www.comoc2016.org

www.comoc2016.org

www.comoc2016.org 

INDEX 

PROGRAMME OVERVIEW 1 

PLENARY LECTURES 14 

SYMPOSIA 16 

INSTRUCTIONAL COURSES - MONDAY 34 

MEDICOLEGAL SESSION - MONDAY 48 

EDUCATION AND RESEARCH – MONDAY & WEDNESDAY 54 

INSTRUCTIONAL COURSES - TUESDAY TO FRIDAY 56 

FREE PAPERS 90 

POSTERS 368 

INDEX OF PRESENTERS 464 

INDEX OF POSTER PRESENTERS 474 

All Abstracts that were submitted have been published as they were 

received. Typing or other errors made by the authors are not corrected. 

Abstracts that were not submitted to the Organisers are not included.

PROGRAMME OVERVIEW 

TIME 

SUNDAY 10 APRIL 

2016 


2016 


2016 

15h00-17h00 REGISTRATION REGISTRATION REGISTRATION 

19h00 

PRESIDENTIAL DINNER 

(by invitation only) 





MONDAY 11 APRIL 

2016 


2016 


2016 

Plenary Venue 1 - Audi 1 Parallel Venue 2 - Audi 2 Parallel Venue 3 - 1.41 


07h30-08h00 

08h00-09h00 

WELCOME (Plenary Venue: Audi 1) 

OPENING CEREMONY AND OPENING SPEAKER "Clearing cartilage: Scraping South African history 

against the grain". A. Grundlingh. (Plenary Venue: Audi 1) 

09h00-10h30 

AMERICAN ORTHOPAEDIC 

ASSOCIATION (AOA) 

SYMPOSIUM: Forging 

Partnerships: Multidisciplinary 

Teamwork to Enhance Patient 

Care 

HIP ARTHROPLASTY 

INSTRUCTIONAL COURSE: 

Primary Hip Arthroplasty 

FOOT AND ANKLE 

INSTRUCTIONAL COURSE: The 

Adult Flat Foot Deformity – where 

do we stand in 2016 

10h30-11h00 TEA TEA TEA 

11h00-12h30 

AMERICAN ORTHOPAEDIC 

ASSOCIATION (AOA) 

SYMPOSIUM: Orthopaedic 

Workforce Needs: Challenges in 

a Changing Environment 

ARTHROPLASTY 

INSTRUCTIONAL COURSE 

FOOT AND ANKLE 

INSTRUCTIONAL COURSE: Sports 

injuries in the Foot and Ankle 

12h30-13h00 

Plenary Lecture American Orthopaedic Association (Audi 1) 

Certification of Competency Throughout an Orthopaedic Surgeons Career 

T. Peabody 

13h00-14h00 

LUNCH 

LUNCH 

13h00-13h30 ARTHREX FOOT ISS: 

Talk on Lateral ligament 

reconstruction and Internal Brace 

application for the Ankle 

LUNCH 

14h00-14h30 

Plenary Lecture American Academy of Orthopaedic Surgeons: (Audi 1) 

The Evidence Base for the Prognosis and Treatment of Adolescent idiopathic Scoliosis 

Stuart Weinstein 

1

COLOR CODING KEY 

TIME 

Instructional courses 

Symposia 

Debates 

Meet the experts 


2016 

Plenary lectures 

Keynote/ Eponymous 

Free Papers 

Poster Session 


2016 

Medicolegal Sessions 

Education & Research 


2016 


19h00 




2016 




2016 




2016 


Parallel Venue 4 - 1.61 Parallel Venue 5 - 2.41 Parallel Venue 6 - 2.61 


07h30-08h00 

08h00-09h00 

WELCOME (Plenary Venue: Audi 1) 

OPENING CEREMONY AND OPENING SPEAKER "Clearing cartilage: Scraping South African history 

against the grain". A. Grundlingh. (Plenary Venue: Audi 1) 

09h00-09h30 

09h30-10h30 

SAMLA - MEDICOLEGAL 

SESSION 

POSTER SESSION 

XIROS: Extra and Intra-articular 

applications of synthetic ligaments 

in knee surgery 


11h00-12h00 

12h00-12h30 

SISTER ASSOCIATIONS 

MEDICOLEGAL SESSION 

POSTER SESSION 

ORTHO-XACT: Interactive 

Workshop: Damage Control and 

High Energy Trauma 

12h30-13h00 

Plenary Lecture American Orthopaedic Association (Audi 1) 

Certification of Competency Throughout an Orthopaedic Surgeons Career 

T. Peabody 

13h00-14h00 

LUNCH 

LUNCH 

DEPUY SYNTHES ISS: 

Metaphyseal Sleeve Stability - 

“A 40 Year Heritage” 

(lunch will be served). 

