of implants and surgical time versus primary fusion when planning anterior cervical decompression surgery. Rates of subsidence were low, therefore we do not consider complications to be significantly higher than decompression with primary fusion as other potential complications impacting outcome are common to both cohorts.

995 - Consent Is a Process Not Just a Form

Olivia Payton, Adrian Gardner

Royal Orthopaedic Hospital, Birmingham, United Kingdom

Background: Scoliosis surgery is a large undertaking for patients and their families and is not without risks. Spinal surgery complications account for a large proportion of medico-legal action. It is therefore vital to ensure that the risks of surgery are understood, and discussions are documented clearly in letters and on the consent form.

We reviewed the consent forms and letters of patients undergoing surgery for adolescent idiopathic scoliosis (AIS) for the complications of corrective surgery.

Methods: Gold standards for consent in AIS were derived following a review of the literature. The consent process was reviewed against these standards. One point was issued for each complication that was deemed essential for consent.

Results: From a maximum score of 12 points the mean was 8 (5-11) on consent forms, rising to 9 (5-12) with clinical letters included. All patients were consented for the risk of paralysis, 90% for damage to nerve root. There was no mention of infection for one patient on consent form or in the letters. Where there were approach specific risks, these were always indicated. This was only applicable for four patients. Blood clots were documented in 75% of cases. Ongoing symptoms were mentioned in all but one patient.

On average most patients had a documented discussion for consent at least once prior to signing a consent form. From the notes available all patients were issued with other sources of information including websites, information booklets and our deformity nurse specialists.

Conclusion: Consent is more than the completed form. It is vital that patients understand the undertaking. A detailed clinical letter provides better evidence of a thorough discussion than a stand alone form. This audit shows that a considered, crafted letter provides more opportunity for detail than the small space on a form filled in.

1000 - The effects of long-term blood thinner usage on the operative complications and patient-reported outcome measures of elective lumbar microdecompression surgery

Madhumita Kolluri, Himanshu Sharma

University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom

Background: An increasing number of patients who undergo lumbar microdecompression surgery also have a history of blood thinner usage secondary to cardiovascular and other co-morbidities. This study aimed to investigate how long-term blood thinner usage in patients before operation affects surgical and patient-reported outcome measures (PROMs) of elective lumbar microdecompression surgery. 

Methods: Medical notes of patients who had elective posterior lumbar microdecompression surgery between 2013 and 2018 at University Hospitals Plymouth NHS Trust (Plymouth, UK) were analysed. Complication rates and PROMs were retrospectively analysed between 26 patients with a history of pre-operative blood thinner usage (BT group) and thirty patients who were not on blood thinners (NBT group). Complication rates and PROMs were then further analysed in n = 22 patients of the BT group according to whether the patient stopped their blood thinner use immediately before the operation (BTstop) or continued blood thinners intraoperatively (BTnstop). A p value < .05 was considered statistically significant.

Results: There were no statistically significant differences in the rates of venous thromboembolisms, wound complications, dural tears, neurological complications, blood transfusions or bleeding complications between BT and NBT groups. The NBT and BT group had similar improvements in post-operative pain and functional scores. In addition, even when patients continued blood thinner use intraoperatively (BTnstop), long-term pre-operative blood thinner usage did not correlate with increased incidence of operative complications or less patient improvement postoperatively. 

Conclusions: This study’s results show that patients with long-term blood thinner use are not at higher risk of important postoperative complications than patients not on blood thinners, even if blood thinner usage is continued intra-operatively. Additionally, patients with a background of blood thinner usage have similar improvements in pain and functional abilities post-operatively to those not on blood thinners.

1050 - Preoperative neutrophil-lymphocyte ratio (NLR) and lymphocyte percentage are useful predictors of postoperative complications after lumbar fusion

Temidayo Osunronbi¹, Balint Borbas², Hiba Lusta², Agbolahan Sofela^3,2, Himanshu Sharma³

¹Hull Royal Infirmary, Hull, United Kingdom; ²University of Plymouth, Plymouth, United Kingdom; ³Southwest Neurosurgery Centre, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom

Background: Although preoperative blood parameters such as neutrophil-lymphocyte ratio (NLR) have shown prognostic value in various fields such as cancer surgery and cardiac surgery, their utility in spine surgery is unclear. Hence, we aimed to determine the prognostic value of preoperative blood tests for predicting postoperative complications after lumbar fusion.

Methods: We performed a single-centre single-surgeon retrospective study of 88 consecutive patients who underwent lumbar fusion. Demographic data and preoperative laboratory biomarkers were collected. The laboratory biomarkers included sodium, creatinine, albumin, haematocrit, platelet count, white-cell count, differential leukocyte counts/percentages (neutrophil, lymphocyte, and monocyte), NLR, platelet-lymphocyte ratio, and monocyte-lymphocyte ratio. The outcome measure was 30-day postoperative complications, and the patients were divided into ‘complication’ and ‘no complication’ groups. Receiver operating characteristics (ROC), Youden's index and binary logistic regression analysis were used to determine the prognostic accuracy of the preoperative variables for complications. p < 0.05 was considered statistically significant.

Results: 11 out of 88 patients had postoperative complications. Pneumonia and surgical site infection were the most common complications (4 patients each).  ROC results showed that preoperative lymphocyte percentage (cut-off ≤ 29.5%; sensitivity: 91%, specificity: 54.9%; AUC= 0.707) and preoperative NLR (cut-off ≥ 2.32; sensitivity: 72.7%; specificity: 64.8%; AUC = 0.693) could significantly discriminate between the 'complication' and 'no-complication' groups. The odds of complications was 4.91 times greater in patients with NLR ≥ 2.32 compared to those with NLR <2.32 (OR= 4.91, 95% CI: 1.19 – 20.2, p= 0.03). The odds of complications was 12.2 times greater in patients with lymphocyte percentage ≤ 29.5% compared to those with values >29.5% (OR= 12.2, 95% CI: 1.48 – 100, p=0.02). 

Conclusion: Patients with preoperative lymphocyte percentage ≤ 29.5% and/or NLR ≥ 2.32 should be closely monitored as a high-risk group susceptible for postoperative complications. Further large scale prospective multicentre studies are needed to confirm our findings.

1082 - Mortality predictors for operative management of acute sub-axial cervical spine fractures in elderly patients

R Mohammed, Abdul Azeem Badurudeen, A N Moideen, S Ahuja

University hospital of Wales, Cardiff, United Kingdom

Background: Despite increasing incidence of sub-axial cervical spine injuries in elderly population, the literature evidence is limited predicting the mortality following operative management of this patient population. The aim of this study is to identify predictors of mortality in surgically treated acute sub-axial cervical spine fractures in patients over 65 years of age.

Methods: A retrospective clinical and radiological review of 37 consecutive patients (27 male) aged >65 years who underwent surgical stabilization of C3-C7 fractures in a large tertiary spine centre was conducted. Basic demographics, pre-operative haemoglobin, lymphocyte count, serum albumin, renal function, neurological deficits, Sub axial cervical spine injury score (SLIC score), type of operation, radiological fusion, complications, need for revision surgeries and mortality rates were analysed. Multiple regression analysis was performed to identify predictors for 30-day and 1-year mortality in these patients.

Results: The mean age was 73.8 years (range 66-94 years). Falls from standing height was the commonest mechanism (82%). 15 patients (41%) had spinal cord injury (SCI) of whom two were complete. 34 (91%) patients had anterior-only surgery, and three underwent 360⁰ stabilization. The 30-day mortality rate was 13% (n = 4) and the 1-year mortality rate was 31% (n = 9). Overall complication rate was 33% with need for revision surgery in 5 (13.5%) patients. No correlation was noted for either 30-day and 1-year mortality with regards to patients age, sex, hematological parameters, SLIC score, presenting neurological deficit, complications, or revision surgery. 

Conclusion: Our study shows that mortality in this subgroup of patients is multi factorial. Surgical stabilization of acute sub-axial cervical spinal fractures in the elderly is associated with significant mortality and morbidity which needs to be considered for careful preoperative counselling of the patient and the family. 

1123 - Comparison of SPECT/CT with MRI in imaging scoliosis: Does SPECT/CT provide superior diagnostic information?

Daniel Thurston, Patrick Hurley, Falaq Raheel, Steven James, Rakesh Gadvi, Rajesh Botchu, Jwalant Mehta

Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom

Combining Single Photon Emission Computed Tomography (SPECT) with standard Computed Tomography (CT) has been shown to be superior to plain scintigraphy and CT alone, but there is little work comparing SPECT/CT with Magnetic Resonance Imaging (MRI), or establishing what role SPECT/CT may play in imaging painful scoliosis. Our aim was to compare SPECT/CT with MRI in a cohort of scoliosis patients to determine if SPECT/CT provided additional information over MRI which altered management.

We performed a retrospective review of all scoliosis patients seen at our tertiary spinal centre who underwent SPECT/CT and MRI within 12 months of one another over a 13 year period. Clinic letters and case notes were reviewed to collect data on diagnosis and whether SPECT/CT altered management. Imaging was reviewed by a specialist musculoskeletal radiologist. Chi-squared test was used to determine any significant difference between MRI and SPECT/CT findings.

