Item Response Theory Validation of the Forgotten Joint Score for Persons Undergoing Total Knee Replacement.

BACKGROUND: The Forgotten Joint Score (FJS), a commonly used patient-reported outcome measure, was developed without fully confirming assumptions such as unidimensionality (all items reflect 1 underlying factor), appropriate weighting of each item in scoring, absence of differential item functioning (in which different groups, e.g., men and women, respond differently), local dependence (pairs of items are measuring only 1 underlying factor), and monotonicity (persons with higher function have a higher score). We applied item response theory (IRT) to perform validation of the FJS according to contemporary standards, and thus support its ongoing use. We aimed to confirm that the FJS reflects a single latent trait. In addition, we aimed to determine whether an IRT model could be fitted to the FJS. METHODS: Participants undergoing primary total knee replacement provided responses to the FJS items preoperatively and at 6 and 12 months postoperatively. An exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and Mokken analysis were conducted. A graded response model (GRM) was fitted to the data. RESULTS: A total of 1,774 patient responses were analyzed. EFA indicated a 1-factor model (all 12 items reflecting 1 underlying trait). CFA demonstrated an excellent model fit. Items did not have equal weighting. The FJS demonstrated good monotonicity and no differential item functioning by sex, age, or body mass index. GRM parameters are reported in this paper. CONCLUSIONS: The FJS meets key validity assumptions, supporting its use in clinical practice and research. The IRT-adapted FJS has potential advantages over the traditional FJS: it provides continuous measurements with finer granularity between health states, includes individual measurement error, and can compute scores despite more missing data (with only 1 response required to estimate a score). It can be applied retrospectively to existing data sets or used to deliver individualized computerized adaptive tests. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Surgeon views regarding the adoption of a novel surgical innovation into clinical practice: systematic review.

BACKGROUND: The haphazard adoption of new surgical technologies into practice has the potential to cause patient harm and there are many misconceptions in the decision-making behind the adoption of new innovations. The aim of this study was to synthesize factors affecting a surgeon's decision to adopt a novel surgical innovation into clinical practice. METHODS: A systematic literature search was performed to obtain all studies where surgeon views on the adoption of a novel surgical innovation into clinical practice have been collected. The databases screened were MEDLINE, Embase, Science Direct, Scopus, the Web of Science, and the Cochrane Library of Systematic Reviews (last accessed October 2022). Innovations covered multiple specialties, including cardiac, general, urology, and orthopaedics. The quality of the papers was assessed using a 10-question Critical Appraisal Skills Programme (CASP) tool for qualitative research. RESULTS: A total of 26 studies (including 1112 participants, of which 694 were surgeons) from nine countries satisfied the inclusion and exclusion criteria. Types of study included semi-structured interviews and focus groups, for example. Themes and sub-themes that emerged after a thematic synthesis were categorized using five causal factors (structural, organizational, patient-level, provider-level, and innovation-based). These themes were further split into facilitators and barriers. Key facilitators to adoption of an innovation include improved clinical outcomes, cost-effectiveness, and support from internal and external stakeholders. Barriers to adoption include lack of organizational support and views of senior surgeons. CONCLUSION: There are multiple complex factors that dynamically interact, affecting the adoption of a novel surgical innovation into clinical practice. There is a need to further investigate surgeon and other stakeholder views regarding the strength of clinical evidence required to support the widespread adoption of a surgical innovation into clinical practice.

A radiological index that influences the outcome following patellofemoral joint arthroplasty: the anterior trochlea offset ratio.

PURPOSE: Although largely successful, patellofemoral joint arthroplasty (PFA) has a less than satisfactory outcome in some patients. It was hypothesized that certain factors can be identified on radiological review that correlate with poor patient reported outcomes following PFA. METHODS: A retrospective cohort review of 369 patients undergoing PFA at our institution between 2005 and 2018 identified 43 "poor outcome" patients with an Oxford Knee Score (OKS) of less than 20 at 2 years follow up. These cases were matched by sex and age with 43 "good outcome" patients who had an OKS above 40 at 2 years post-op. Multiple radiological measurements were performed including anterior trochlea offset ratio (ATOR), component flexion/extension, component varus/valgus, component to bone width ratio and retinacular index. The OKS PROM was the primary outcome of the study. Stepwise logistic regression was performed to analyze the differences in radiological indices between the two groups. RESULTS: Intraclass correlation coefficients for inter-observer and intra-observer reliability were 0.90-0.98 for all indices measured. The only index demonstrating statistical significance between the groups was the ATOR (p = 0.003). The good outcome group had a mean ATOR of 0.19 whereas the poor outcome group had a mean ATOR of 0.24. CONCLUSIONS: Lower ATOR on radiological review was strongly associated with improved outcomes following PFA. The surgeon should therefore take particular care to prevent increasing the anterior offset of the trochlea component when performing PFA. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Tibial tuberosity-trochlear groove distance: does it measure up?

Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability. Cite this article: Bone Jt Open 2022;3(3):268-274.

The economic burden of open tibia fractures: A systematic review.

BACKGROUND: Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment. METHODS: All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary. RESULTS: We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months. CONCLUSION: The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.

Systematic review of patient reported outcomes from open tibia fractures in low and middle income countries.

BACKGROUND: Open tibia fractures are a common cause of admission following road traffic accidents in low and middle income countries (LMICs), resulting in substantial mortality and disability. It is important to summarise the clinical course of this injury using patient reported scores in order to assess best treatment in LMICs. OBJECTIVES: To summarise the disability after sustaining an open tibia fracture in LMICs METHODS: All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. Studies were performed in a low or middle income country. The primary outcome was any validated patient reported outcome score reported after three months. Secondary outcomes included economic impact and complications such as infection, non-union and amputation. Data was extracted and summarised. RESULTS: We reviewed 3,593 articles from our search. A total of 18 studies were included from 10 countries with 8 different outcome scores. The average age was 35 years old and 86% of the patients were male. Thirty-one percent were Gustilo I, 28% Gustilo II, 19% Gustilo IIIA, 17% Gustilo IIIB and 5% Gustilo IIIC. The most common complications reported were 18% infection, 15% non-union and 15% amputation. Economic impact was reported in only one study with 100% patients working pre-injury and 20% post-injury at 12 months. Mean follow-up duration for outcome scores was 19.8 months. There was heterogeneity between the studies in terms of subject of the studies, outcome criteria, fracture type, surgical technique and length of follow-up. Therefore, no meta-analysis could be performed. CONCLUSION: The clinical history of open tibia fractures in low or middle income countries remains largely unknown in terms of patient reported outcomes. Further studies are required to define these outcomes in open tibia fractures before best treatments can be assessed.

Current concepts in the surgical management of patellar instability.

BACKGROUND: Patellar instability is a common condition, and recurrent instability can be highly disabling. It is important to understand the patho-anatomy of patellar instability in order to treat it effectively, with the trochlear shape, patellar height and the integrity of the medial retinaculum being the most important factors in determining the risk of ongoing instability. CLINICAL ASSESSMENT AND RADIOGRAPHIC ASSESSMENT: Clinical assessment is based around correct diagnosis of instability, identification of at risk features and an assessment of neuromuscular control and factors that may affect the potential for rehabilitation before or after surgery. Radiology is important to assess features predisposing to instability and to determine the best treatment plan for each individual. TREATMENT: There are a range of surgical options for the treatment of patellar instability and these should be chosen based on an each patients individual patho-anatomy. Lateral release is not recommended as a treatment for patellar instability. Medial patello-femoral ligament reconstruction, tibial tubercle distalisation, trochleoplasty or occasionally tibial or femoral osteotomies for correction of rotational or coronal plane mal-alignment may all be used either individually or in combination. High quality physiotherapy is an essential part of post-operative management and should address the whole of the kinetic chain, working on strength and control of the lower limbs to optimise balance and movement patterns in order to achieve the best results.

Using Bayesian adaptive designs to improve phase III trials: a respiratory care example.

BACKGROUND: Bayesian adaptive designs can improve the efficiency of trials, and lead to trials that can produce high quality evidence more quickly, with fewer patients and lower costs than traditional methods. The aim of this work was to determine how Bayesian adaptive designs can be constructed for phase III clinical trials in critical care, and to assess the influence that Bayesian designs would have on trial efficiency and study results. METHODS: We re-designed the High Frequency OSCillation in Acute Respiratory distress syndrome (OSCAR) trial using Bayesian adaptive design methods, to allow for the possibility of early stopping for success or futility. We constructed several alternative designs and studied their operating characteristics via simulation. We then performed virtual re-executions by applying the Bayesian adaptive designs using the OSCAR data to demonstrate the practical applicability of the designs. RESULTS: We constructed five alternative Bayesian adaptive designs and identified a preferred design based on the simulated operating characteristics, which had similar power to the original design but recruited fewer patients on average. The virtual re-executions showed the Bayesian sequential approach and original OSCAR trial yielded similar trial conclusions. However, using a Bayesian sequential design could have led to a reduced sample size and earlier completion of the trial. CONCLUSIONS: Using the OSCAR trial as an example, this case study found that Bayesian adaptive designs can be constructed for phase III critical care trials. If the OSCAR trial had been run using one of the proposed Bayesian adaptive designs, it would have terminated at a smaller sample size with fewer deaths in the trial, whilst reaching the same conclusions. We recommend the wider use of Bayesian adaptive approaches in phase III clinical trials. TRIAL REGISTRATION: OSCAR Trial registration ISRCTN, ISRCTN10416500 . Retrospectively registered 13 June 2007.