VENUE: ROOF TERRACE 

14h00-14h30 

Plenary Lecture American Academy of Orthopaedic Surgeons: (Audi 1) 

The Evidence Base for the Prognosis and Treatment of Adolescent idiopathic Scoliosis 

Stuart Weinstein 

2



Symposia 






2016 


2016 


2016 


14h30-15h00 

15h00-15h30 

AMERICAN ACADEMY OF 

ORTHOPAEDIC SURGEONS 

(AAOS) SYMPOSIUM: An 

International Perspective on 

Value-Based Healthcare 

HIP ARTHROPLASTY 


Primary Hip Arthroplasty 

FOOT AND ANKLE FREE PAPERS 

Stryker ISS: Advancements in Foot 

& Ankle Plating (tea will be provided) 

15h30-16h00 

TEA (15h30-16h00) 

16h00-16h30 

16h30-17h00 

17h00-18h00 

TEA (16h00-16h30) 

AMERICAN ACADEMY OF 

ORTHOPAEDIC SURGEONS 

(AAOS) SYMPOSIUM: Hot Topics 

and Controversies in Total Hip 

Replacement. 

ARTHROPLASTY FREE PAPERS 

FOOT AND ANKLE FREE PAPERS 

FOOT AND ANKLE DEBATE 

18h30 

COCKTAIL FUNCTION AT 

CTICC 


CTICC 


CTICC 

NOTES 

3


14h30-15h00 

15h00-15h30 

Debates 



2016 

Free Papers 



2016 


2016 


EDUCATION AND RESEARCH: 

EFORT’s work in education and 

standardization in Europe. 

15h00-16h00. DEPUY SYNTHES 

ISS: The Attune Knee System 

Proving the promise 

SPINE FREE PAPERS 

CORIN SA: Corin Optomised 

Positioning System (OPS) 


15h30-16h00 

TEA (15h30-16h00) 

TEA (15h30-16h00) 

TEA (15h30-16h00) 

16h00-17h30 


British Bone & Joint Journal: 

Getting your work published and 

achieving the highest impact 


XIROS: ACJ reconstruction using 

the Infinity-Lock device 

17h30-18h00 

18h30 


CTICC 


CTICC 


CTICC 

NOTES 

4



Symposia 





TUESDAY 12 APRIL 

2016 


2016 


2016 


08h00-10h00 

AUSTRALIAN ORTHOPAEDIC 

ASSOCIATION (AuOA) 

SYMPOSIUM: National Joint 

Replacement Registry 

HAND INSTRUCTIONAL 

COURSE: Total Wrist 

Arthroplasty 

PAEDIATRICS INSTRUCTIONAL 

COURSE: Clubfoot and 

Congenital Vertical Talus 


10h30-12h30 

AUSTRALIAN ORTHOPAEDIC 

ASSOCIATION (AuOA) 

SYMPOSIUM: Computer 

Navigation in Orthopaedic 

Surgery 

HAND INSTRUCTIONAL 

COURSE: Management of 

radiocarpal arthritis 

PAEDIATRICS INSTRUCTIONAL 

COURSE: Slipped Capital Femoral 

epiphysis 

12h30-13h00 

Plenary Lecture Australian Orthopaedic Association (Audi 1) 

Initiatives in Orthopaedic Education and Training - Ian Incoll 

13h00-14h00 

LUNCH 

ATHREX HAND ISS: Mini 

Tightrope “An Arthroscopic look” 

STEPS ISS: Emerging Technologies 

and Potential Applications in Clubfoot 

Management 

LUNCH 

LUNCH 


14h00-14h30 

Plenary Lecture New Zealand Orthopaedic Association (Audi 1) 

Paediatric Orthopaedics in the 21st Century - Sue Stott 

14h30-15h30 

NEW ZEALAND ORTHOPAEDIC 

ASSOCIATION (NZOA) 

SYMPOSIUM: Clinical 

Prioritisation of Elective 

Orthopaedic Surgery 

HAND FREE PAPERS PAEDIATRICS FREE PAPERS 


16h00-16h30 HAND FREE PAPERS PAEDIATRICS FREE PAPERS 

16h30-17h00 

17h00-17h30 

NEW ZEALAND ORTHOPAEDIC 

ASSOCIATION (NZOA) 

SYMPOSIUM: Orthopaedic 

Practice in a No Fault Accident 

Compensation Environment 

PAEDIATRICS DEBATE 

PAEDIATRICS MEET THE 

EXPERTS 

19h00 

SOCIAL FUNCTION - Gold 

Restaurant 


Restaurant 


Restaurant 

5


08h00-10h00 

Debates 



2016 

Free Papers 



2016 


2016 


SPINE INSTRUCTIONAL 

COURSE: Where 3rd and 1st 

worlds collide 

AOTRAUMA EUROPE (AOTEU) 

SYMPOSIUM: Lower limb 

trauma: All things considered 

FOOT AND ANKLE FREE 

PAPERS 


10h00-10h30 

TEA 

AOTRAUMA EUROPE (AOTEU) 

SYMPOSIUM: Audience 

participation 

TEA 

10h30-11h00 

TEA 

11h00-12h30 

SPINE INSTRUCTIONAL 

COURSE: Spine sports injuries 

AOTRAUMA/AORECON 

SYMPOSIUM—Periprosthetic 

fractures in hip and knee 

replacements 

HIP ARTHROPLASTY FREE 

PAPERS 

12h30-13h00 

Plenary Lecture Australian Orthopaedic Association (Audi 1) 