140 patients identified. Average age 30 years (Range: 9 — 84). MRI and SPECT/CT reported no spinal abnormality in 72 and 85 patients, respectively. No significant difference in abnormality detection between MRI and SPECT/CT (p=0.92). Of MRI scans reported normal, SPECT/CT only detected spinal abnormality in 12 patients (17%). Where both scans reported spinal abnormality, there was agreement in only 53.5%.

SPECT/CT has proven a useful adjunct in imaging the painful post-operative spine and is superior to MRI here due to metal artefact. It has also been demonstrated to identify pain generators in patients with degenerative spinal disease. In our study, we have not found any clinically useful diagnostic information to be gained from SPECT/CT compared with MRI in patients with painful scoliosis. Combined with the increased radiation exposure the modality necessitates, we would not recommend SPECT/CT in this cohort of patients.

188 - Identification of Lumbar Spine kinematics with the use of inertial measurement units (IMU)

Georgios Papagiannis^1,2, Athanasios Triantafyllou^1,2, Panayiotis Papagelopoulos¹, Elias Papadopoulos³, Panayiotis Koulouvaris¹

¹Orthopaedic Research and Education Center “P.N.Soucacos”, Biomechanics and Gait Analysis Laboratory “Sylvia Ioannou”, “Attikon” University Hospital, 1st Department of Orthopaedic Surgery, Medical School, National and Kapodistrian University of Athens, Greece; ²Laboratory of Neuromuscular and Cardiovascular Study of Motion, Physiotherapy Department, Faculty of Health and Care Sciences, University of West Attica, Athens, Greece; ³Konstantopouleio General Hospital, Nea Ionia, 2nd Department of Orthopaedic Surgery, Medical School, National and Kapodistrian University of Athens, Greece

Background: The literature reports 5%-15% recurrence rate of lumbar spine microdiscectomies (LSMs). Lumbar spine flexion (LSF) is mentioned as the most harmful load to the intervertebral disc that could lead to recurrence during the 6 post-operative weeks. Patients with sagittal plane ROMs more than 10° during that period had a recurrence rate of 26.5%, whereas those with less than 10° had a rate of 4.1%. The purpose of this study is to quantify LSFs, following LSM, by quantifying (monitoring during daily activities) the frequency of more than 10° LSF ROM, at the period of 6 weeks postoperatively. 

Methods: ROMs where recorded during 33 subjects’ daily activities for 24 hours twice per week. MetaMotionR+, Inertial Measurement Unit (IMU), was used for the measurement of lumbar spine kinematics. 

Results: The mean number of more than 10 degrees of LSFs per hour were: 40,1/hour during the 1st  postoperative week (P.W.) ( 29% normal subjects-N.S.), 2nd P.W. 61,2/h ( 44% N.S.), 3rd P.W. 72,9/h ( 52,7% N.S.), 4th P.W. 61,1/h ( 61,1% N.S.), 5th P.W. ( 69,7% N.S.) and 6th P.W. 106,25 ( 76,9% N.S.).

Discussion: LSFs constitute important risk factors for rLDH. Although patients’ data report less sagittal plane movements than normal, further in vitro studies should be done by using our results of the patients' kinematic, to identify if such a kinematic pattern could cause re-herniation of microdiscectomied lumbar discs. Furthermore IMUs could be additionally used as a precaution measure, to alert patients by vibration, whenever they exceed acceptable rates of LSFs.

548 - Post-void bladder scanning in the assessment of patients with suspected Cauda Equina Syndrome: Single centre experience during the Covid-19 pandemic

Michael Price¹, Joseph Attwood¹, Philippa Banks¹, James Davies¹, Aneil Shenolikar²

¹Health Education England, Yorkshire and the Humber, United Kingdom; ²Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom

This was an audit and retrospective observational cohort study of local practice during the first eight months of the United Kingdom’s response to the Covid-19 pandemic, beginning with the World Health Organisation’s declaration of Pandemic status on 11.03.2020. The aim of this study was to describe presentation patterns and out-of-hours management of Cauda Equina Syndrome (CES) and its mimics in our district general hospital in the setting of the SARS-CoV-2 (Covid-19) pandemic. Primary outcome was local validation of Katzouraki et al’s recent findings in relation to post-void residual urinary bladder volumes (PVR) greater than 200ml as a sensitive and specific indicator of cauda equina compression. Secondary outcomes included evaluation of the level of detail and clarity of documented examination findings within the Emergency Department and orthopaedic clerking notes to support efficient neurosurgical referral and decision making. 

104 consecutive patients (38 male, 66 female) were referred out of hours with suspected cauda equina syndrome between 13.03.2020 and 11.11.2020, excluding those who self-discharged from the emergency department and those ineligible for MRI scan on account of having incompatible pacemakers or nerve stimulating devices. Mean age was 47.2yrs (23-94yrs). 4 patients (M:F 1:1) had MRI-proven intervertebral disc protrusion causing cauda equina compression, all of whom were transferred for urgent neurosurgical management. PVR >200ml was found to be a statistically significant (p=0.02), 75% sensitive and 83.82% specific predictor of cauda equina compression (OR 15.6, 95% CI 1.48-163.55) but an under-utilised resource, having been neglected in 31% of patients. Local education and quality improvement programmes may improve consistency and help to risk-stratify patients.

693 - Fulcrum bending radiographs give superior results to lateral bending radiographs for surgical planning in adolescent idiopathic scoliosis

Ben Barkham, Kieran Kelly, Rachel Williams, Bisola Ajayi, Darren Lui, Timothy Bishop, Jason Bernard

St Georges Hospital, London, United Kingdom

Introduction: When planning surgery for correction of adolescent idiopathic scoliosis, the flexibility of the spine is assessed with radiographs pre-operatively. This is assessed by measuring the Cobb angle, using an AP whole-spine radiograph and comparing this with lateral flexion in an attempt to eliminate the curvature. This can be achieved with a ‘lateral bend’ or a ‘fulcrum bend‘ radiograph. The fulcrum bend radiograph was introduced in our institution in 2017 and in this study we look at the impact of the introduction of this investigation. 

Method: All pre-operative radiographs of patients who underwent scoliosis surgery in our institution between 2012-2020 were reviewed. AP radiographs were measured for the Cobb angle. Radiographs performed prior to 2017 also had the lateral bend radiograph cobb angle measured. Radiographs after 2017 had the cobb angle measured using the fulcrum view. Patients were excluded if they did not have a lateral or fulcrum bend radiograph respectively.  

Result: 125 patients were identified between 2012 and 2017. 73 of these patients had AP and lateral bending radiographs. The mean AP Cobb angle was 62^o and the mean lateral bend cobb angle was 52^o. 107 patients were identified between 2017 and 2020. 42 of these patients had a fulcrum radiograph that was performed satisfactorily. The mean Cobb angle on AP radiograph was 59^o and the mean angle of the fulcrum bend radiograph was 31^o.

Conclusion: When assessing flexibility of adolescent idiopathic scoliosis, the fulcrum bend radiograph is the superior investigation when compared with the lateral bend radiograph.

33 - Positive predictors of a good outcome following surgical fasciotomies for chronic exertional compartment syndrome (CECS) and a predictive scoring system to guide management

Christopher Trew, Thomas Parsons, Cezary Kocialkowski, Tristan Barton

Royal United Hospital, Bath, United Kingdom

Background: Chronic Exertional Compartment Syndrome (CECS) of the lower limb usually responds well to fasciotomies.  A careful history from the patient and positive compartment pressure testing are both required in order to accurately diagnosis CECS. This study sought to evaluate a cohort of post-fasciotomy patients for proposed predictive criteria of a good surgical outcome. 

Methods: 28 post-fasciotomy patients were reviewed retrospectively.  Case notes and their subjective pre- and post-operative pain scores were gained via patient questionnaire. All patients underwent pre-operative dynamic compartment pressure monitoring. Point-Biserial and Pearson Correlation coefficient were used to calculate correlation between multiple diagnostic criteria and pain score reduction following surgical fasciotomies.

Results: A peak compartment pressure of over 40mmHg (r=0.71, p=0.0007) and an Area Under the Curve (AUC) of greater than 22,000mmHgSec² (r=0.7, p=0.00016) were found to strongly correlate with a positive surgical outcome. A moderate correlation was found between having a classical history (r=0.61, p=0.006), a duration of symptoms less than 1 hour after stopping exercise (r=0.6, p=0.006), and an average gradient of greater than 10 (r=0.6, p=0.006). No correlation was found with the other criteria. When combined into an objective, weighted scoring system (2 points if correlation >0.7, 1 point if >0.5 and <0.7) a score of 4 points or more (out of 7) had a correlation coefficient of r=0.85 (p=0.0001) with a good improvement in pain scores following surgical fasciotomies. Linear regression of this score found a good fit (R²=0.61, p<0.0001), indicating a degree of predictive power. 

Conclusion: We have identified diagnostic criteria in the history and investigation of patients with CECS that can be used to help predict positive outcomes following fasciotomies. We propose a scoring system to aid clinicians in their management of such patients. We recommend taking these results forward for prospective trials to test the efficacy of predictive scoring.

