Introduction:There is uncertainty around the pathogenesis and prevalence of distal femoral cortical irregularities (DFCI). We aimed to assess the prevalence of DFCI in a cohort of adolescents that underwent MRI and identify and assess associated risk factors. Methods:A historical cohort study of adolescents (age 10 - <20 years) undergoing MRI scans was conducted. Data was collected for a period of five years using the Picture Archive and Communication System database at a large tertiary hospital. Data collected included sex, age, mechanism of injury and other pathology present in the original MRI report. Binary logistic regression was used to investigate potential risk factors for DFCI. Results:897 scans (mean age, 15.3 (SD 2.59) years; 499 (55.6 %) male) were analysed. Prevalence of DFCI among adolescents who had a MRI scan was 9.1 % (95 % CI: 7.3 %-11.2 %). Patients that had experienced DFCI were younger than those that had not (mean age 14.5 vs 15.3 years, P = 0.002). The mechanism of injury differed between patient groups (P = 0.015); Patients with DFCI were more likely to have had a patella instability/dislocation (22.8 % vs 16.1 %), and less likely to have had a pivotal knee injury (12.7 % vs 29.0 %). When compared to patients aged 10-13 years, older children had reduced odds of a DFCI: 13-16 years had an adjusted odds ratio (aOR) of 0.79 (95 % CI: 0.45 to 1.39); 16-20 years (aOR = 0.36; 95 % CI: 0.18 to 0.71). Males had reduced odds of a DFCI (aOR = 0.38; 95 % CI: 0.22 to 0.66). Conclusions:Female sex and younger age were risk factors for development of DFCI. There was no statistically significant association between mechanism of injury and developing a DFCI. Further research is required to establish its prevalence in those who are asymptomatic and why younger adolescent females are more likely to experience DFCI.

BACKGROUND:The incidence of patellofemoral instability is 5.8 per 100,000 in the general population, rising to 29-43 per 100,000 in adolescents. Up to 85% of recurrent instability is associated with trochlea dysplasia. The Dejour sulcus deepening trochleoplasty can be used to effectively treat patellofemoral instability, however the effect on patellofemoral cartilage and survival of the osteochondral flap is not known. The aim of the study was to determine changes in the patellofemoral articular surface in the early postoperative period with MRI analysis. PATIENTS AND METHODS:MRI analysis of a single-surgeon series, retrospective review of 61 sulcus deepening trochleoplasties between 2014 and 2022, of which 40 had a postoperative MRI and were assessed - including 26 women (65%) and 22 (55%) right knees. Trochleoplasty was performed in conjunction with medial reefing and lateral release in 26 patients (65%), in conjunction with MPFL reconstruction alone in 12 (30%), and in conjunction with MPFL reconstruction and tibial tubercle osteotomy in 2 (5%). Preoperative and postoperative MRIs were assessed for articular cartilage loss, percentage of full thickness cartilage loss as well as volume and number of bone marrow lesions using a modified version of the MRI osteoarthritis knee score (MOAKS). RESULTS:Mean age at operation was 25.3 years (SD: 7.3). The modal number of comorbidities was zero, and no patient had diabetes or was taking immunosuppressive medication. Mean time between preoperative MRI and trochleoplasty was 8.7 months (SD: 6.9). Mean time between trochleoplasty and postoperative MRI was 19.9 months (SD 14.9). There were further episodes of symptomatic instability in 8 (20%) of patients. In all anatomical subregions (medial and lateral patellar, medial and lateral trochlear groove) there was a significant increase in articular cartilage loss between pre- and post-operative MRIs (p < 0.001). There was a significant decrease in the volume and number of bone marrow lesions (BMLs) in the medial patella only, with static or nonsignificant increases in the lateral patella and medial trochlear groove, and significant increases in the number and volume of BMLs in the lateral trochlea (p < 0.001). MOAK grade 1 was seen in at least one anatomical subregion in every patient post-operatively and there was progression in MOAK grade in all subregions. Progression in MOAK grade was seen in the medial patella in 20 patients (50%), lateral patella in 18 patients (45%), medial trochlea in 22 patients (45%) and lateral trochlea in 31 patients (78%). DISCUSSION AND CONCLUSION:Whilst patellofemoral osteoarthritis is common post trochleoplasty, the history of its development is not clear. Few studies report cartilage condition post-surgery. Authors in the only other MRI study found no change in cartilage condition at a mean of 64-months. A small case series of histological samples taken from trochleoplasty patients during subsequent arthroscopy also found normal cartilage and a healing osteochondral flap. Our study evaluated the entire patellofemoral surface using MRI and found that patellofemoral articular cartilage loss was seen in at least one anatomical subregion in every patient post-operatively, with progression in chondral damage seen in between 45% and 78% of anatomical subregions. LEVEL OF EVIDENCE:IV; observational cohort study.

