Validation of a Prototype Augmented Reality Navigation System for Total Hip Replacement.

INTRODUCTION: Assistive technologies are becoming more common in total hip replacement (THR) procedures, improving surgeons' abilities to achieve target implant orientations. These systems can be large, absorbing limited space in the operating theatre, and they can add complexity to surgery. MATERIALS AND METHODS: We developed a small footprint prototype system that can assist in the accurate placement of implant components using augmented reality (AR) technology into preoperatively planned positions. This technology augments the 3D pelvis and the cup in its target position and displays the real-time position of instruments. The accuracy of the developed prototype system was assessed through a cadaveric study, comparing the achieved implant positions to the preoperative target. All cadavers received preoperative 3D planning to identify the target cup position and orientation. Cadaveric surgeries were completed using the AR system to achieve the target cup placement. Postoperative computed tomography (CT) was used to measure the achieved component position for each hip. RESULTS: The mean absolute deviation (range) from target acetabular placement to the achieved acetabular placement was 2.9° (-8.7 to 3.3°), 3.0° (-5.7 to 7°) and 1.6mm (-1.2 to 3.5mm) for inclination, anteversion, and depth, respectively. Sixty-six percent of results were within +/-5° of the preoperative target orientation. CONCLUSION: We present a cadaver validation study on a small footprint prototype system using augmented reality to enable accurate cup placement and provide additional information intraoperatively. Our results are comparable with reported results for image-based navigation from the literature.

Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures.

OBJECTIVES: To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes. DESIGN: Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data. SETTING, PARTICIPANTS: Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016. MAIN OUTCOME MEASURES: Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome. RESULTS: Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%). CONCLUSIONS: Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials.

Oblique proximal locking screw in tibial fracture intramedullary nailing: a clinical imaging study of proximity to common peroneal nerve.

Intramedullary nailing (IMN) is the treatment of choice in the surgical management of most tibia shaft fractures. The aim of the study was to evaluate the proximity of the common peroneal nerve (CPN) to the oblique proximal locking screw inserted from the anteromedial to the posterolateral direction. We identified all the patients who underwent the IMN of the tibia between 2008 and 2018. Patients who underwent post-operative computed tomography for any reason were identified. Patients were included if the CPN was visible on the axial slices, the proximal oblique locking screw was used, or the line of the drilling could be reconstructed. Twenty-nine patients met the inclusion criteria. The median length of the intramedullary nail was 345 mm. The median nail diameter was 10 mm. The median number of proximal interlocking screws was 2. All scans were reviewed by the musculoskeletal radiologist for verifying the visibility and marking of the CPN. The mean screw trajectory angle to the CPN was 9° (± 9°). Most of the drilling trajectories passed posterior to the CPN (79%). The depth of the intramedullary nail was on average - 8 mm (± 10 mm). A negative correlation was observed between the depth of the nail and the distance from the CPN (P < 0.001). During the insertion of the oblique proximal locking screw from the anteromedial to the posterolateral direction, the CPN is potentially at risk if the drill is allowed to plunge or an incorrectly long screw is used. Sinking the nail provides a better margin of safety.

Severe acute pain and persistent post-surgical pain in orthopaedic trauma patients: a cohort study.