127 - Return to competition following clavicle fractures in professional road cyclists

Alastair Konarski¹, Matthew Walmsley¹, Neil Jain²

¹Royal Bolton NHS Foundation Trust, Manchester, United Kingdom; ²Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom

Background: Clavicle fractures are amongst the most common injuries sustained by road cyclists, but there is little evidence about return to competition times (RTCT) in elite athletes. Our aim was to investigate this, and risk factors for delayed return.

Methods: We identified cyclists who sustained clavicle fractures between 2015-2020.  Freely available records were reviewed to validate data for the primary outcome, which was RTCT.  Secondary outcomes included return to outdoor cycling time, management, time to surgery, cause of injury, other injuries, and ability to complete the event they returned to.

Results: We reviewed records of 1,117 cyclists, (669 male, 448 female) identifying 157 with clavicle fractures.  Recurrent fractures were excluded, leaving 140.  99.3% returned to elite competition, and mean RTCT was 60 days (range 14-206d, male 60d vs female 53d, p=0.51).  Where information was obtainable, 80% underwent surgery at an average of 2.7 days post-injury.  The most common cause was a crash with other cyclists.  Average return to outdoor cycling was 25 days and 90% completed the event they returned to. There was no significant difference in the RTCT between surgically (61d) and conservatively managed fractures (51d, p=0.15).   Isolated clavicle fractures returned quicker than multiple injuries (55.4 vs 75.5d, p<0.05). RTCT was lower for injuries sustained January-July (53d) than September-December (97d, p<0.05)

Conclusion: This is the largest study of RTCT in elite athletes with clavicle fractures.  Elite cyclists are at high risk of clavicle fractures and the majority are managed surgically.  No statistical difference was seen between operative or conservative management, although we did not differentiate grade of injury, and would not recommend management of individual fractures based on this.  Isolated injuries and those in the early season returned quicker. RTCT is higher than often expected by the media, and this data can help plan rehabilitation, and manage cyclists’ expectations.

639 - Strength and proprioception are preserved following internal brace repair of the anterior cruciate ligament

William Wilson¹, Matthew Banger², Graeme Hopper³, Mark Blyth³, Gordon MacKay⁴, Philip Riches¹

¹University of Strathclyde, Glasgow, United Kingdom; ²Imperial College, London, United Kingdom; ³NHS Greater Glasgow & Clyde, Glasgow, United Kingdom; ⁴Rosshall Hospital, Glasgow, United Kingdom

Anterior cruciate ligament (ACL) repair, where the ligament is re-attached and augmented with suture tape negates the need for graft harvest, maintaining native anatomy. The aim of this study is to compare functional outcomes including strength and proprioception following ACL repair and reconstruction surgery. 

Nineteen ACL repair and nineteen hamstring ACL reconstruction patients (mean 4 years post-operatively), were recruited post-operatively along with twenty healthy volunteers. Knee laxity using Rolimeter and range of movement (ROM) were recorded. Maximal isometric quadriceps and hamstring strength at 90° knee flexion was measured using a fixed myometer. Knee angles were measured using a 16-camera Vicon 3D motion capture system with joint position sense (JPS) assessed actively at 15° and 50°. Participants performed a single leg hop test battery and limb symmetry index (LSI) was calculated as operated:uninjured side.

There were no differences in demographics between groups; mean age 29, 64% male, Tegner 6.4. LSI was greater for hamstring strength in the repair group (95%) than the reconstruction group (81%). Hamstring strength of the reconstructed legs was lower than healthy volunteers by 0.29 Nm/kg (p<0.05), but the repair group showed no significant weakness. Reconstructed knees had greater laxity and less ROM than healthy volunteers, with no difference for the repairs. For JPS, the mean error difference between operated and uninjured knees was 0.4° higher at 15°, and at 50° was 3.3° higher for reconstruction than repair (p<0.05). No significant difference was evident for hop tests.

Hamstring weakness and proprioceptive deficits seen following ACL reconstruction are not evident following ACL repair. This asymmetry could contribute to re-injury and influence functional performance. Longer term, altered biomechanics may lead to development of osteoarthritis. The absence of these deficits in the repair group, supports the theory that this technique may be suitable for use in clinical practice.

971 - Factors Associated with Return to Work and Sport following a Humeral Shaft Fracture

William Oliver¹, Samuel Molyneux¹, Timothy White¹, Nicholas Clement¹, Andrew Duckworth^1,2

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²University of Edinburgh, Edinburgh, United Kingdom

Background: The primary aim was to determine the rate of return to work and sport following a humeral diaphyseal fracture. The secondary aim was to identify factors associated with failure to return to work and sport.

Methods: From 2008-2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Details of pre- and post-injury work and sport were obtained via postal survey. The Work Group comprised 177 patients in employment prior to injury (mean age 47yrs [17-78], 50.8% female [n=90/177]) and the Sport Group comprised 182 patients involved in sport (mean age 52yrs [18-85], 57.1% female [n=104/182]).

Results: Mean follow-up for the Work Group was 5.8yrs (1.3-11). Eighty-five percent (n=151/177) returned to work at a mean of 14wks post-injury (range 0-104). Of these, 59.9% (n=106/177) returned full-time to their previous employment. Female sex (OR 2.5, p=0.042), alcohol-abstinence (OR 3.0, p=0.024), heavy-manual work (OR 5.5, p=0.031), sustaining a right- (OR 2.8, p=0.019) or dominant-sided injury (OR 2.4, p=0.044) and proximal-third fracture (OR 4.6, p=0.014) were associated with failure to return to work.

Mean follow-up for the Sport Group was 5.4 years (1.3-11). The mean University of California, Los Angeles Activity Score reduced from 6.9 before injury to 6.1 afterwards (p<0.001). Eighty-nine percent (n=162/182) returned to sport, 7.7% (n=14/182) within 3 months, 34.1% (n=62/182) within 6 months and 69.8% (n=127/182) within 1yr. Age ≥60yrs (p=0.016), having comorbidities (OR 4.5, p=0.015), being unemployed/retired (OR 4.2, p=0.002), concomitant radial nerve palsy (OR 4.8, p=0.030) and persistent nonunion (OR 17.9, p=0.032) were associated with failure to return to sport.

Conclusions: Most patients successfully return to work and sport following a humeral diaphyseal fracture. Specific risk factors exist for failure to return to work and sport, which may be useful for surgeons counselling patients about expected return to activity after these injuries.

101 - Anatomic reconstruction of acute unstable syndesmotic injuries in elite athletes using suture tape (InternalBrace)

Nick Harris^1,2, Gareth Nicholson², Ippokratis Pountos³

¹Spire Leeds Hospital, Jackson Avenue, Leeds, United Kingdom; ²Department of Sports Medicine, Leeds Becket University, Leeds, United Kingdom; ³Academic Department of Trauma and Orthopaedics, University of Leeds, Leeds, United Kingdom

Background:  The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment modalities used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyse the functional outcome and the return to play of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. 

Methods: Data on a consecutive group of elite athletes with unstable syndesmotic injuries treated with the use of the InternalBrace was collected prospectively. Our patient group consisted of 19 elite athletes with a mean age of 24.5 years. Isolated injuries were seen in 12 patients while associated injuries were found in 7 patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture and posterior malleolus fracture). All patients were followed for a minimum of 17 months. 

Results: All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The average return to play was 8.9 weeks (range 7-12 weeks) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 14.9 weeks (range 8 to 28 weeks). The AOFAS score returned to 100 postoperatively in all patients. Knee to wall measurements were the same as the contralateral site in 18 patients while one patient lacked 2 cm compared to the contralateral side.

Conclusion: In conclusion, this study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilisation with good short term results including early return to sports in elite athletes.

Disclosures: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this study.

107 - Fracture healing in patients with human immunodeficiency virus in South Africa: a prospective cohort study

Simon M Graham^1,2,3, Sithombo Maqunho¹, Maritz Laubscher¹, Michael Held¹, Nando Ferriera⁴, William J Harrison³, Hamish Simpson⁵

¹Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa; ²Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom; ³Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom; ⁴Division of Orthopaedic Surgery, Stellenbosch University, Cape Town, United Kingdom; ⁵Univeristy of Edinburgh, Edinburgh, United Kingdom

Background: Human immunodeficiency virus (HIV) reduces bone mineral density, mineralisation and turnover, and may impair fracture healing. This prospective cohort study in South Africa investigated whether HIV infection was associated with impaired fracture healing following trauma.

Methods: All adults with acute tibia and femur fractures who underwent intermedullary nailing (IM) for fracture fixation between September 2017 and December 2018, at two tertiary hospitals, were followed for a minimum of 12 months post-operatively. The primary outcome was delayed bone union at 6 months (defined by the radiological union scoring system for the tibia [RUST] score <9), and the secondary outcome was non-union (defined as RUST score <9) at 9 months. Multivariable logistic regression models were constructed to investigate associations between HIV status and impaired fracture healing.

Results: In total, 358 participants, who underwent 395 IM nailings, were enrolled in the study and followed up for 12 months. Seventy-one participants (71/358, 19·8%) were HIV positive (83 IM nailings [83/395], 21.0%). HIV was not associated with delayed fracture healing after IM nailing of the tibia or femur (multivariable odds ratio [OR]: 1·06; 95% confidence interval [CI]: 0·50–2·22). HIV-positive participants had a statistically significant lower odds of non-union compared to HIV-negative participants (multivariable OR: 0·17; 95% CI: 0·01–0·92).