Aims:To determine whether obesity and malnutrition have a synergistic effect on outcomes from skeletal trauma or elective orthopaedic surgery. Methods:Electronic databases including MEDLINE, Global Health, Embase, Web of Science, ScienceDirect, and PEDRo were searched up to 14 April 2024, as well as conference proceedings and the reference lists of included studies. Studies were appraised using tools according to study design, including the Oxford Levels of Evidence, the Institute of Health Economics case series quality appraisal checklist, and the CLARITY checklist for cohort studies. Studies were eligible if they reported the effects of combined malnutrition and obesity on outcomes from skeletal trauma or elective orthopaedic surgery. Results:A total of eight studies (106,319 patients) were included. These carried moderate to high risk of bias. Combined obesity and malnutrition did not lead to worse outcomes in patients undergoing total shoulder arthroplasty or repair of proximal humeral fractures (two retrospective cohort studies). Three studies (two retrospective cohort studies, one case series) found that malnourishment and obesity had a synergistic effect and led to poor outcomes in total hip or knee arthroplasty, including longer length of stay and higher complication rates. One retrospective cohort study pertaining to posterior lumbar fusion found that malnourished obese patients had higher odds of developing surgical site infection and sepsis, as well as higher odds of requiring a revision procedure. Conclusion:Combined malnutrition and obesity have a synergistic effect and lead to poor outcomes in lower limb procedures. Appropriate preoperative optimization and postoperative care are required to improve outcomes in this group of patients.

Background Unicompartmental knee replacements (UKRs) have become an increasingly attractive option for end-stage single-compartment knee osteoarthritis (OA). However, there remains controversy in patient selection. Natural language processing (NLP) is a form of artificial intelligence (AI). We aimed to determine whether general-purpose open-source natural language programs can make decisions regarding a patient’s suitability for a total knee replacement (TKR) or a UKR and how confident AI NLP programs are in surgical decision making. Methods We conducted a case-based cohort study using data from a separate study, where participants (73 surgeons and AI NLP programs) were presented with 32 fictitious clinical case scenarios that simulated patients with predominantly medial knee OA who would require surgery.Using the overall UKR/TKR judgments of the 73 experienced knee surgeons as the gold standard reference, we calculated the sensitivity, specificity, and positive predictive value of AI NLP programs to identify whether a patient should undergo UKR. Results There was disagreement between the surgeons and ChatGPT in only five scenarios (15.6%). With the 73 surgeons’ decision as the gold standard, the sensitivity of ChatGPT in determining whether a patient should undergo UKR was 0.91 (95% confidence interval (CI): 0.71 to 0.98). The positive predictive value for ChatGPT was 0.87 (95% CI: 0.72 to 0.94). ChatGPT was more confident in its UKR decision making (surgeon mean confidence = 1.7, ChatGPT mean confidence = 2.4). Conclusions It has been demonstrated that ChatGPT can make surgical decisions, and exceeded the confidence of experienced knee surgeons with substantial inter-rater agreement when deciding whether a patient was most appropriate for a UKR.

Rationale The National Health Service (NHS) Long Term Plan was published in January 2019. One of its objectives was restructuring outpatient services, as part of an Outpatient Transformation initiative. Monitoring of trusts' adherence to the objectives of the Long Term Plan is therefore required to benchmark progress against national objectives. Aims and Objectives We aimed to explore whether outpatient transformation initiatives and phlebotomy services that are managed by outpatients are appropriately staffed and to evaluate trusts' adherence to the objectives outlined in the Long Term Plan. Method A freedom of information (FOI) request was sent in January 2023 to 153 trusts across Great Britain (time span: 1 January 2022-31 December 2022). Parameters requested included number of outpatients seen/discharged, phlebotomy episodes, number of sites/wards covered by phlebotomy, target/actual did not attend (DNA) rates, time since inception of the outpatient transformation project (OTP), advice and refer (A&R) and patient-initiated follow-up (PIFU), phlebotomy and outpatient managerial establishment and use of electronic notes and patient portals. Results A total of 117 trusts (76.5%) provided responses to the FOI request. The mean number of new outpatients seen face-to-face was 185,810. Of 73 trusts reporting both actual and target DNA rates, 62 (84.9%) did not meet their DNA targets. The actual DNA rate was significantly greater than the target DNA rate across trusts (p < 0.001, mean: 8.8% vs. 6.5%, respectively). A total of 58 different electronic systems and 29 patient portals were utilised across trusts. Thirty-six trusts (30.3%) did not have an outpatient transformation project manager and 16 trusts (13.7%) did not initiate an OTP. With phlebotomy provision, the mean number of outpatient phlebotomy episodes was lower than inpatient episodes (83,383 vs. 91,020, respectively). Conclusion There are deficiencies in current outpatient establishments that may hinder the achievement of objectives set in the NHS Long Term Plan. Changes at all levels of healthcare are required, with increased reliance on technologies and investment in support for transformation management.