BACKGROUND: We conducted a cohort study of adult patients presenting for orthopaedic trauma surgery at a statewide trauma centre, with the aims of determining (i) the incidence and risk factors for severe acute pain in the PACU, and (ii) the incidence and risk factors for persistent post-surgical pain at 3 months. METHODS: Data were collected before operation, in the PACU, 72 h after surgery and 3 months after surgery, and included numerical rating scale (NRS) scores for pain, and modified Brief Pain Inventory-Short Form, Kessler Psychological Distress Scale, World Health Organization Disability Assessment Schedule, and Pain Catastrophizing Scale scores. RESULTS: Severe acute pain in the PACU was reported by 171 (56%; 95% confidence interval [CI]: 51%, 62%) of the 303 included patients. Female sex (odds ratio [OR]: 1.86; 95% CI: 1.06, 3.26) and prior post-injury surgery (OR: 2.21; 95% CI: 1.11, 4.41) remained associated with severe acute pain after multivariable adjustment. Persistent post-surgical pain at 3 months was reported by 149 (65%; 95% CI: 59%, 71%) of the 229 included patients. The preoperative NRS score (OR: 1.17; 95% CI: 1.03, 1.32) remained associated with persistent pain after multivariable adjustment. CONCLUSIONS: We identified three easy-to-measure risk factors: female sex, prior post-injury surgery for severe acute pain, and preoperative NRS scores for persistent pain. Further research is required to identify pain management strategies and psychosocial interventions to reduce the burden of pain, disability, and distress in these patients.

Acute medial clavicle fracture in adults: a systematic review of demographics, clinical features and treatment outcomes in 220 patients.

BACKGROUND: Medial third clavicle fractures are rare injuries, with limited information available on their characteristics or treatment results. MATERIALS AND METHODS: We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management and treatment outcome. Electronic searches of the MEDLINE, EMBASE and Cochrane databases were performed. RESULTS: Seventeen studies were included, consisting of 7 case series and 10 case reports. Two hundred twenty fractures were identified. Seventy-eight percent of fractures occurred in men with mean age of 48 years (16-94 years). Road traffic accident was the most common mechanism of injury (64%). Associated injuries occurred in 81% of patients, with thoracic trauma being the most common (47%). The most common fracture type was extra-articular, with no or minimal displacement (60%). In 9% of patients the fracture was segmental. One hundred ninety-one patients received nonoperative treatment. Twenty-nine patients were treated operatively. The overall nonunion rate was 5% (7/137). The nonunion rate following nonoperative management was 4.6% (5/108). The functional result following nonoperative treatment indicated overall "good" functional outcome. There was no report of catastrophic intraoperative complication amongst patients undergoing surgical fixation. CONCLUSION: Medial third clavicle fractures represent a distinct subgroup of clavicle fractures. Nonoperative treatment of these fracture seems to result in high union rate and overall favourable functional outcome. Further high-quality research in this area is warranted to investigate the outcomes and indication for nonoperative versus operative management of these fractures. LEVEL OF EVIDENCE: IV.

Comparing ICD-10 external cause codes for pedal cyclists with self-reported crash details.

Accurate coding of injury event information is critical in developing targeted injury prevention strategies. However, little is known about the validity of the most universally used coding system, the International Classification of Diseases (ICD-10), in characterising crash counterparts in pedal cycling events. This study aimed to determine the agreement between hospital-coded ICD-10-AM (Australian modification) external cause codes with self-reported crash characteristics in a sample of pedal cyclists admitted to hospital following bicycle crashes. Interview responses from 141 injured cyclists were mapped to a single ICD-10-AM external cause code for comparison with ICD-10-AM external cause codes from hospital administrative data. The percentage of agreement was 77.3% with a κ value of 0.68 (95% CI 0.61 to 0.77), indicating substantial agreement. Nevertheless, studies reliant on ICD-10 codes from administrative data should consider the 23% level of disagreement when characterising crash counterparts in cycling crashes.

Morbidity and Safety of Iliac Crest Reference Array Pins in Navigated Total Hip Arthroplasty: A Prospective Cohort Study.