The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis.

BACKGROUND: Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known. PURPOSE: To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores. RESULTS: A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms. CONCLUSION: Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.

Does overstuffing of the patellofemoral joint in total knee arthroplasty have a significant effect on postoperative outcomes?

BACKGROUND: There is ongoing debate in the literature as to whether or not patellofemoral joint overstuffing has a clinically significant effect on postoperative outcomes following total knee arthroplasty (TKA). This study investigates the effect of patellofemoral joint overstuffing on patient-reported outcomes using novel methods of radiographic measurement. METHODS: The study population consisted of a prospective cohort of 266 patients receiving a Triathlon® (Stryker, Kalamazoo, MI, USA) TKA between 2006 and 2009. Participants completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire preoperatively and at 12 months postoperatively. Pre- and postoperative radiographic measurements were taken according to a defined protocol to assess for patellofemoral overstuffing. Measurement reproducibility was assessed using inter-observer intraclass correlation coefficients. Associations between radiographic measurements and patient-reported outcomes were analysed using linear regression analysis. RESULTS: A total of 107 patients had adequate images and were included in the analysis for this study. Three different radiographic measurements were used to identify patellofemoral overstuffing all with good intra- and inter-observer reliability. There was no association identified between combined (patella and trochlea) patellofemoral overstuffing measurements and WOMAC scores. However, a statistically significant association was identified between an increase in anterior trochlear offset and worse knee pain and function scores (P < 0.05). CONCLUSIONS: There is no identifiable association between true patellofemoral overstuffing and clinical outcome; however, there is a small association with the anterior trochlear offset though further studies are warranted to confirm the clinical significance of this finding.

Adoption of a novel surgical innovation into clinical practice: protocol for a qualitative systematic review examining surgeon views.

INTRODUCTION: Efficient adoption of clinically effective novel surgical innovations has great potential benefits for patients. Factors affecting the adoption of surgical innovation are not well understood and proposed models of adoption do not accurately correlate with historical evidence. This protocol is for a systematic review that aims to identify the qualitative evidence relating to surgeon views regarding the adoption of novel surgical innovation into clinical practice. METHODS AND ANALYSIS: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance will be performed. Two independent reviewers will search the following databases: MEDLINE, Embase, Science Direct, Scopus, Web of Science and the Cochrane Library of Systematic Reviews. Inclusion criteria are studies which report on the views of surgeons who adopt a novel surgical innovation into clinical practice. Each article will be screened for inclusion and assessed according to a Critical Appraisal Skills Programme tool. Data will be synthesised and analysed according to thematic analysis. Given the anticipated yield of a small heterogeneous body of evidence meeting the eligibility criteria for the review, a narrative-based summary is planned. ETHICS AND DISSEMINATION: This review does not require formal ethical approval as it does not involve direct patient contact or patient-identifiable data. The results of this review will be published in a peer-reviewed journal and presented at relevant conferences. The results will also inform an empirical qualitative study exploring surgeon and other stakeholder views regarding the introduction of novel surgical technology and procedures into clinical practice. PROSPERO REGISTRATION NUMBER: CRD42017076715.

Cortical Bony Thickening of the Lateral Intercondylar Wall: The Functional Attachment of the Anterior Cruciate Ligament.