INTRODUCTION:The initial assessment of pregnant women presenting with significant injuries is more complicated than that of non-pregnant women because of physiological and anatomical changes, and the presence of the fetus. The aim of this study was to determine whether guidelines for the early management of severely injured pregnant women exist, which aspects of assessment/management they cover and to what extent there is national consistency. METHODS:A freedom of information request was submitted to 125 acute National Health Service trusts in England and six in Wales. The trusts were asked to confirm whether they have a guideline for the management of major trauma in pregnant women presenting to the emergency department and what the guidelines were. RESULTS:In total, 96.2% of trusts responded, of which 19% have a specific guideline and 7.9% have a generic guideline for assessing pregnant women in the emergency department, irrespective of injury severity. Of the responding trusts, 19.8% have a protocol that specifies when an obstetric trauma call should be put out by the emergency department and when a pregnant woman should be transferred to a major trauma centre for definitive management. Our results found that 69.8% routinely call obstetrics or gynaecology to the trauma call compared with 36.5% calling paediatrics. CONCLUSIONS:The heterogeneity evident across trusts necessitates the establishment of national guidelines for the assessment of pregnant women with major trauma to standardise communication and delivery of care.

The volume of total knee arthroplasty (TKA) cases being performed worldwide is ever increasing. However, approximately 20% of patients remain dissatisfied following the procedure. Therefore, research evaluating the factors that influence the outcome following TKA is important.

Background: As part of their religious obligation, Muslims abstain from food and drink from dawn until dusk for a 30-day period during Ramadan. Fasting may affect daily functioning, such as increased risk of collision for drivers. A study of the impact of fasting during Ramadan on trauma incidence may allow for the creation of public health campaigns targeting this potential phenomenon. We aimed to determine whether trauma incidence increases during Ramadan, and to characterise the trauma occurring during Ramadan. Methods: Both published and unpublished literature, along with conference proceedings and reference lists from the selected studies, were searched up until the 1st of July 2023. A narrative synthesis was conducted, and the included studies were evaluated using appropriate tools based on their study design. Results: Seventeen studies (964,631 subjects) were included. There were methodological concerns pertaining to their low level of evidence and risk of bias. Of nine studies reporting on road traffic accidents (RTAs), six found a higher incidence during Ramadan. Road traffic accidents and occupational injuries (OIs) were more likely to occur near or at sunset (marking the end of the fast). Two studies presented conflicting evidence regarding the effect of fasting in Ramadan on sports-associated injuries. Current evidence suggests that falls and violence-related trauma do not occur more frequently during Ramadan, with insufficient evidence to determine the occurrence of other injury mechanisms. Conclusion: Individuals who fast may be at a higher risk of RTAs and OIs during Ramadan than outside this month. Due to the lack of studies performed in the Americas and Europe, it is unclear whether the findings are applicable to these regions. Current evidence is limited by lack of stratification according to time of trauma occurrence, and high risk of bias.