BACKGROUND: Navigated total hip arthroplasty (THA) can employ intra-osseous pins through a separate incision to secure reference arrays to the iliac crest. This study is the first to investigate the consequences of pin use in THA in vivo. METHODS: A prospective, consecutive series of 43 patients presenting for navigated THA were included. Two temporary 125 × 4 mm Schanz screws were inserted into the iliac crest for the attachment of a reference array. Telephone follow-up occurred at 6 and 12 weeks post-operatively. Patients were asked about pain, interference with daily activities, how often the wound was noticed, and duration of discomfort. Patient body mass index was recorded. RESULTS: The follow-up rate was 100%. Pin site pain at any time post-operatively was reported by 24 patients (56%). This improved to 30%, 9%, and 2% at 3, 6, and 12 weeks, respectively. On average, pain lasted for 16 days total. The most common complaints after pain were clothing discomfort (23%), pain when wearing a belt (12%), or pain when mobilizing (9%). For the majority (98%) of patients, all symptoms had resolved by 12 weeks. There was no nerve injury, pin site fracture, infection, or screw breakage. Patients with body mass index greater than 30 kg/m2 were up to 3 times more likely to experience pin site pain (P = .05), and had a longer duration of pain (P = .04). CONCLUSION: Surgeons and patients should be aware that using navigational pins for array fixation carries low complication rates but often will cause pain and irritation that resolves in the short term.

Clinicians' perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma.

Objective The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma. Methods A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews. Results Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients' requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer. Conclusions The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making. What is known about the topic? Little is known about the drivers for referral to, or acceptance at, in-patient rehabilitation following acute hospital care for traumatic injury in Victoria, Australia, including who makes these decisions of behalf of patients and how these decisions are made. What does this paper add? This paper provides information regarding the perceptions of acute hospital consultant surgeons and allied health, as well as rehabilitation clinicians, in terms of discharge destination decision making from the acute hospital following trauma. The use of case studies further highlights differences between, and within, these specialities with regard to this decision making. This research also highlights the importance of financial considerations as drivers of decision making, and the lack of consistency of the factors thought to be important drivers of discharge between these different clinical groupings. What are the implications for practitioners? This research shows that financial factors are significant drivers of discharge destination decision making for trauma patients. The present study highlights opportunities to engage with stakeholders (acute care, rehabilitation, administration, government and patients) to develop more consistent discharge processes that optimise the use of rehabilitation resources for those patients who could benefit from in-patient rehabilitation.

Discharge from the acute hospital: trauma patients' perceptions of care.

Objective The involvement of orthopaedic trauma patients in the decision-making regarding discharge destination from the acute hospital and their perceptions of the care following discharge are poorly understood. The aim of the present study was to investigate orthopaedic trauma patient experiences of discharge from the acute hospital and transition back into the community. Methods The present qualitative study performed in-depth interviews, between October 2012 and November 2013, with patients aged 18-64 years with lower limb trauma. Thematic analysis was used to derive important themes. Results Ninety-four patients were interviewed, including 35 discharged to in-patient rehabilitation. Key themes that emerged include variable involvement in decision-making regarding discharge, lack of information and follow-up care on discharge and varying opinions regarding in-patient rehabilitation. Readiness for discharge from in-patient rehabilitation also differed widely among patients, with patients often reporting being ready for discharge before the planned discharge date and feeling frustration at the need to stay in in-patient care. There was also a difference in patients' perception of the factors leading to recovery, with patients discharged to rehabilitation more commonly reporting external factors, such as rehabilitation providers and physiotherapy. Conclusion The insights provided by the participants in the present study will help us improve our discharge practice, especially the need to address the concerns of inadequate information provision regarding discharge and the role of in-patient rehabilitation. What is known about the topic? There is no current literature describing trauma patient involvement in decision-making regarding discharge from the acute hospital and the perception of how this decision (and destination choice; e.g. home or in-patient rehabilitation) affects their outcome. What does this paper add? The present large qualitative study provides information on patients' opinion of discharge from the acute hospital following trauma and how this could be improved from their perception. Patients are especially concerned with the lack of information provided to them on discharge, their lack of involvement and understanding of the choices made with regard to their discharge and describe concerns regarding their follow-up care. There is also a feeling from the patients that they are ready to leave rehabilitation before their actual planned discharge date, a concept that needs further investigation. What are the implications for practitioners? The patient insights gained by the present study will lead to a change in discharge practice, including increased involvement of the patient in the decision-making in terms of discharge from both the acute and rehabilitation hospitals and a raised awareness of the need to provide written information and follow-up telephone calls to patients following discharge. Further research into many aspects of patient discharge from the acute hospital should be considered, including the use of rehabilitation prediction tools to ensure patient involvement in decision-making and a discharge and/or follow-up coordinator to ensure patients are aware of how to access information after discharge.