BACKGROUND: The anatomy of the anterior cruciate ligament (ACL) has become the subject of much debate. There has been extensive study into attachment points of the native ligament, especially regarding the femoral attachment. Some of these studies have suggested that fibers in the ACL are of differing functional importance. Fibers with higher functional importance would be expected to exert larger mechanical stress on the bone. According to Wolff's law, cortical thickening would be expected in these areas. PURPOSE: To examine cortical thickening in the region of the ACL footprint (ie, the functional footprint of the ACL). STUDY DESIGN: Descriptive laboratory study. METHODS: Using micro-computed tomography with resolutions ranging from 71 to 91 µm, the cortical thickness of the lateral wall of the intercondylar notch in 17 cadaveric knees was examined, along with surface topography. After image processing, the relationship between the cortical thickening and surface topology was visually compared. RESULTS: A pattern of cortical thickening consistent with the functional footprint of the ACL was found. On average, this area was 3 times thicker than the surrounding bone and significantly thicker than the remaining lateral wall ( P < .0001). This thickening was roughly elliptical in shape (with a mean centroid at 23.5 h:31 t on a Bernard and Hertel grid) and had areas higher on the wall where greater thickness was present. The relationship to previously reported osseous landmarks was variable, although the patterns were broadly consistent with those reported in previous studies describing direct and indirect fibers of the ACL. CONCLUSION: The findings of this study are consistent with those of recent studies describing fibers in the ACL of differing functional importance. The area in which the thickening was found has been defined and is likely to represent the functional footprint of the ACL. CLINICAL RELEVANCE: This information is of value to surgeons when determining the optimal place to position the femoral attachment site of the reconstructed ACL.

The Journey patellofemoral joint arthroplasty: A minimum 5year follow-up study.

BACKGROUND: The Journey patellofemoral joint arthroplasty (PFA) was designed to improve patient outcomes following surgical management of patellofemoral joint osteoarthritis. It is based on the asymmetric trochlear geometry of the Genesis II total knee arthroplasty, with Oxinium components, to provide a reliable treatment option in an often young, high demand group of patients. METHODS: We report the minimum five year functional outcome and survivorship of the Journey PFA performed at our institution between October 2005 and September 2009. RESULTS: A total of 101 Journey PFAs were implanted in 83 patients, and we have complete outcomes for 90 implants (89%). There were 80 implants in female patients, and the mean age at time of surgery was 60years (26 to 86). The median Oxford Knee Score (0 to 48) improved from 18 to 30, and median Western Ontario and McMaster University Osteoarthritis Short Form Index (0 to 60) improved from 22 to 35. There were a total of 12 revisions, with mean time to revision 50months (10 to 99). CONCLUSIONS: The Journey PFA gives a good medium-term functional outcome with 88% survivorship at a mean of seven years. This is the largest study of Journey PFA in the literature, and it provides a reliable option for patients with isolated patellofemoral joint osteoarthritis when arthroplasty is considered.

The Cardiff Arthroplasty Satisfaction Index (CASI). A simple tool for the assessment of outcome following knee arthroplasty.

Our aim was to develop a patient reported outcome measure of satisfaction following total knee arthroplasty (TKA) and assess its correlation with Oxford knee score (OKS), Quality of life (EQ5D) and Visual analogue scale for pain (VAS). 172 patients with minimum 5year follow up post primary total knee arthroplasty completed CASI, OKS, EQ5D and VAS for pain. Receiver-operator curve analysis was performed to identify an OKS threshold of poor satisfaction defined by CASI rarely/never. The CASI showed positive correlation with the OKS, VAS for pain, and EQ5D, (Spearman's rho); 0.779; 0.711; 0.629. A threshold of 20 for the Oxford Knee score had 85% specificity and 85% sensitivity for poor satisfaction on CASI. The CASI is a useful measure of patient satisfaction following TKA.

Is knee osteoarthritis a symmetrical disease? Analysis of a 12 year prospective cohort study.

BACKGROUND: The aim of this study was to document the development of bilateral knee osteoarthritis over a 12 year period using a middle-aged population-based cohort with knee pain at inclusion. METHODS: One hundred and forty three patients aged 35 to 54 were recruited from a population based cohort of 279 subjects who had knee pain at baseline and assessed with clinical and radiographic data, with 5 and 12 year follow up. The data was analysed with regard to the development and progression of uni- and bilateral knee osteoarthritis over 12 years. A definition of KL = 1 was used to define radiographic disease. RESULTS: 24 of the 30 (80%) patients with unilateral disease at baseline developed bilateral disease after 12 years. At baseline 37 patients (26%) had bilateral disease, whereas that number increased to 65 (52%) at 5 years and 100 (70%) at the 12 year follow up. The most common pattern was medial compartment involvement in both knees. Six patients had lateral compartment disease in one knee and medial in the other whereas only two had lateral compartment disease bilaterally. CONCLUSIONS: Bilateral knee osteoarthritis is very common with time, as the majority of sufferers will eventually develop radiographic disease in both knees. Clinicians need to be aware of the 'joint at risk' and researchers need to remember to account for both knees when assessing the relationship between physical function, pain and structural disease. The other knee should not be used for comparison, even if it appears to be normal at baseline.