Conclusions: Fractures sustained in HIV-positive individuals can undergo surgical fixation as effectively as those in individuals who are HIV negative, with no increased risk of delayed union or non-union.

Disclosures: This study was funded by a Wellcome Trust Research and Training PhD Fellowship and support from the AOUK foundation.

108 - Identifying Research Priorities in Musculoskeletal Trauma Care in Sub-Saharan Africa

Simon M Graham^1,2,3, On behalf of Orthopaedic Research Collobroative in Africa (ORCA)⁴

¹Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom; ²Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom; ³Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, United Kingdom; ⁴Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa

Background: Musculoskeletal (MSK) injuries occur at disproportionately higher rates in low- and middle-income countries (LMICs). Despite the large burden of death and disability from MSK injuries in LMICs there has been little policy, research and funding invested in addressing this clearly neglected problem. This study used a consensus-based approach to identify research priorities for clinical trials and research in MSK trauma care in sub-Saharan Africa. 

Methods: A modified Delphi technique was used, which involved an initial scoping survey, a two- round Delphi process and an expert panel formed of members of the Orthopaedic Research Collaborative in Africa. The survey was conducted amongst MSK health care practitioners treating trauma in sub-Saharan Africa. 

Results: Participants from 34 countries across sub-Saharan Africa contributed to the two rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Public health topics related to trauma care ranked higher than those focused on clinical effectiveness, with the top ten public health research questions scoring higher than the top questions for clinical effectiveness. Ten public health and ten clinical effectiveness question related to musculoskeletal trauma care were identified, with the top highest ranked questions in respective categories relating to education and training and the management of femur fractures.

Conclusion: This consensus-based research agenda will guide healthcare professionals, academics and funders to improve the evidence in MSK trauma care across sub-Saharan Africa and inform funders about priority areas of future research. 

Disclosures: This study was not funded but it was supported by AO Alliance.

117 - Ankle Injury Rehabilitation (AIR): a multicentre randomised controlled trial and economic evaluation

Rebecca Kearney¹, Rebecca McKeown¹, Nicholas Parsons¹, Helen Parsons¹, Aminul Haque¹, Jaclyn Brown¹, Siobhan Kefford¹, Martin Underwood¹, Anthony Redmond², James Mason¹, Henry Nwankwo¹, Matthew Costa³

¹University of Warwick, Coventry, United Kingdom; ²University of Leeds, Leeds, United Kingdom; ³University of Oxford, Oxford, United Kingdom

Background: Ankle fractures are common and usually immobilized in a cast or functional brace. 

The objective was to compare function, quality of life, complications and resource use in adults treated with cast immobilisation vs. functional brace after an ankle fracture.

Methods: A multi-centre randomised clinical trial registered on the International Standard Randomized Controlled Trial Number registry with reference number ISRCTN15537280 on 24th July 2017.

20 UK hospital trusts recruited participants aged 18 years or over with an acute ankle fracture, suitable for cast immobilisation. Exclusion criteria included fractures secondary to metastatic disease; complex intra-articular fracture; requiring close contact casting; surgical wound complications or pre-existing neuropathic joint.

Participants received either cast (n=334) and completed active unloaded ankle range of movement exercises once the cast was removed; or functional brace (n=335) and completed active unloaded ankle range of movement exercises immediately. 

The primary outcome was the Olerud Molander Ankle Score (OMAS: score range 0 (totally impaired) to 100 (completely unimpaired) at 16 weeks, analysed by intention to treat.

Results: 669 participants were randomized and 502 (75%) completed the study. There was no significant difference in the 16-week primary analysis (favours brace: 1.8; 95% CI -2.0 to 5.5; p=0.296) or secondary unadjusted, imputed or per protocol analyses. Functional bracing was more costly (£67; 95% CI -9 to 139) but increased quality-of-life (0.01 QALYs, 95% CI 0∙004 to 0∙015) after 16 weeks. The incremental cost-effectiveness ratio was £6887/QALY (p=0.99; ICER <£30,000/QALY) indicating functional brace is cost effective.

Conclusions: We found no difference in the Olerud Molander Ankle score between the trial arms at 16 weeks. The health economic evaluation indicates that functional bracing is likely to be a cost-effective alternative to plaster casting and good value to the NHS.

Disclosure: Funded by the National Institute for Health Research (NIHR; CDF-2016-09-009).

174 - Manipulation of Distal Radius Fractures: A Comparison of Bier’s block Vs Haematoma block

Ben Oakley¹, Chris Busby², Sammie-Jo Arnold³, Sanat Kulkarni⁴, Sushrut Kulkarni², Ben Ollivere¹

¹Queens Medical Centre, Nottingham, United Kingdom; ²Kings Mill Hospital, Mansfield, United Kingdom; ³Queens Medical Centre, Mansfield, United Kingdom; ⁴Kings Mill Hospital, Mansfield, United Kingdom

Background: Distal radius fractures are a common injury, displaced fractures often require manipulation under anaesthesia. There are many anaesthetic techniques described, the two most commonly used are Bier’s Block (BB) and haematoma block (HB), there is a limited evidence base comparing the two techniques. Despite national guidance preferring a Bier’s block, a haematoma block is often performed instead. 

Aims: To compare the properties of a Bier’s block to a haematoma block when manipulating distal radius fractures. 

Method: This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two NHS trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A Numeric rating scale pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters. Regression analysis was used to compare the outcomes of HB to BB.

Results: 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB 66.5 IQR 55-74: 67 IQR (55-74) HB, p=0.79) or fracture characteristics (p=0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p<0.005). Those undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p<0.005). The BB was performed mainly by Senior House Officers, the HB were performed by a range of clinicians from Emergency Nurse practitioners to Consultants. 

Conclusion: Bier’s block provides superior analgesia and is more likely to result in a successful reduction. This can be reliably performed by Senior House Officers. 

202 - Exposing the incidence of ileus in pelvic and acetabular fractures: a retrospective case analysis

Alex Ward, Ramsha Ahmed, Janine Adedeji, Jonathan McGregor-Riley

Sheffield Teaching Hospitals, Sheffield, United Kingdom

Background: Paralytic ileus is a temporary inhibition of gastrointestinal mobility in the absence of mechanical obstruction. Ileus has previously been observed in up to 40% of patients undergoing bowel surgery, leading to increased morbidity and length of stay. Pelvic and acetabular fractures are often caused by high energy trauma and are associated with risk of visceral injury. Prior to this study, there were no reported figures for the incidence of ileus in patients presenting with pelvic and/or acetabular fractures.

Methods: All patients over the age of 16 presenting to a major trauma centre throughout 2019 were included. Data collected included patient demographics, injury pattern, fracture management and presence of ileus. As in previous studies, patients were identified as having ileus if they failed to tolerate an oral diet and open their bowels for more than three days (GI-2). Analysis assessed risk factors for ileus as well as its effect on length of stay. 

Results: The incidence of ileus observed in the 57 patients included was 40.35%. Across all patients, ileus was three times more common in patients with a diagnosis of diabetes mellitus (p= 0.56) and 2.5 times more common in the presence of an open pelvic/acetabular fracture (p= 0.73). Length of stay was significantly longer in patients under 65 years identified as having ileus (p= 0.046). Gender, age, opiate use, fracture management and surgical approach were not identified as risk factors for ileus.

Conclusion: This is the first study to report the incidence of and risk factors for ileus following admission with pelvic and/or acetabular fractures. Due to the morbidity and cost associated with this condition, further research is required to assess the effect of interventions to reduce its incidence in this patient subgroup.

788 - Surgical treatment of dorsally displaced distal radius fractures with a volar locking plate versus conventional percutaneous methods: minimum ten-year follow-up of a randomised controlled trial

Sandeep Deshmukh¹, Ben Marson², Reuben Ogollah², Tim Davis³, Alexia Karantana¹

¹Centre for Evidence Based Hand Surgery, University of Nottingham, Nottingham, United Kingdom; ²University of Nottingham, Nottingham, United Kingdom; ³Queen's Medical Centre, Nottingham, United Kingdom

Background: We report a minimum ten-year follow-up of a single-centre, pragmatic, randomised controlled trial (RCT) conducted in a tertiary care UK institution which compared the functional outcomes of dorsally displaced distal radius fractures treated with volar locking plate or percutaneous wire fixation.

Methods: Of the original trial cohort of 130 patients, 11 had not consented to further contact and 14 were deceased. Therefore 105 patients were sent the Patient Evaluation Measure (PEM), QuickDASH and EuroQol-5D-3L (EQ-5D-3L) questionnaires at a minimum follow-up of 10 years. They were also asked if they had received further treatment for their injured wrist and whether additional problems had developed in the hand/wrist after the original 1 year follow-up period. A complete case analysis, and sensitivity analysis via a mixed-effects model, were performed.

Results: Approximately 75% of the 105 participants responded. There were no significant differences between the scores of the two treatment groups in the PEM p=0.651 (95% CI, -4.8 to 3.0), QuickDASH p=0.862 (95% CI, -7.8 to 6.5) or the EQ-5D-3L index value p=0.256 (95% CI, -0.18 to 0.05) and health state p=0.377 (95% CI, -4.8 to 12.8). Results of mixed-effects model analysis were similar, suggesting that our findings were robust. One patient required plate removal 6 years after fixation. No major difference was found in the requirement for further treatments.