Bridging the osteoporosis treatment gap: performance and cost-effectiveness of a fracture liaison service.

Individuals who sustain fragility fractures are at high risk of refracture. However, osteoporosis treatment rates remain low for these patients. Therefore, we aimed to assess the performance and cost-effectiveness of introducing a fracture liaison service (FLS) into a tertiary hospital. In "nonhospitalized" ambulatory patients who had sustained fragility fractures, we assessed baseline osteoporosis investigation and treatment rates, and subsequently, the impact of introducing an orthopedic osteoporosis policy and an FLS. Outcomes measured were uptake of osteoporosis intervention, patient satisfaction, and quality-adjusted life years (QALYs) gained. QALYs were calculated over 5 years using predicted fracture risks without intervention and estimated fracture risk reduction with intervention. At baseline (n = 49), 2% of ambulatory patients who had sustained fragility fractures underwent dual-energy X-ray absorptiometry (DXA) and 6% received osteoporosis-specific medication. After introduction of an osteoporosis policy (n = 58), 28% were investigated with DXA (p < 0.0001). However, treatment rates were unchanged. An FLS was introduced, reviewing 203 new patients over the inaugural 2 years (mean age [standard deviation], 67 (11) years; 77% female). All underwent DXA, and criteria for osteoporosis and osteopenia were identified in 44% and 40%, respectively. Osteoporosis medications were prescribed to 61% patients (risedronate: 22%, alendronate: 16%, strontium ranelate: 13%, zoledronic acid: 8%, other: 2%). Eighty-five of 90 questionnaire respondents were very satisfied or satisfied with the FLS. With the treatment prescribed over 5 years, we conservatively estimated that this FLS would reduce nonvertebral refractures from 59 to 50, improving QALYs by 0.054 and costing $1716 per patient (incremental cost-effectiveness ratio: $31749). This FLS model improves uptake of osteoporosis intervention guidelines, is popular among patients, and improves cost-effectiveness. Thus, it has the capacity to substantially improve health in a cost-effective way.

Awareness of psychological and relationship problems amongst brain tumour patients and its association with carer distress.

OBJECTIVE: The aim of this research was to investigate if brain tumour patients underestimate the severity of their impairments and the impact of this behaviour on carer distress . This study also aimed to identify the support services that patients and carers experiencing distress would find most beneficial. METHOD: A total of 32 post-surgery brain tumour patients, their carers, and a control group of 29 patients following surgery to extra-cerebral areas and their carers were recruited from outpatient clinics. Patients and carers rated the patient's psychological well-being and the impact of a range of changes since diagnosis/surgery. Patients and carers also rated their own level of distress and the support services they would find most beneficial. RESULTS: When compared with the control group, brain tumour patients were more likely to underestimate their psychological problems (p < 0.005) and the negative impact of changes to their emotional function (p < 0.05), interpersonal relationships (p < 0.05), cognition (p < 0.05) and coping skills (p<0.05). A multiple regression analysis showed that underestimation of psychological and interpersonal problems by brain tumour patients explained 35% of the variance in their carer's anxiety. CONCLUSION: The finding of reduced awareness or denial in brain tumour patients and its contribution to increased carer anxiety highlights the need for therapeutic interventions, which improve patient insight/denial and encourage patient and carer communication.

Adverse outcomes associated with elective knee arthroscopy: a population-based cohort study.