Purpose: The British Orthopaedic Association Standards for Trauma-4 includes pediatric Gustilo–Anderson type I upper limb open fractures and recommends surgical debridement as the preferred method of treatment. The reported incidence of fracture-related infection is low in patients with this injury pattern and the evidence supporting debridement is therefore weak. The aim of this systematic review is to compare infection rates between non-operative management and operative debridement in children with Gustilo I upper limb fractures who did not require surgical fixation. Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligibility criteria included patients <18 years with Gustilo–Anderson type I upper limb fractures managed with either antibiotics alone or with operative debridement. Patients in whom the fracture was stabilized were excluded, and the Risk Of Bias In Non-randomized Studies—of Interventions tool was used to evaluate bias. Results: Eleven, predominantly retrospective studies were identified, involving 537 patients with fractures including 466 forearm, 70 wrist, and one humerus. A non-operative management strategy was used in 293 patients with one superficial infection (0.3%). Operative debridement was used in 244 patients with one superficial infection (0.4%). Conclusion: The optimal management of Gustilo–Anderson type I pediatric upper limb fractures is unclear. Based on the current evidence base, surgical debridement does not appear to reduce the rate of infection. The decision to manage these injuries aggressively should therefore be individualized to consider patient age, mechanism, and clinical extent of injury. Level of evidence: level II.

Introduction:medial patellofemoral ligament reconstruction (MPFLr) is a common surgical procedure for treating patellar instability. Grafts can be fixed to the femur using a bone-tunnel technique with an interference screw. However, this may lead to femoral tunnel enlargement (FTE) post-operatively. The aim of this study was to assess the correlation between time after MPFLr and FTE, to evaluate factors that might influence FTE and to determine if FTE can be reliably evaluated with plain radiographs. Methods:we conducted a single-surgeon series, retrospective review of 70 MPFLr (52 female; 18 male) between 2014 and 2022. We assessed change in femoral tunnel area compared with original tunnel area (TP0), on lateral radiographs at two time points. Time point one (TP1): mean 34 days (standard deviation (SD): 25); and Time Point 2 (TP2): mean 490 days (SD: 333). We analysed the relationship between surgical characteristics to FTE, and assessed inter- and intra-rater reliability of FTE. Results:tunnel area significantly increased from TP0 to TP1 and TP2 (p < 0.001). Mean percentage increase in cross-sectional tunnel area (CTA) between TP0 and TP1 was 113 % (SD: 49 %). Mean percentage increase in CTA between TP0 and TP2 was 139 % (SD: 64 %). There were 25 cases (36 %) of tunnel malposition. There was no significant correlation between distance from the isometric point and FTE at TP1 (r = 0.05; 95 % confidence intervals (CI): -0.19 to 0.29) or TP2 (r = 0.17: 95 % CI: -0.068 to 0.39). There were no other significant correlations with FTE. Inter-rater reliability for FTE at TP1 was moderate (Inter-Class Coefficient (ICC): 0.67; 95 % CI: 0.47 to 0.80; p < 0.001), with intra-rater reliability being excellent (ICC: 0.94; 95 % CI: 0.90 to 0.96; p < 0.001). Conclusion:FTE after MPFLr is common. Plain radiographs can be used reliably to monitor tunnel enlargement in clinical practice.

Purpose Tourniquets are commonly used intraoperatively in orthopaedic surgery to control bleeding and improve visibility in the surgical field. Recent evidence has thrown into question the routine use of tourniquets in the adult population resulting in a British Orthopaedic Association standard for intraoperative use. This systematic review evaluates the evidence on the practice, benefits, and risks of the intraoperative use of tourniquets for trauma and elective orthopaedic surgery in the paediatric population. Methods A prospectively registered systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO: CRD42022359048). A search of MEDLINE, Embase, the Cochrane Library and a Grey literature search was performed from their earliest record to 23 March 2023. Studies reporting tourniquet data in paediatric patients undergoing orthopaedic surgery were included. Data extracted included demographics, involved limb, trauma versus elective use, tourniquet use as primary or secondary measure, and tourniquet parameters and complications. Results Thirty-nine studies were included. Tourniquet practices and information reporting varied considerably. Tourniquets were used uneventfully in the majority of patients with no specific benefits reported. Several physiological and biochemical changes as well as complications including nerve injury, compartment syndrome, skin burns, thrombosis, post-operative limb swelling, and pain were reported. Conclusions Tourniquets are routinely used in both trauma and elective paediatric orthopaedic surgery with no high-quality research affirming benefits. Severe complications associated with their use are rare but do occur. High-quality studies addressing their benefits, the exact indication in children, and the safest way to use them in this population are necessary.