Conclusion: This study has a high follow-up rate considering the protracted follow-up period. It demonstrates that, as with the original 1-year functional outcomes, the 10-year outcomes of these two treatments are not significantly different. The original trial reported better anatomical reduction of fractures treated with volar plate fixation – our findings suggest that this does not make a difference to use of the hand or wrist in the long-term.

836 - Implications of a Specialist Hip Fracture Service on Outcomes after Internal Fixation of a Trochanteric Hip Fracture

Alexandra Macmillan, Martyn Parker

Peterborough City Hospitals, Peterborough, United Kingdom

Background: Trochanteric hip fracture fixations are common and usually undertaken by orthopaedic surgeons of varied grades and sub-specialisms. The purpose of this study was to compare outcomes of these operations performed by a specialised hip fracture surgeon to those performed by other surgeons. 

Methods: A review was performed of patients with trochanteric hip fractures treated with a sliding hip screw or an intramedullary nail at a single centre over 22 years. A hip fracture database of a consecutive series of patients was used. Outcomes of operations performed by a hip fracture specialist were compared with those performed by other surgeons. Outcomes of intra- and extra-medullary fixations and of A1, A2 and A3 fractures were considered separately.  

Results: 3078 patients were identified. 1858 operations were undertaken or directly supervised by a specialised hip fracture surgeon, 214 by a consultant orthopaedic surgeon with a different sub-specialism and 1008 by an orthopaedic trainee. 

There was no significant difference in outcomes or complications for the consultant with a different specialised interest and the trainee surgeons therefore the results for these two groups were combined. For A2 trochanteric hip fractures treated with an intramedullary nail, there was a statistically significant reduction in the risk of cut out (1.0 versus 9.7 percent) and need for revision surgery (1.6 versus 8.1 percent) for operations performed by a specialised surgeon compared to those performed by other surgeons. 

Conclusion: These findings indicate that fixation of a trochanteric hip fracture with a sliding hip screw has acceptable outcomes for the different levels of surgical expertise but for intramedullary fixation of A2 unstable trochanteric fractures, reduced fracture fixation complications may be obtained with a specialised surgeon.

907 - Timing of surgery for internal fixation of intracapsular hip fractures and complication at 1 year; a 35-year clinical study of 2,366 patients at a single Level 2 trauma centre

Senthooran Kanthasamy^1,2, Kendrick To^1,2, Jeremy Ian Webb^3,2, Mohamed Elbashir^4,2, Martyn J Parker²

¹Department of Trauma and Orthopaedic Surgery, Addenbrookes Hospital, Cambridge University Hospitals, Cambridge, United Kingdom; ²Department of Trauma and Orthopaedics, Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, United Kingdom; ³Department of Trauma and Orthopaedics, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom; ⁴Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Background: Internal fixation has a limited role in intracapsular fractures due to concerns of non-union and avascular necrosis. We looked at a 35-year period analysing 2,366 patients who underwent osteosynthesis following intracapsular fractures assessing the risk of non-union or avascular necrosis.

Methods: A multivariate regression analysis was performed looking at factors predictive of non-union and avascular necrosis after intracaspular hip fracture fixed by internal fixation between December 1988 to February 2020. We focused on patient demographics, time to surgery from presentation, type of fixation, fracture pattern and complications at one year. Primary outcome measures assessed whether delay to surgery contributed to risk of complications, defined as non-union or avascular necrosis. Secondary outcomes assessed if other factors influenced these rates. 

Results: 2,366 patients were identified with an average age of 74.7 (16-103) of which 66.5% were female (n=1573). 50.3% of fracture were displaced (n=1189) with the remaining undisplaced. 20.3% had complications at one year following fixation (n=481). 3.3% were fixed by dynamic hip screw (n=78), 0.3% by intramedullary nail (n=6), 53.1% by cannulated screws (n=1257) and 43.3% by Targon® screw (n=1025). Multivariate regression analysis revealed no significant correlation between delay to surgery and complication rates (OR 0.99, 95% CI 0.99, 1.01, p=0.55). Significant findings for complications include female sex (OR 2.03, 95% CI 1.58, 2.62, p<0.0001), displacement of fracture (OR 4.8, 95% CI 3.79, 6.14, p<0.0001). Factors reducing complication rates were independent mobility status (OR 0.64, 95% CI 0.47, 0.87, p=0.004) and use of Targon® screws in comparison to parallel screws (OR 0.61, 95% CI 0.48, 0.76, p<0.0001). 

Conclusions: Our study demonstrates no relationship between timing of surgery for fixation of intracapsular fracture and complication rates. Female sex and displacement increases risk. Independent mobility as well as use of Targon® screw device in comparison to parallel screws are protective against complications. 

913 - Hindfoot Ankle Reconstruction Nail Trial (HARNT) - A National collaborative study of complex ankle fractures in the United Kingdom

Caesar Wek¹, Thomas Stringfellow², Duncan Coffey³, Ines Reichert¹, Raju Ahluwalia¹

¹King's College Hospital, London, United Kingdom; ²Broomfield Hospital, Chelmsford, United Kingdom; ³Whipps Cross Hospital, London, United Kingdom

Introduction: The management of open or unstable ankle and distal tibial fractures pose many challenges. In certain situations, hindfoot nailing (HFN) is indicated, however this depends on surgeon preference and regional variations exist. This study sought to establish the current management and outcomes of complex ankle fractures in the UK.

Methods: We conducted a National collaborative study in affiliation with BOTA. Data was collected retrospectively between January 1^st – June 30^th 2019. All adult patients with open and closed complex ankle fractures (AO43/44) were included. Complex fractures included the following patient characteristics: diabetes +/- neuropathy, rheumatoid arthritis, alcoholism, polytrauma and cognitive impairment. We obtained data on fixation choice and patient outcomes. Ethical approval was obtained, and statistical analysis was performed including propensity matching.

Results: Fifty-six centres provided data for 1360 patients. The average age of the cohort was 53.9 years +/-19 (SD) with a male/female ratio of 552/708. 920 patients were ASA 1/2, 440 were ASA 3/4. There were 316 diabetic patients in the cohort and 275 open fractures. Most fractures were AO44 (71.2%) with 28.8% AO43.

1227 patients underwent primary fixation (111 HFN), with the remainder treated with external fixation (84 definitive). Of the 111 HFN, 35% underwent primary fusion. The wound complication rate was observed to be greater in the HFN group compared to the ORIF group ((16.2% v 10.5%). This was more evident in the HFN group with primary fusion. However, 1081 patients were non-weightbearing post-op contrary to the BOAST guidance.

Conclusion: The study conducted is the first National collaborative audit of complex ankle fractures. Hindfoot nails were used in 9% of patients and we observed more complications in this group when compared to the other cohorts. Despite guidance from BOAST, only 21% of patients who underwent operative management were instructed to fully weightbear post-operatively.

968 - Factors Associated with Long-term Outcome Following a Humeral Shaft Fracture: Results for 291 Patients at a Minimum One-Year Follow-Up

William Oliver¹, Henry Searle¹, Samuel Molyneux¹, Timothy White¹, Nicholas Clement¹, Andrew Duckworth^1,2

¹Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ²University of Edinburgh, Edinburgh, United Kingdom

Background: The primary aim was to assess patient-reported outcomes at ≥1yr following a humeral diaphyseal fracture.  The secondary aim was to compare the outcomes of patients who achieved union after initial management (operative/non-operative) with those who achieved union after nonunion surgery.

Methods: From 2008-2017, 291 patients (mean age 55yrs [17-86], 58% [n=168/291] female) were retrospectively identified and available for longer-term follow-up.  Sixty-four (22%) were managed operatively (within 12wks of injury) and 227 (78%) non-operatively.  After initial management, 227 patients (78%) achieved union (n=62 operative, n=165 non-operative), two had a delayed union (both non-operative) and 62 (21%) developed a nonunion (n=2 operative, n=60 non-operative).  Fifty-two of 56 patients (93%) subsequently achieved union after nonunion surgery.  Patient-reported outcomes (abbreviated Disabilities of the Arm, Shoulder and Hand score [QuickDASH], EuroQol 5-Dimension [EQ-5D] and Visual Analogue Scale [EQ-VAS], 12-item Short Form scores [SF-12]), were obtained via postal survey at a mean of 5.5yrs (1.2-11.0) post-injury.

Results: The mean QuickDASH was 20.8, EQ-5D 0.730, EQ-VAS 74, SF-12 pain component summary (PCS) 44.8 and mental component summary 50.2.  Patients who united after nonunion surgery reported a worse functional outcome (mean QuickDASH 27.9 vs. 17.6, p=0.003) and health-related quality of life (HRQoL; mean EQ-5D 0.639 vs. 0.766, p=0.008; EQ-VAS 66 vs. 76, p=0.036; SF-12 PCS 41.8 vs. 46.1, p=0.036) than those who united after initial management.   When adjusting for confounders, union after nonunion surgery was independently associated with poorer function (difference in QuickDASH 8.1, p=0.019) and HRQoL (difference in EQ-5D -0.102, p=0.028).