PURPOSE: The aims of this study were to quantify the frequency of adverse outcomes after elective knee arthroscopies in Victoria, Australia, and to identify risk factors associated with adverse outcomes. METHODS: We performed a retrospective, longitudinal cohort study of elective orthopaedic admissions using the Victorian Admitted Episodes database, a routinely collected public and private hospital episodes database linked to death registry data, from July 1, 2000, to June 30, 2009. Adverse outcome measures included pulmonary embolism (PE), deep vein thrombosis (DVT), hemarthrosis, effusion and synovitis, cellulitis, wound infection, synovial fistula, acute renal failure, myocardial infarct, stroke, and death. Patients were excluded if they had an additional procedure performed during the arthroscopy admission. We identified complications during the admission and within readmissions up to 30 days after the procedure. PE, DVT, and death within 90 days of the arthroscopy episode were also examined. We used logistic regression analysis to identify risk factors associated with complications. RESULTS: After we excluded 16,807 patients (8.5%) with an additional procedure during their admission, there were 180,717 episodes involving an elective arthroscopy during the period studied. The most common adverse outcomes within 30 days were DVT (579, 0.32%), effusion and synovitis (154, 0.09%), PE (147, 0.08%), and hemarthrosis (134, 0.07%). The 30-day orthopaedic readmission rate was 0.77%, and there were 55 deaths (0.03%). Within 90 days of arthroscopy, we identified 655 events of DVT (0.36%) and 179 PE events (0.10%). Logistic regression analysis identified that potential risk factors for complications were older age, presence of comorbidity, being married, major mechanical issues, and having the procedure performed in a public hospital. CONCLUSIONS: Our study found 6.4 adverse outcomes per 1,000 elective knee arthroscopy procedures (0.64%), with the 3 most common complications being DVT, effusion and synovitis, and PE. We have also identified risk factors for adverse outcomes, particularly chronic kidney disease, myocardial infarction, cerebrovascular accident, and cancer. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Accuracy of Leg Length and Offset Measurements During Total Hip Arthroplasty Using an Imageless Navigation System.

Introduction Leg length and offset are important considerations in total hip arthroplasty (THA). Navigation systems are capable of providing intra-operative measurements of leg length and offset, and high accuracy has been shown in experimental studies. This study assesses the accuracy of an imageless navigation system with a pinless femoral array (Hip 5.1, BrainLAB, Feldkirchen, Germany) in measuring leg length and offset changes in vivo. Methods A prospective, consecutive series of 37 patients undergoing navigated THA were included in the study. Intra-operative measurements of leg length and offset were recorded using the navigation system. For each patient, pre- and post-operative digital radiographs were scaled and analyzed to provide radiographic measurements for comparison. Results Measurements of leg length change made by the navigation system showed a strong correlation with the size of change measured radiographically (R = 0.71; p<0.0001). The mean difference between the radiographic and navigational measurement was 2.6mm ± 3.0mm (0.0-16.0mm) (mean, SD, range). The navigation system was accurate to within 1mm of the radiographic measurement in 49% of cases, within 2mm in 66% of cases, and within 5mm in 89% of cases. Measurements of offset change by the navigation system also showed a correlation with radiographic measurements, albeit less pronounced (R = 0.35; p=0.035). The mean difference between navigational and radiographic measurements was 5.5mm ± 4.7mm (0.0-16.0mm) (mean, SD, range). The navigation system was accurate within 1mm of the radiographic measurement in 22% of cases, within 2mm in 35% of cases, and within 5mm in 57% of cases. Conclusions This research demonstrates in vivo that an imageless, non-invasive navigation system is a reliable tool for intra-operative leg length (accurate within 2mm) and to a lesser extent offset measurement (accurate within 5mm) when compared to standard practice of plain film radiographs.

Fixation of pelvic acetabular fractures using 3D-printed fracture plates: a cadaver study.