Noise-Induced Hearing Loss (NIHL) is a condition caused by repeated exposure to loud noise, with operating theatre personnel potentially at risk. The aims of this study were to establish the typical noise levels in orthopaedic theatres and to compare these to The Control of Noise at Work Regulations 2005. We measured the average noise levels in 40 trauma and orthopaedic surgeries in a single centre. We used the Decibel X app to take measurements, then performed corrections to ascertain noise levels at the surgeon’s ear (Leq). The daily noise exposure level for theatre staff for each procedure (LEP, d) and the LEP, d over an average 8-hour working day when performing different groups of procedures were calculated. Data were analysed using descriptive statistics, ANOVA, t-test and the Pearson coefficient of correlation. The LEP, d lower action value (80 dBA) as set by the Health and Safety Executive (HSE) was met by performing a single revision total knee replacement or a right open ankle debridement. Assuming three procedures are conducted per list, lists consisting of joint replacements (82 dBA) or medium elective procedures (81 dBA) exceed this lower limit. Additionally, lists comprising large and medium bone fractures would be within 1 dB of the limit (79 dBA and 79 dBA, respectively). Soft tissue (74 dBA), arthroscopic (73 dBA), and small bone fracture (71 dBA) procedures had the lowest LEP, d. The greatest contributors to noise levels were surgical instruments. The number of people in the room made a significant difference to noise levels (p = 0.032). We have established the baseline noise levels in various orthopaedic procedures. Measures should be taken to meet UK regulations. Further research should determine suitable measures for protection from hearing damage for theatre staff and evaluate the risks high noise levels pose to patients.

Introduction:Hypermobility describes the movement of joints beyond normal limits. Whether hypermobility predisposes to patellar instability is yet to be established. We aimed to determine if joint hypermobility leads to an increased risk of patellar instability, and to evaluate outcomes of treatment for patellar instability in those who exhibit hypermobility. Methods:Published and unpublished literature databases were searched to September 7, 2023. Studies comparing prevalence of patellar dislocation/differences in treatment outcomes in patients with and without hypermobility were included. Results:We identified 18 eligible studies (4,391 patients). The evidence was low in quality. A case series on 82 patients found that there was a relationship between generalised joint laxity and patellar instability. This was corroborated by a study comparing 104 patients with patellar dislocation to 110 patients without. Prevalence of generalised joint laxity was six time higher in the former (64.4% vs 10.9%, p < 0.001).Five studies found surgical intervention aimed at correcting patellar dislocation in patients with idiopathic hypermobility led to satisfactory outcomes. There was conflicting evidence regarding if hypermobile patients have worse outcomes than non-hypermobile patients following medial patellofemoral ligament reconstruction (MPFLR) in two studies. In addition, this procedure had a 19.1% failure rate in patients with Ehlers Danlos Syndrome (EDS), with hypermobility associated with a higher failure rate (p = 0.03). One study showed the type of graft used made no difference in outcome scores or re-dislocation rates (p > 0.5). Another study had 7/31 (22.6%) autografts which failed, compared to 2/16 allografts (12.5%) (p = 0.69). Conclusion:Joint hypermobility is a risk factor for patellar instability. Identification of at-risk groups may aid prevention of dislocations and allow for appropriate treatment. Patients with EDS experience poor outcomes following patellar stabilization surgery, with post-operative monitoring required.

INTRODUCTION:Trauma accounts for 20% of deaths in pregnant women. Injury characterisation and outcome in pregnant women following trauma is poorly described. To understand and inform optimum care of this key injury population, a study was conducted using the Trauma Audit Research Network (TARN) database.METHODS:In total, 341 pregnant and 26,774 non-pregnant female patients aged 15 to 46 years were identified for comparison from the TARN database. Mortality, cross-sectional imaging, blood product administration and EQ-5D scores were compared between the two groups. Mechanism of injury, Injury Severity Score (ISS) and mortality rate before and after the creation of regional trauma networks were reported for pregnant patients.RESULTS:Pregnancy was recorded in 1.3% (341/27,115) of included patients, with the most common cause of injury being road traffic collisions. A reduction in crude maternal mortality was observed over the course of the study period (7.3% to 2.9%). Baseline mean EQ-5D (0.47) and EQ-VAS (54.08) improved to 0.81 (p < 0.001) and 85.75 (p = 0.001), respectively, at 6 months following injury.CONCLUSION:The incidence of trauma in pregnancy is small and mortality in injured pregnant women decreased over the study period. Pregnant patients have significantly improved patient-reported outcome measures 6 months after injury although this is limited in impact because of poor response rates and outcome reporting. Construction and validation of tools aiding in outcome reporting will help considerably in understanding further gains in the care of pregnant women.