Conclusions:  Humeral diaphyseal union after nonunion surgery was associated with poorer limb-specific function and HRQoL compared to patients who united after initial management.  Targeting early operative intervention to patients at risk of nonunion may have an important role, given the potential impact of nonunion on longer-term outcome.

203 - Manipulating paediatric forearm fractures in A&E: A positive outcome from the COVID-19 pandemic

Jacob Koris, Sunny Deo

Great Western Hospital, Swindon, United Kingdom

Background: Paediatric forearm fractures are a common presentation to hospitals. Traditionally, initial manipulation has been performed using awake sedation in A&E, however for a number of reasons, this is decreasingly common. BOA guidance during the COVID-19 pandemic put greater emphasis on non-operative intervention. This research looks to assess differences in behaviours between the lockdown, and non-lockdown periods of 2020.

Methods: A prospective database of all paediatric (<18 years old) patients presenting with fractures of the forearm, with an unacceptable level of displacement for 2020 was collected. Patient demographics, fracture morphology, intervention, length of stay in A&E, and operative interventions was collected and compared between those presenting during lockdown 2020, and those presenting outside of lockdown 2020.

Results: 117 patients were included.  58 (49.6%) presented to A&E during lockdown and 59 (50.4%) outside this period.

There were no significant differences in the demographics or fracture morphology of the two groups. 

Significantly more patients during lockdown had manipulations in A&E (86.21% vs 45.75%, p<0.05).Significantly less patients required a general anaesthetic during lockdown (34.48% vs 72.88%, p<0.05). Patients manipulated in A&E during lockdown were also significantly less likely to require further surgical intervention than those manipulated outside of lockdown (26.00% vs 48.15%, p<0.05). 

When surgery was required, rates of different operations were comparable.

The average time in spent in the A&E department in the lockdown group was significantly shorter (03:04, range 00:42 = 07:08), than that of the non-lockdown group (03:51, range 00:56 – 09:31).

Conclusion: During lockdown 202, a much higher proportion of paediatric forearm fractures underwent manipulation in A&E, and these significantly more likely to be successful as the definitive treatment, avoiding the need for general anaesthetic and manipulation in theatre.

Further studies are looking at parent acceptability of these interventions.

236 - Distal Femur Fractures: Is Nail-Plate Fixation the Solution?

Kanai Garala, Darryl Ramoutar, James Li, Farhan Syed, Mateen Arastu, Jayne Ward, Sunit Patil

UHCW, Coventry, United Kingdom

Objectives: Distal femur fractures can occur in osteoporotic bone and with high energy trauma. Options for fixation include a locking plate or femoral nail. Locking plates have a risk of metalwork failure. Intramedullary nails lack the distal locking options which are vital in very distal and comminuted fractures. This study compares the outcomes of single lateral femoral plating (SLP) and combined nail-plate fixation (NPF).

Design: Retrospective case control study

Setting: A single major trauma centre

Patients and Participants: All patients who sustained distal femur fractures (OTA 33-A2, 33-A3, 33-C, 33-V3B and 33-V3D) over the study period 

Intervention: Single lateral plating compared to nail-plate fixation

Main Outcome Measure: The main outcome measure was union rates. Secondary outcome measures was reoperation rate, mortality and post-operative weight bearing

Results: 68 distal femoral fractures were included in the study. 19 patients had peri-prosthetic distal femur fractures. 40 were treated by SLP, 28 were managed with NPF. 17 (43%) of patients in the SLP group were given instructions to non-weight bear for 6 weeks post-surgery compared to 1 (4%) in the NPF group (p=0.0002). 7 (18%) patients treated with SLP experienced metalwork failure due to non-union. The union rate in the SLP group was 72% compared to 100% in the NPF group (p=0.04) Reoperation rates and mortality were comparable between the 2 groups. 

Conclusions: NPF has a superior union rate for native and peri-prosthetic distal femur fractures when compared to SLP and allows reliable early weight-bearing. 

592 - Definitive fixation to flap coverage within a 48 hour ‘safe window’ reduces deep infection rate in type 3B open tibial shaft fractures

Khalid Al-Hourani¹, Clary Foote², Andrew Duckworth¹, Tim White¹, Michael Kelly³, Paul Tornetta III⁴

¹Edinburgh Orthopaedics, Edinburgh, United Kingdom; ²McMaster University, Ontario, Canada; ³Southmead Hospital, Bristol, United Kingdom; ⁴Boston Medical Centre, Boston, USA

Introduction: Open tibial shaft fractures requiring flap coverage are potentially devastating injuries. To date, there remains debate as to the optimal timing from definitive fixation to definitive flap coverage. This study aimed to delineate whether a ‘safe-window’ exists for timing from definitive fixation to definitive flap coverage.

Methods: Retrospective cohort study of 373 patients from 15 United States/United Kingdom trauma centres. Patients who underwent definitive fixation and flap coverage in the same sitting (n=183) were compared to those undergoing definitive fixation and subsequent flap coverage at separate intervals (n=190). The primary outcome was deep infection rate. The timing groups were ascertained utilising ROC curves, with significant cut-points for a negative outcome identified at days 0, 2 and 5.

Results: Mean age of 42.4 years (SD 18.2); 270 males (72.4%) and remaining 103 females (27.6%). A delay of up to 2 days was not associated with an increased risk of infection, (RR 1.12, 95% CI 0.92 to 1.37, p=0.26). There was a relative risk increase for deep infection for delays between 2-5 days (RR 1.55, 95% CI 0.96 to 2.50, p=0.09). The risk increased further for patients flapped later than five days (RR 1.64, 95% CI 1.01 to 2.65, p=0.04). The infection rate difference between groups (i.e. risk difference) would be expected to be 4.9% (95% CI 0.1 to 10.5%) at 2-5 days versus single-stage definitive fix and flap, and >5 days at 9.3% (95% CI 1.7 to 20.3%).

Conclusions: This multi-centre cross-Atlantic study is the largest known to focus on the timing of definitive fixation to flap cover in type IIIB open tibial shaft fracture, observing a ‘safe window’ of 48 hours between stages. Minimizing the delay from definitive fixation (i.e. nailing) to flap coverage has the potential to reduce the deep infection rate in Gustilo IIIB open fractures by 4.9%.

704 - The Effects of Anaesthetic Modalities on Post-Operative Outcomes for Patients with Neck of Femur Fractures

Charmilie Chandrakumar¹, Talhah Atcha¹, Sebastien Ho², Gemma Green³, Amanda Humphreys²

¹Barts Health NHS Trust, London, United Kingdom; ²Croydon University Hospital, London, United Kingdom; ³Barts Health NHS Trust, London, United Kingdom

Background: Hip fractures continue to be devastating injuries and they can be extremely painful. The aim of this study was to evaluate the effects of various anaesthetic modalities on postoperative outcomes in patients who underwent surgery for neck of femur fractures. 

Methods: All patients >65years old who underwent hip fracture surgery at Croydon University Hospital from 1 January 2016 to 31 December 2019. Interventions: Hip fracture surgery under general anaesthesia (GA), spinal anaesthesia (SA), general anaesthesia with nerve block (GANB) or spinal anaesthesia with nerve block (SANB). Primary and secondary outcome measures: The primary outcomes were the length of stay (LOS) in hospital and commencement of early mobilisation. The secondary outcomes were duration of surgery, duration of anaesthetic and post-operative pain requiring pharmacological intervention. 

Results: 1121 patients underwent hip fracture surgery, 192 (GA), 312 (GANB), 158 (SA) and 459 (SANB). Length of stay in hospital in days was lower in SANB + SA groups compared to GANB + GA groups (5.7 +/- 1.2 vs 7.3 +/- 1.5, p<0.02). The incidence of day 1 mobilisation was higher in SANB + SA groups than GANB + GA groups (415 (37.3%) vs 186 (16.6%), p<0.00001, 95% CI 0.021 to 0.053. The incidence of day 1 post-operative pain was lower in SANB than GANB group (235 (21.0%) vs 288 (25.7%), p<0.0001, 95% CI 0.016 to 0.041. In general, there was reduced time in surgery and under anaesthesia time for SA + SANB groups to GA + GANB groups. 

Conclusion: Spinal anaesthesia with nerve block was associated with better outcomes than general anaesthesia with nerve block, in terms of length of stay, post-op pain, in patients with severe co-morbidities who underwent hip fracture surgery.

Disclosure: These are preliminary results and more data is being looked into.

105 - Investigating Mirels’ scoring for Upper Limb Metastasis: Should the cut-off for prophylactic surgery be different?

Katie Hoban¹, Samantha Downie¹, Jamie MacLean¹, Douglas Adamson¹, Paul Cool², Arpit Jariwala¹

¹NHS Tayside, Dundee, United Kingdom. ²The Robert Jones and Agnes Hunt Orthopaedic Hospital, Keele, United Kingdom

Background: Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. Its reproducibility and reliability are questioned in the upper limb given small number of patients with metastasis here. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastatic disease and validate its use in pathological fracture prediction. 

Methods: A retrospective cohort study of patients with upper limb metastases, referred to a UK Orthopaedic Trauma Centre over 6-years (2013-18).  Mirels’ score was calculated in 32 patients; plain radiographs at index presentation scored using Mirels’ system by 6 raters. The radiological aspects (lesion size &radiological appearance) were scored twice by each rater (2-weeks apart).  Inter- and intra-observer reliability were calculated using Fleiss’ kappa test. Bland-Altman plots compared variances of individual score components and total Mirels’ score.