Open reduction and internal fixation of pelvic acetabular fractures are challenging due to the limited surgical exposure from surrounding abdominal tissue. There have been a number of recent trials using metallic 3D-printed pelvic fracture plates to simplify and improve various elements of these fracture fixation surgeries; however, the amount of time and accuracy involved in the design and implantation of customised plates have not been well characterised. This study recorded the amount of time related to the design, manufacture and implantation of six customised fracture plates for five cadaveric pelvic specimens with acetabular fracture, while manufacturing, and surgical accuracy was calculated from computed tomography imaging. Five of the fracture plates were designed within 9.5 h, while the plate for a pelvis with a pre-existing fracture plate took considerably longer (20.2 h). Manufacturing comprised 3D-printing the plates in Ti6Al4V with a sintered laser melting (SLM) 3D-printer and post-processing (heat treatment, smoothing, tapping threads). The manufacturing times varied from 27.0 to 32.5 h, with longer times related to machining a thread for locking-head screws with a multi-axis computer numerical control (CNC) mill. For the surface of the plate in contact with the bone, the root-mean-square errors of the print varied from 0.10 to 0.49 mm. The upper range of these errors was likely the result of plate designs that were relatively long with thin cross-sections, a combination that gives rise to high thermal stresses when using a SLM 3D-printer. A number of approaches were explored to control the trajectories of locking or non-locking head screws including guides, printed threads or hand-taps; however, the plate with CNC-machined threads was clearly the most accurate with screw angulation errors of 2.77° (range 1.05-6.34°). The implanted position of the plates was determined visually; however, the limited surgical exposure and lack of intra-operative fluoroscopy in the laboratory led to high inaccuracies (translational errors of 1.74-13.00 mm). Plate mal-positioning would lead to increased risk of surgical injury due to misplaced screws; hence, it is recommended that technologies that can control plate positioning such as fluoroscopy or alignment guides need to be implemented into customised plate design and implantation workflow. Due to the plate misalignment and the severe nature of some acetabular fractures comprising numerous small bone fragments, the acetabular reduction exceeded the clinical limit of 2 mm for three pelvises. Although our results indicate that customised plates are unsuitable for acetabular fractures comprising six or more fragments, confirmation of this finding with a greater number of specimens is recommended. The times, accuracy and suggested improvements in the current study may be used to guide future workflows aimed at producing customised pelvic fracture plates for greater numbers of patients.

Trends in elective knee arthroscopies in a population-based cohort, 2000-2009.

OBJECTIVE: To assess the use of elective knee arthroscopy procedures for all adults 20 years and older, and for adults with a concomitant diagnosis of osteoarthritis (OA) in Victoria. DESIGN, SETTING AND PATIENTS: Retrospective, longitudinal cohort study of 807 030 elective orthopaedic admissions using routinely collected public and private hospital data from 1 July 2000 to 30 June 2009. MAIN OUTCOME MEASURE: Trends in rates of elective knee arthroscopy in the time period (defined as a statistically significant change in the incident rate ratio for each financial year with respect to the reference year). Subgroup analyses were undertaken for patients with an associated diagnosis of OA. RESULTS: There were 190 881 admissions for 159 528 patients having an elective knee arthroscopic procedure. There was a significant decrease in arthroscopic procedures from the 2000-01 financial year, after adjusting for growth in elective orthopaedic volume and relevant patient and hospital characteristics. The trend did not apply to patients with osteoarthritis of the knee. A significant shift in the use of multiday procedures undertaken in high volume, public hospital settings to same-day admissions in the private sector was also identified. CONCLUSIONS: The overall rate of elective knee arthroscopy in Victorian hospitals has decreased. There has been no sustained reduction in arthroscopy use for people with a concomitant diagnosis of OA, despite published evidence questioning the effectiveness of the procedures.

Return to pre-injury health status and function 12 months after hospitalisation for sport and active recreation related orthopaedic injury.