Spontaneous locking of the knee after anterior cruciate ligament reconstruction as a result of a broken tibial fixation device.

The Intrafix device (DePuy Mitek, Raynham, MA) is one of a number of recently developed products whose aim is to improve fixation of quadrupled hamstring grafts when used for anterior cruciate ligament reconstruction. We present a case of failure and intra-articular migration of the sleeve of an Intrafix device causing locking of the knee 10 weeks after anterior cruciate ligament reconstruction. We were unable to identify the cause of the failure or migration of the device. Rehabilitation had been progressing normally and without incident. The broken fragments were removed arthroscopically, and the reconstruction was found to be intact and healing well. Presumably, the device retained enough mechanical function to allow healing to progress, despite failure of the sleeve. This is, to our knowledge, the first reported case of such an event occurring with the new generation of hamstring graft fixation devices.

Standardised proformas improve patient handover: Audit of trauma handover practice.

BACKGROUND: The implementation of the European Working Time Directive has meant the introduction of shift patterns of working for junior doctors. Patient handover between shifts has become a necessary part of practice in order to reduce the risk of medical errors. Data handed over between shifts are used to prioritise clinical jobs outstanding, and to create theatre lists. We present a closed-loop audit of handover practice to assess whether standardised proformas improve clinical data transfer between shifts during handover in our Orthopaedic Unit. METHODS: We collected data handed over between shifts for a period of one week at our department. The data were in the form of hand written data on plain paper used to assist verbal handover. Data were analysed and a standardised handover sheet was trialled. After feedback from juniors the sheet was revised and implemented. A re-audit, of handover data, was then undertaken using the revised standardised proforma during a period of 1 week. RESULTS: Forty-eight patients were handed over in week 1 while 55 patients were handed over during re-audit. The standardised proformas encouraged use of pre-printed patient labels which contained legible patient identifiers, use of labels increased from 72.9% to 93.4%. Handover of outstanding jobs increased from 31.25% to 100%. Overall data handed over increased from 72.6% to 93.2%. Handover of relevant blood results showed little improvement from 18.8% to 20.7% CONCLUSION: This audit highlights the issue of data transfer between shifts. Standardised proformas encourage filling of relevant fields and increases the data transferred between shifts thereby reducing the potential for clinical error cause by shift patterns.

Asymmetrical fracture fixation: stability of oblique fractures is influenced by orientation.

BACKGROUND: Although clear differences in fracture site displacement have previously been demonstrated between transverse and oblique fracture models stabilised by an asymmetrical method, the direction of the obliquity has not been examined biomechanically. METHODS: Eight Sawbones tibiae were cut to represent oblique fractures: four ran from antero-inferior to postero-superior and four from antero-superior to postero-inferior. These were fixed with a Sheffield Ring Fixator and cyclically loaded in axial and off-axis compression. Direct measurements were taken of inter-fragmentary displacement. RESULTS: Significant differences were detected between the fracture directions (P < 0.01) and inter-fragmentary displacements were generally reduced in antero-superior to postero-inferior fractures compared with antero-inferio to postero-superior fractures. INTERPRETATION: Fixation asymmetries need to be tailored to specific fracture orientation to improve fracture site mechanics.

Tibial fractures treated with circular fixation: does the use of olive wires at the fracture site improve healing?

Clinical experience and published studies suggest that oblique fractures of the tibia are associated with delayed healing and non-union. Experimental studies have attributed this to increased shear at the fracture site. We have adopted the practice of using supplementary olive wires to reduce shear when using circular fixation for these fractures. A complete cohort of 54 oblique tibial fractures treated with the Sheffield Ring Fixator (Orthofix, Verona) was reviewed to elucidate the effect of using additional olive wires on fracture healing/treatment times. Fifty patients were studied in the final analysis. With low-energy injuries, the use of olive wires reduced treatment times significantly (no olives: 37 weeks, olives: 22 weeks, P<0.05), although this was not seen with higher energy injuries (no olives: 44 weeks, olives: 39 weeks, P=NS). There was no evidence of additional complications related to their use. We recommend the use of additional olive wires in the circular fixation of these difficult fractures.