Results: Mirels’ score of ≥9 did not accurately predict lesions which would fracture (11% 5/46 versus 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%.  When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture than not (48% 22/46 versus 28% 13/46, p=0.045).  Sensitivity rose to 62.9%, but specificity fell to 54.6%. 

Kappa values for interobserver variability were k=0.358 (fair, 0.288-0.429) for lesion size, k=0.107 (poor, 0.02-0.193) for radiological appearance and k=0.274 (fair, 0.229-0.318) for total Mirels’ score.  Values for intraobserver variability were k=0.716 (good, 95% CI 0.432-0.999) for lesion size, k=0.427 (moderate, 95% CI 0.195-0.768) for radiological appearance and 0.580 (moderate, 0.395-0.765) for total Mirels’ score.

Conclusions: We showed moderate to substantial agreement between and within raters using Mirels’ score on upper limb radiographs. This study demonstrates Mirels’ has poor sensitivity and specificity in predicting upper limb fractures.  We recommend the score cut-off for prophylactic surgery in upper limb metastases should be lower than that for lower limb lesions.

312 - Prediction models for survival, local recurrence and metastases of Leiomyosarcomas of trunk wall and extremities: A multicentre study

Sudhir Kannan^1,2, Jay-Dee Ferguson³, Byan Chew⁴, Han Hong Chong⁴, Thomas McCulloch⁵, Kenneth Rankin⁶, Robert Ashford⁴

¹Health Education England, Newcastle Upon Tyne, United Kingdom; ²Newcastle University, Newcastle upon Tyne, United Kingdom; ³Newcastle University, Newcastle Upon Tyne, United Kingdom; ⁴University Hospitals Of Leicester, Leicester, United Kingdom; ⁵Nottingham University Hospitals, Nottingham, United Kingdom; ⁶Newcastle University, Newcastle Upon Tyne, United Kingdom

Leiomyosarcomas (LMS) are aggressive neoplasms with poorly understood pathogenesis. The accurate prediction of their behaviour has proven difficult, and there are no universally accepted prognostic factors. We aimed to identify the risk factors for early recurrence, metastases, and poor survival and build a prediction model.

Methods: We included 121 patients who had LMS involving trunk wall and extremities. Overall survival, local recurrence, and metastasis were the outcome measures. We have used the Kaplan Mier plot and multivariate analysis for prognostication. Nomograms were built using STATA 16.

Results: The mean survival was 38.2 months (SD 44.4). 17.4% (15/86) patients had local recurrence, 47% (7/15) of these local recurrences were within 12 months of diagnosis. 58% (66/107) of patients developed metastases, 3.7% (4/107) had metastasis at presentation. 62.1% of metastasis occurred in less than 36 months. 

Our analysis shows that younger age (p 0.03), deep location (p 0.01), and mitoses> 10/HPF (p 0.001) are independent prognostic factors predicting a higher risk of metastasis. 

Even though the univariate analysis suggested that age (p 0.0001), size (p 0.041), deep location (p 0.049), mitosis (p 0.0001), grade (p 0.0001), necrosis (p 0.023), presence of IHC CD 34 (p 0.004), and absence of estrogen/progesterone receptor (p 0.005) predicted poor survival, the multivariate analysis of these factors did not attain statistical significance.

The univariate analysis suggested that younger age (p 0.005), site of occurrence (p 0.027), deep location (p 0.002), mitoses (p 0.002), and IHC AE1/3 (p 0.05) predicted increased local recurrence, these factors were not independent predictors on multivariate analysis. 

Conclusion: The young age of occurrence, deep location, and mitoses> 10/HPF are prognostic factors for a higher risk of metastasis. Several factors were associated with local recurrence and poor survival, but, none of them were independently predictive. The multivariate predictive models have displayed a good predictive accuracy.

385 - The management of spinal oligometastases at a supra-regional centre in the era of Stereotactic Ablative Radiotherapy

Vino Sivasubramaniam, Philip Ho, Ben Barkham, Bisola Ajayi, Timothy Bishop, Jason Bernard, Darren Lui

St George's Hospital, London, United Kingdom

Background: Spinal Oligometastatic disease (SOD) is a low volume disease state where en bloc resection of the tumour, based on oncological principles, can achieve maximum local control (MLC).

Methods: Retrospective review of SOD at a supra-regional centre between 2017 and 2021. Demographics, operative course, complications and Instrument type are examined.

Results:

Demographics: 24 patients, mean age 53.8y (range 12-77), 51% male. 

Histology: Breast, Renal and Sarcoma, 16.7% each; Thyroid, Prostate and Chordoma, 8.3% each.  Primary disease 7%, Synchronous 15%, Metachronous 78%.

Instrumentation: Carbon-fibre (85%), TiAl (11%), Non-Instrumented (3%).

Separation Surgery (70%), En-bloc resection/Tomita (30%); SABR/Proton Beam Planned: 70%.

Average length of stay 19.1 days; 20 patients’ required ICU admission.

30 Day Mortality 8.3% (n=2: COVID-19 during admission), 1y Mortality – 16.7%, 3y Mortality – 25%; Synchronous mortality 75% (n=3) at 3 years. 

30 Day infection rate 3%; 1y infection rate 7%.

Local Recurrence (LR): Of 15 patients for whom postoperative imaging were readily available:  LR – 6 (range 1 -22 months), No LR - 9; 4 patients demonstrated systemic disease progression before/without LR. 2-year Revision for LR 5% (Revision at 23 months).

Conclusion: 92% of cases were eligible for SABR. The majority (85%) of cases were performed with Carbon-fibre instrumentation and has been shown to be safe with no mechanical failures in this series.  Infection rates are in keeping with patients requiring radical radiotherapy with 3% early and 7% late. Mortality is highest with synchronous disease and should be operated on sparingly. Surgery for local recurrence was uncommon (5%) with 4 cases where there was local control despite systemic progression.

All SOD cases deserve extra consideration and specialist MDT as not all are suitable for SABR. Multimodal Hybrid therapy, incorporating less invasive surgical techniques and SABR, represents a paradigm shift in achieving MLC in oligometastatic spinal disease. 

594 - Retrospective analysis of risk factors for progression to fracture in patients with metastatic bone disease (MBD)

Samantha Downie¹, Alison Stillie², Matthew Moran², Catherine Sudlow¹, A Hamish RW Simpson¹

¹University of Edinburgh, Edinburgh, United Kingdom; ²NHS Lothian, Edinburgh, United Kingdom

Background: There is a poor evidence-base for predicting risk of pathological fracture in patients with bone metastases managed non-surgically.  Radiological scoring systems like Mirels fail to incorporate patient-specific variables such as primary cancer type and lesion location.  The aim was to identify predictors of fracture at 12 months in patients with long bone metastases.

Methods: This was a pilot study of 112 consecutive patients to power a larger multivariate regression analysis.  Patients with a new long bone metastasis and x-ray/CT imaging were identified from radiology reports and excluded if they presented with a fracture.  A literature review identified 15 potential predictors of fracture (variables of interest), including primary cancer type and radiological appearance.  

Results: We reviewed data for 200 lesions in 112 patients (51% female, mean age 69 range 28-91 years).  73% were dead at follow-up (146/200 median survival 8.5 months IQR 18-3 months) and median follow-up in living patients was 2 years (range 8 months-6.5 years).

The 12-month fracture rate was 16% (32/200), recommending a powered sample size of 1055 lesions to investigate 15 variables (confidence level 95%, error margins 4-4.5).  Factors associated with risk of fracture included Mirels score ≥9 (fracture rate 34% 22/64 vs 9% 10/114, p<0.001), lytic radiological appearance (28% 19/68 versus 10% 13/132 mixed/sclerotic, p<0.01) and increasing pain (35% 30/85 versus 2% 2/115, p<0.0001).

Conclusion: Predicting risk of pathological fracture is vital in managing patients with bone metastases to avoid unnecessary surgery.  This pilot study has generated a recommended sample size to validate the 15 variables of interest, and provided preliminary evidence for their utility in predicting pathological fracture.

782 - The Role of Intraoperative Cell Salvage for Musculoskeletal Sarcoma Surgery

Raja Bhaskara Rajasekaran, Christopher LMH Gibbons, Duncan Whitwell, Thomas DA Cosker

NDORMS, Oxford Sarcoma Service, Oxford, United Kingdom

Background: The efficacy and safety of cell salvage for musculoskeletal sarcoma surgery has not been reported, and concerns over re-infusion of tumour cells remain. The aim of this study is to i) describe the intra-operative blood loss and cell salvage reinfusion volumes for lower limb sarcoma procedures ii), explore whether there is evidence of tumour cells in reinfused blood.

Methods: Retrospective analysis of 109 consecutive surgical procedures for biopsy proven sarcoma or bone metastasis performed between 1 July 2015 and 30 October 2019. Salvaged blood was processed and reinfused when intraoperative blood loss exceeded 500ml. Primary bone tumour (n=86 (79%)) and metastasis (n=23 (21%) constituted the study group and surgeries were classified under hemipelvectomy (n=43 (39%)), lower limb endoprosthesis replacement (LLE) (n=50 (46%)) and wide excision surgery (WE) (n=16 (15%)). Microscopic examination of imprint cytology was performed for reinfused blood.