BACKGROUND: Hospitalised sport and active recreation injuries can have serious long-term consequences. Despite this, few studies have examined the long-term outcomes of these injuries. The purpose of this study was to establish whether patients hospitalised with orthopaedic sport and active recreation injuries, have returned to their pre-injury levels of health status and function, 12 months post injury and identify factors associated with poor outcomes. The present work was a cohort study with retrospective assessment of pre-injury status and prospective assessment of outcome at 12 months post injury. METHODS: Adults with orthopaedic sport and active recreation injuries, captured by the Victorian Orthopaedic Trauma Outcomes Registry were recruited to the study. Pre-injury and 12-month outcomes were assessed using the 36-item Short Form Health Survey (SF-36) and the extended Glasgow Outcome Scale. Differences in pre-injury and post-injury SF-36 scores were examined and demographic, injury, hospital and physical activity variables were assessed for associations with outcome using multivariate linear regression. RESULTS: Of the 324 participants 98% were followed-up at 12 months post injury. At 12 months, participants reported a mean 7.0-point reduction in physical health (95% CI 5.8 to 7.8) and a 2.5-point reduction in mental health (95% CI 1.2 to 3.0), with 58% (95% CI 52.6% to 63.4%) reporting reduced function. Sporting group (p=0.001), Injury Severity Score >15 (p=0.007) and high pre-injury vigorous activity levels (p=0.04), were related to poorer physical health outcomes. CONCLUSIONS: At 12 months post injury, most participants reported large reductions in physical health and reduced function. This information is important for furthering our understanding of the burden of sport and active recreation injury and setting priorities for treatment and rehabilitation.

Early magnetic resonance imaging in acute knee injury: a cost analysis.

PURPOSE: Acute knee injury is common, and MRI is often only used when non-operative management fails because of limited availability. We investigated whether early MRI in acute knee injury is more clinically and cost-effective compared to conventional physiotherapy and reassessment. METHODS: All patients with acute indirect soft tissue knee injury referred to fracture clinic were approached. Recruited patients were randomised to either the MRI group: early MRI within 2 weeks or the control group: conventional management with physiotherapy. Patients were assessed in clinic initially, at 2 weeks and 3 months post-injury. Management costs were calculated for all patients until surgical treatment or discharge. RESULTS: Forty-six patients were recruited: 23 in the MRI and 23 in the control group. Male sex and mean age were similar in the two groups. The total management cost of the MRI group was £16,127 and control group was £16,170, with a similar mean cost per patient (NS). The MRI group had less mean physiotherapy (2.5 ± 1.9 vs. 5.1 ± 3.5, p < 0.01) and outpatient appointments (NS). Median time to surgery and time off work was less in the MRI group (NS). The MRI group had less pain (p < 0.05), less activity limitation (p = 0.04) and better satisfaction (p = 0.04). CONCLUSIONS: Early MRI in acute knee injury facilitates faster diagnosis and management of internal derangement at a cost comparable to conventional treatment. Moreover, patients had significantly less time off work with improved pain, activity limitation and satisfaction scores. LEVEL OF EVIDENCE: II.

Generation of hemipelvis surface geometry based on statistical shape modelling and contralateral mirroring.

Personalised fracture plates manufactured using 3D printing offer an improved treatment option for unstable pelvic ring fractures that may not be adequately secured using off-the-shelf components. To design fracture plates that secure the bone fragments in their pre-fracture positions, the fractures must be reduced virtually using medical imaging-based reconstructions, a time-consuming process involving segmentation and repositioning of fragments until surface congruency is achieved. This study compared statistical shape models (SSMs) and contralateral mirroring as automated methods to reconstruct the hemipelvis using varying amounts of bone surface geometry. The training set for the geometries was obtained from pelvis CT scans of 33 females. The root-mean-squared error (RMSE) was quantified across the entire surface of the hemipelvis and within specific regions, and deviations of pelvic landmarks were computed from their positions in the intact hemipelvis. The reconstruction of the entire hemipelvis surfaced based on contralateral mirroring had an RMSE of 1.21 ± 0.29 mm, whereas for SSMs based on the entire hemipelvis surface, the RMSE was 1.11 ± 0.29 mm, a difference that was not significant (p = 0.32). Moreover, all hemipelvis reconstructions based on the full or partial bone geometries had RMSEs and landmark deviations from contralateral mirroring that were significantly lower (p < 0.05) or statistically equivalent to the SSMs. These results indicate that contralateral mirroring tends to be more accurate than SSMs for reconstructing unilateral pelvic fractures. SSMs may still be a viable method for hemipelvis fracture reconstruction in situations where contralateral geometries are not available, such as bilateral pelvic factures, or for highly asymmetric pelvic anatomies.

