Artificial intelligence in orthopaedics surgery: transforming technological innovation in patient care and surgical training.

Artificial intelligence (AI) is an exciting field combining computer science with robust data sets to facilitate problem-solving. It has the potential to transform education, practice and delivery of healthcare especially in orthopaedics. This review article outlines some of the already used AI pathways as well as recent technological advances in orthopaedics. Additionally, this article further explains how potentially these two entities could be combined in the future to improve surgical education, training and ultimately patient care and outcomes.

Do partial glenohumeral degenerative changes in patients undergoing arthroscopic rotator cuff repair influence clinical outcomes?

BACKGROUND: The prognostic factors for patients with full-thickness rotator cuff tears (RCTs) include tear size, muscle atrophy and fatty infiltration. However, the influence of early coexisting degenerative changes on RCT outcomes is unappreciated. The purpose of this study was to calculate the impact that pre-existing partial glenohumeral cartilaginous changes have on patients undergoing arthroscopic RCT repair. METHODS: A study of 54 patients undergoing arthroscopic RCT repair was undertaken. The presence of co-existing patches of glenohumeral degenerative cartilaginous changes and RCT size was recorded at surgery. Pre- and postoperative outcomes were assessed using traditional (Oxford Shoulder Score [OSS], 5-level EuroQol-5D [EQ-5D-5L] questionnaire and EuroQol visual analog scale [EQ-VAS]) and patient-centric re-formatted prisms. Outcomes were assessed as an entire dataset, and sub-group analysis was performed according to the grade of co-existing arthritis and tear size. RESULTS: Significant improvements (p<0.05) in clinical outcomes were recognized when assessed using either the traditional or reformatted prisms (average % improvements in OSS, EQ-5D-5L and EQ-VAS were 47%, 33% and 43%, respectively; average improvements in pain, function, and psychological well-being were 48%, 33% and, 29%, respectively). Positive gain was noted in all sub-groups of arthritic grading and tear size. CONCLUSIONS: Good clinical outcomes can be achieved following RCT repair even in the presence of local partial degenerative cartilage changes and advancing tear size. These benefits are patient-centered but require RCT repairability.

Dislocations of the elbow - An instructional review.

Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.

Comprehensive review of surgical approaches to the elbow.

The choice of the most suitable surgical approach to the elbow forms the foundation of any successful elbow surgery. The surgical approach is based on the injury or pathology to be addressed and therefore specific anatomical details need to be considered. The surgeon must be comfortable with the bony, ligamentous and neurovascular anatomy of the elbow to consider and execute the best approach for each problem. This is an imperative to avoid iatrogenic injury. This article provides a detailed analysis, valuable technical tips, advantages and disadvantages of the most common approaches to the elbow. The lateral approaches include the Kocher, Kaplan and Extensor Digitorum Communis (EDC) Split approaches, the medial approaches include the Hotchkiss, Flexor carpi ulnaris (FCU) splitting approach, the Taylor and Scham approach. The anterior approach includes the anterior neurovascular interval approach and the posterior approaches include the Olecranon osteotomy, triceps sparing, triceps reflecting approach and finally the Boyd interval approach. The text and illustrations will provide a structured overview for the practicing surgeon.

Improving the efficiency of ankle fracture care through home care and day-surgery units: Delivering safe surgery on a value-based healthcare model.

OBJECTIVES: Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling following a decision to undertake operative fixation has been made. We aim to assess the safety, efficiency, cost-effectiveness and differences in clinical & patient outcomes of day surgery unit (DSU) care for ankle fracture treatment in selected patients. Our study combined home therapy treatment with DSU care for suitable ankle fractures. DESIGN: Prospective cohort study. SETTING: Trauma Centre. PATIENTS: Fifty-three patients requiring operative fixation for an ankle fracture were divided into 2 groups. Patients in group 1 entered the home care combined with DSU treatment pathway whilst in group 2 were treated as in patient in the main trauma theatre in our standard pathway. INTERVENTION: Comparison of Home Care & Day Case Surgery vs. in patient admission for patients requiring operative ankle fractures fixation. MAIN OUTCOME MEASURES: Prospective data collection was undertaken over a 2-year period, on fracture type, logistical outcomes including time to surgery and total length of stay in the hospital and clinical outcomes including the rate of post-operative complications, incidence of unplanned surgical revisions and objective patient satisfaction. Economic analysis was performed to compare the marginal cost saving per case for group 1 vs. group 2. RESULTS: There were 21 patients in group 1. They waited for on average 5.8 days at home for their operation and none were admitted pre or post operatively. There were no associated complications and the majority of patients were discharged from follow-up at 6 weeks post-surgery. In-group 2, there were 32 patients. They waited on average 2.4 days for their operation in the hospital and had an average length of stay of 4.9 days. One patient in group 2 suffered from a deep vein thrombosis. The benefit from our chargeable tariff for group 1 patients was £2295 per case while the margin for group 2 patients was £277 per case. The financial benefit to the health care provider was £2018 in favour of home care and DSU treatment, with high service satisfaction and low complication rates. DISCUSSION: This study provides focused evidence supporting the use of home care for the management of ankle fractures. The DSU pathway improves the value in healthcare delivery with high patient satisfaction scores when compared to the traditional pathway. Our model demonstrates predictably good clinical outcomes with a financial cost benefit over in-patient admission care model for selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Value-based healthcare analysis of joint replacement surgery for patients with primary hip osteoarthritis.