Results: Mean (SD) intra-operative blood loss was 2390 (2342) ml for hemipelvectomy, 1017 (747) ml for LLE and 1279 (917) ml for WE. Salvaged blood was re-infused in 102 of 109 (94%) patients. Mean (SD) volume of re-infusion was 445 (425) ml for hemipelvectomy, 206 (131) ml for LLE, and 184 (106) ml for WE. Cytology analysis of imprints taken from the filtered blood which were available in 95 (87%) patients did not reveal evidence of tumour cells on microscopic examination of any samples.

Conclusion: Our study demonstrates that lower limb sarcoma surgery is associated with significant blood loss and cell salvage permits reinfusion of autologous blood in the most patients.  Cytological analysis did not reveal evidence of tumour cells in reinfused blood, consistent with other studies where cell salvage is used for cancer surgery. Future studies should aim to analyse if any increased risk of metastasis associated with use of cell salvage to further quantify its efficacy.

853 - Incidence of unexpected positive margin following excision of primary bone and soft tissue tumours in a tertiary centre and the impact on patient outcomes

George Matheron, Amir Ardakani, Ahmad Nasir, Panagiotis Gikas

Royal National Orthopaedic Hospital, London, United Kingdom

Background: Primary bone and soft tissue sarcoma treatment includes surgical resection, with or without peri-operative chemoradiotherapy. The aim of surgery is to achieve complete excision, to prevent localised recurrence and achieve cure. For various reasons, excision with adequate margins is not always possible. Our aim is to assess the incidence of unexpected positive margins following primary excision within a tertiary centre, and the impact on patient outcomes.

Methods: A retrospective analysis of 567 patients discussed at the Royal National Orthopaedic Hospital Multi-disciplinary team (MDT) meeting with positive margins between 1999-2020 was performed. Exclusion criteria included: excisions performed externally and lesions treated with curettage. Information gathering from electronic records highlighted 23 cases with unexpected positive margins following primary excision. 

Results: All patients pre-operatively expected to achieve complete primary resection. Median age was 60 years (8-92), 10M:13F. Tumour location included lower limb (12), upper limb (6), pelvis (2) and trunk (3); 8 bone tumours and 15 soft tissue. The overall recurrence rate was 30.4% (7/23). In those recommended for re-excision (n=16), the recurrence rate was 31.25% (5/16). Of the patients not initially recommended for re-excision (n=7), 4 proceeded to surveillance alone with 50% recurrence (2/4), both with metastatic disease not surviving to follow-up. A further 3 patients underwent post-operative radiotherapy alone with no recurrences at follow-up, 1 patient not surviving for further treatment due Stroke. The mean follow-up for patients was 3.1 years.

Conclusion: When positive margins do occur unexpectedly, the impact due to need for further treatment and ultimately increased risk of recurrence can be significant. Results can be compared to those for unplanned excisions. Therefore, surgeons should be aware of the different circumstances in which positive margins occur, to help guide treatment planning, and managing patient expectations.

950 - Tumours of the Proximal Humerus: A Tertiary Referral Centre Experience

Thomas Cosker, Varun Sethurajah, Max Gibbons, Duncan Whitwell, Harriet Branford-White

Nuffield Orthopaedic Centre, Oxford, United Kingdom

Among the musculoskeletal malignancies, proximal humeral lesions are common. They are the second most common site of a long bone malignancy. Pathology includes primary bone tumours or metastatic bone disease. The purpose of this study was to review our cohort of proximal humerus patients over the last 20 years and to compare how different implant designs impacted patients’ functional outcome.

Retrospective review was performed using clinical records of patients who had surgical treatment for humeral malignancies for the last 20 years. We analysed sex, age distribution, tumour type, surgery, generation of implant used and functional outcome. 

Results: 52 patients 73% (n=38) were women, mean age at time of surgery of 52.7 (Range 15 – 86) years. 59.6% (n=31) of lesions were primaries and 40.4% (n=21) lesions were metastatic disease. Among primary tumours Chondrosarcoma (n=11) = 35.4%, Osteosarcoma (n=10) 32.2%, Ewing sarcoma (n=4)12.9% and others (n=6) 29%. Renal cell carcinoma was the main metastatic disease (n=8) 38%. 47 patients were managed by EPR [80.8% (n=38) hemiarthroplasty, 8.5% (n=4) total humeral replacement, 10.6% (n=5) total shoulder replacement]. Three patients had forequarter amputation, two vascularised fibula graft.

1^st generation 19% (n=9), 2nd generation 19% (n=9) and 3^rd generation of humeral implants used in 37% (n=23) of patients who had EPR. The functional outcome assessed by Oxford Shoulder Score (OSS) was 27 for 1st generation implant, 30 for 2nd generation and 36 for 3rd generation implant design.

Conclusion: Complete resection of the tumour is the primary aim of tumour surgery but increasingly patients are expecting every improving functional outcomes. Implant design has evolved including bone-implant integration, stem design and soft tissue attachments. The proximal humerus is an extremely challenging joint and good functional outcome remains difficult to achieve. Small modifications in design using new technology may yet provide a significant improvement in function. 

890 - Does endoscopy affect recurrence rate when used in curettage of benign osteolytic lesions?

Hazem Mohamed

The Princess Alexandra Hospital NHS Trust, Harlow, United Kingdom

Background: Benign osteolytic lesions of bone represent a diverse group of pathological and clinical entities. The aim of this study is to highlight the importance of intraoperative endoscopic assessment of intramedullary osteolytic lesions in view of the rate of complications during the postoperative follow up period.  

Methods: 69 patients (median age 27 years) with benign osteolytic lesion had been prospectively followed up from December 2017 to December 2018 in a university hospital in Cairo, Egypt and in a level-1 trauma center in United Kingdom. All patients had been treated by curettage with the aid of endoscopy through a standard incision and 2 portals.  Histological analysis was confirmed from intraoperative samples analysis. All patients had received bone allografts from different donor sites (iliac crest, fibula, olecranon, etc). None of them received chemo or radiotherapy. 

Results: Most of lesions were enchondroma (n=29), followed by Aneurysmal bone cyst (ABC) (n=16), Fibrodysplasia (n=13), Chondromyxoid fibroma (n=3), simple bone cyst (n= 3), non-ossifying fibroma (n= 3), giant cell tumour (n= 1) and chondromyxoid fibroma (n = 1). Site of lesion varied from metacarpals (n = 29), femur (n= 1), lower leg (n= 31), and upper limb (n=18). Complications happened only in 9 cases (pathological fractures (n=2), infection (n= 1), recurrence (n=3, all aneurysmal bone cyst), residual pain (n= 3, all in tibia). None of cases developed malignant transformation. 

Conclusion: Endoscopy is recommended in management of benign osteolytic bone lesions; as it aids in better visualization of the hidden lesions that are missed even after doing apparently satisfactory blind curettage. From our study the recurrence rate is 2% compared to the known 12-18% recurrence rate in the blind technique from literature.

965 - The prevalence of iron deficiency anaemia, and association with peri-operative transfusion rates in patients undergoing resections of bone and soft tissue sarcomas and metastatic bone disease

Rachel Mahoney, Usman Khattak, Zakaria Djoudi, Scott Evans, Kudakwashe Nyangoni, Ben Smith

Royal Orthopaedic Hospital, Birmingham, United Kingdom

Background: We previously demonstrated 27% of this patient cohort requires blood transfusion. Peri-operative anaemia is associated with increased risks of post-operative complications, blood transfusion and mortality. Correction of anaemia in patients undergoing elective orthopaedic surgery and colorectal oncological resections has been shown to reduce transfusion requirements and improve outcomes.

Aim: The aim of this study was to identify the prevalence of iron deficiency anaemia in our patient cohort, and the association with peri-operative transfusion requirements and complication rates, in order to facilitate targeted patient pre-operative optimisation.

Methods: Data was collected on pre- and post-operative haemoglobin, iron studies and transfusion requirements, in addition to demographics and complications in patients undergoing oncological resections and amputations at a single centre from 1st November 2020 to 1^st May 2021. 

Results: Iron studies were available for 57 patients undergoing surgery during this time. Mean haemoglobin pre-operatively and post-operatively was 126.6g/L and 98.6g/L respectively. The mean serum iron was 10.5 ug/dl (normal range 11.6-31.3 ug/dl), with 52% of our cohort iron deficient. Transfusion rates in iron deficient patients were 51%, compared to 11.5% in the non-iron deficient patients, with a mean post-operative haemoglobin of 89.4g/L compared to 109.7g/L in those not deficient. A further 9.7% of the iron deficient patients received either intravenous or oral iron supplementation during admission, giving a total of 66.7% requiring therapy for anaemia peri-operatively. Of the 19 transfused patients, 79% were iron deficient, with mean serum iron 7.2 (range 2.5-22.5). 

Conclusion: Peri-operative anaemia is a significant problem in our patient cohort. We have identified that iron deficiency is a significant risk factor for requiring peri-operative transfusion. By targeted optimisation these patients prior to surgery we could potentially reduce the transfusion requirements, associated morbidity, post-operative complications and length of stay.