Impaired health-related quality of life, psychological distress, and productivity loss in younger people with persistent shoulder pain: a cross-sectional analysis.

PURPOSE: To investigate wellbeing and work impacts in younger people with persistent shoulder pain. MATERIALS AND METHODS: People aged 20-55 years with shoulder pain of >6 weeks' duration (excluding those with recent fracture or dislocation) were recruited from orthopaedic clinics at three major public hospitals. Health-related quality of life (HRQoL) and psychological distress were evaluated using the Assessment of Quality of Life (AQoL) and K10 instruments and compared to population norms. Shoulder-related absenteeism and presenteeism were quantified using the Work Productivity and Activity Impairment (WPAI) Questionnaire. RESULTS: Of the 81 participants (54% male), 69% had shoulder pain for over 12 months. Substantial HRQoL impairment was evident (mean reduction from population norms 0.33 AQoL units, 95% CI -0.38 to -0.27; minimal important difference 0.06 AQoL units). High or very high psychological distress was three times more prevalent among participants than the general population (relative risk 3.67, 95% CI 2.94 to 4.59). One-quarter of participants had ceased paid employment due to shoulder pain and 77% reported shoulder-related impairment at work. CONCLUSIONS: The broader impacts of painful shoulder conditions on younger people extend well beyond pain and upper limb functional limitations. In particular, the work-related impacts should form a routine part of patient assessment and rehabilitation.Implications for rehabilitationPersistent shoulder pain in younger people (aged 20-55 years) is associated with substantially reduced health-related quality of life and greater psychological distress, compared to population norms, as well as work participation and productivity impacts.As rotator cuff conditions, shoulder capsule pathology, and glenohumeral instability are relatively common, our data suggest that persistent shoulder pain is likely to have a high community impact among people of working age.Information resources that people with painful shoulder conditions can share with their families, employers, and colleagues may assist others to better understand the broader impacts of these conditions.Work-related challenges associated with shoulder pain should be considered within routine clinical care, and may require referral to an occupational health clinician or vocational rehabilitation service.

Retrospective cohort study evaluating the efficacy and safety of an orthopaedic consultant-led virtual fracture clinic in an Australian level 1 trauma centre.

BACKGROUND: In Australian health care, the consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges in the provision of quality care. This study investigates the efficacy and safety of a virtual fracture clinic (VFC) as an alternative model of care for the management of acute injuries and musculoskeletal conditions in the Australian public hospital setting. METHODS: A retrospective cohort study of consecutive emergency department (ED) referrals to the Department of Orthopaedic Surgery was conducted comparing outcomes prior to (November 2015-February 2017) and after (March 2017-June 2018) implementation of a VFC. The primary outcome measures assessed were the proportion of referrals virtually discharged and unplanned 30-day ED re-attendance rates. RESULTS: A total of 737 (36.4%) referrals managed by the VFC were discharged without requiring orthopaedic outpatient clinic attendance. The rate of unplanned ED re-attendances was 5.2% post-VFC implementation compared to 6.5% at baseline (P = 0.01). VFC implementation was also associated with reductions in the average number of orthopaedic outpatient clinic attendances per referral (1.1 versus 1.7, P < 0.01) and the number of referrals lost to follow-up (7.2% versus 14.7%, P < 0.01). In addition, patient wait times for first contact by the orthopaedic team were significantly reduced from a median of 7 (IQR 5, 9) days to 2 (IQR 1, 3) days post-intervention (P < 0.01). No complications or adverse events were reported. CONCLUSION: This study demonstrates that a VFC is applicable to the Australian healthcare system, and can lead to effective and safe provision of orthopaedic outpatient care.