Background: A quarter of the population present at least once a year with a musculoskeletal disorder. Primary hip osteoarthritis is a high-volume condition with significant clinical need and population-level costs. There remains much variation in patient outcomes and care delivery costs for this condition. Aims: The study aimed to gauge if pathway redesign based on the principles of value-based healthcare (VBHC) could increase value. The aim was to calculate the value of treatment for primary hip osteoarthritis through measuring outcomes that matter to patients, as well as the costs of delivering them. Additionally it aimed to compare two care pathways to identify which elements may better promote the delivery of high-value clinical care. Methods: Two care models were evaluated: the first being a traditional model with multiple entry points and without pathway standardisation, and the second an intentionally designed standardised multidisciplinary pathway. Mandated National Health Service patient-reported outcomes were assessed but were restructured into a patient-centred format to assess the impact on pain, function and psychological outcomes. Patient-level pathway economic evaluation was performed. Using these data, outcomes were mapped against cost to calculate value. Results: There were no significant differences in clinical outcomes between the two models. The intentionally designed model delivered better value care, having lower pathway costs. This model produced a small but inconsistent positive financial margin. Conclusions: Intentionally designed, integrated elective services offer an opportunity to develop and evaluate VBHC models. Analysis of two care pathways from a VBHC perspective demonstrated that an intentionally designed pathway had higher value. The higher value pathway maximised the benefits of having physiotherapists and orthopaedic surgeons working side by side. Developing and measuring patient-orientated outcomes and performing accurate economic evaluation are the key to understanding and achieving better value care.

Scapular spine stress fractures: To fix or not to fix, our experience in a patient with bilateral fractures and review of the literature.

We report a case of bilateral scapular spine stress fracture, treated conservatively on one side and operatively on the other side. Besides, we performed a literature review to establish management options. A 61-year-old right-handed gentleman came to our clinic with acute on chronic deterioration of shoulder pain and loss of arm function. Clinical assessment and investigations revealed long-standing bilateral rotator cuff tear and scapular spine stress fractures. The fracture on the right side united with conservative management for 2 months. However, his left side remained symptomatic with pain, abnormal mobility and no radiological evidence of union. The fracture progressed to union after fixation and bone grafting. At the final follow-up at 2 years, the patient was asymptomatic with regards to the fractures with Oxford Shoulder Score (OSS)-30 and Disabilities of the Arm, Shoulder and Hand (DASH)-30.8. Fracture union either by conservative or operative treatment is associated with good functional outcome and is supported by our review.

An analysis of acromioclavicular joint morphology as a factor for shoulder impingement syndrome.

BACKGROUND: The present study aimed to determine whether acromioclavicular (AC) joint morphology was a factor in the development of symptomatic impingement necessitating AC joint excision. METHODS: We performed a prospective cohort study on all patients undergoing AC joint excision for symptomatic joint pain unresponsive to conservative treatment between 2009 and 2011. This involved 106 consecutive patients (57 women, 49 men, average age 54 years, age range 33 to 76 years). Prior to surgery, radiographic classification of the AC joint was performed producing three main groups: oblique, flat or curved. Pre- and postoperative assessment was performed using the Oxford Shoulder Score and the Disabilities of the Arm, Shoulder and Hand questionnaire. RESULTS: A significantly (p < 0.05) higher frequency of oblique AC joint morphology was seen in the AC joint excision study population compared to the normal population. Postoperative outcome demonstrated no significant difference (P > 0.05) between any of the three AC joint morphologies. CONCLUSIONS: The present study demonstrates a significant association between the oblique AC joint morphology and those patients who develop AC joint pain requiring surgery. Outcomes of surgery were independent of joint morphology, gender or age, with all patient subgroups demonstrating significant improvement by the end of the study.

Histologic evaluation of the glenohumeral joint capsule after radiofrequency capsular shrinkage for atraumatic instability.

We evaluated histologically 10 biopsy specimens taken preoperatively from the anterior-inferior glenohumeral ligament from patients with atraumatic instability who had undergone radiofrequency capsular shrinkage, 10 taken immediately postoperatively, and 13 taken before revision. The synovial and subsynovial layers returned to normal histology in biopsy specimens taken from 6 months onwards. Collagen bundles in the fibrous layer continued to have a reparative histology during the period of the study (up to 37 months). The type of radiofrequency probe used (monopolar or bipolar) had no effect on the histologic healing process (P > 0.5, chi2 test). A histologic score was introduced, and this was found to have an excellent intraobserver agreement (weighted kappa, 0.840) and a moderate interobserver agreement (weighted kappa, 0.698).

Acute Gluteal and Thigh Compartment Syndrome following Pelvic Fracture and Superior Gluteal Artery Bleed : A Case Report and Review of the Literature.

Injury to the superior gluteal artery as a result of pelvic fracture is well recognized. Superior gluteal artery bleed leading to gluteal compartment syndrome without fracture of the pelvis has been reported but is extremely rare. Similarly, acute compartment syndrome of the thigh is rare. As far as is known, no previous case has been reported where a combination of pelvic fracture and superior gluteal artery bleed has led to acute gluteal and thigh compartment syndrome. We report on such a patient who developed these complications and highlight the importance of early detection, which may be difficult in an unconscious or comatose patient.