Initiatives in Orthopaedic Education and Training - Ian Incoll 

13h00-14h00 

LUNCH 

LUNCH 

LUNCH 


14h00-14h30 

Plenary Lecture New Zealand Orthopaedic Association (Audi 1) 

Paediatric Orthopaedics in the 21st Century - Sue Stott 

14h30-15h30 


AORECON 

SYMPOSIUM—Controversies in 

knee replacement surgery 


PAPERS 


16h00-16h30 

16h30-17h00 


SPINE DEBATE 

AORECON 

SYMPOSIUM—Controversies in 

knee replacement surgery 


PAPERS 

17h00-17h30 

19h00 


Restaurant 


Restaurant 


Restaurant 

6



Symposia 





Time 

WEDNESDAY 13 

APRIL 2016 

WEDNESDAY 13 

APRIL 2016 

WEDNESDAY 13 

APRIL 2016 


07h00-08h00 

ARTHREX ISS: Proximal 

Hamstring Reconstruction, portals 

for the 4th compartment and sciatic 

nerve release 

08h00-10h00 

BRITISH ORTHOPAEDIC 

ASSOCIATION (BOA) 

SYMPOSIUM: The International 

Musculoskeletal Time Bomb – 

Better outcomes, lower cost 

HIP ARTHROSCOPY 

INSTRUCTIONAL COURSE: Hip 

Scope Basics 

LIMB LENGTHENING AND 

RECONSTRUCTION 


Traumatic bone loss 


10h30-12h00 

BRITISH ORTHOPAEDIC 

ASSOCIATION SYMPOSIUM 

(BOA): Creating an evidence 

based cost effective arthroplasty 

service 



Advanced Hip Arthroscopy 

TRAUMA INSTRUCTIONAL 

COURSE: Trauma care delivery 

debate 

12h00-12h30 

12h30-13h00 

Robert Jones Plenary Lecture British Orthopaedic Association (Audi 1) 

The use and abuse of data and evidence in Orthopaedics - Tim Wilton 

13h00-14h00 

LUNCH 

14h00-15h00 

15h00-15h30 

HIP ARTHROSCOPY FREE 

PAPERS 

TRAUMA FREE PAPERS 


16h00-17h30 


17h30-18h00 

19h00 ABC Dinner (by invitation only) ABC Dinner (by invitation only) ABC Dinner (by invitation only) 

19h00 FREE EVENING FREE EVENING FREE EVENING 

7

Time 


07h00-08h00 

Debates 


WEDNESDAY 13 

APRIL 2016 

Free Papers 


WEDNESDAY 13 

APRIL 2016 

WEDNESDAY 13 

APRIL 2016 



08h00-09h30 

ISAKOS - SPORT MEDICINE 


HAND FREE PAPERS 

PAEDIATRICS FREE PAPERS 

09h30-10h00 

TEA 

10h00-10h30 TEA TEA 

10h30-12h00 


American Journal of Bone & Joint 

Surgery: Advance your career in 

scholarly publications 



PAEDIATRICS FREE PAPERS 

12h00-12h30 

11h50-12h30: ALLERGAN: A 

practical approach to optimizing 

ultrasound techniques in children 

12h30-13h00 

Robert Jones Plenary Lecture British Orthopaedic Association (Audi 1) 

The use and abuse of data and evidence in Orthopaedics - Tim Wilton 

13h00-14h00 

LUNCH 

ORTHOCELL: Advancements in 

Biologic Therapy Treatments for 

Tendinopathy: the Translation of 

Tendiopathic Pathology to Clinical 

Management 

LUNCH 

14h00-15h00 

15h00-15h30 

GENERAL FREE PAPERS 



BMG: The treatment of difficult 

cases with the Medial Pivot Knee 


16h00-17h30 

17h30-18h00 

GENERAL FREE PAPERS 


CASE PRESENTATIONS 

19h00 ABC Dinner (by invitation only) ABC Dinner (by invitation only) ABC Dinner (by invitation only) 

19h00 FREE EVENING FREE EVENING FREE EVENING 

8



Symposia 





THURSDAY 14 

APRIL 2016 

THURSDAY 14 

APRIL 2016 

THURSDAY 14 APRIL 

2016 


08h00-09h00 

09h00-10h00 

CANADIAN ORTHOPAEDIC 

ASSOCIATION: The Role of a 

Competency Based Curriculum 

in Orthopaedic Training: 

Bridging the Gap between 

Theory and Clinical Practice 

KNEE INSTRUCTIONAL 

COURSE: Advances in Soft 

Tissue Knee Surgery 

SHOULDER AND ELBOW 


Approach to Shoulder Instability 

and Trauma around the Shoulder 

10h00-10h15 

10h15-10h30 

10h30-10h45 

TEA 

TEA 

TEA 

10h45-12h30 

CANADIAN ORTHOPAEDIC 

ASSOCIATION SYMPOSIUM: 

Clinical Trials (and Tribulations): 

The Promise of Multinational 

Research 

KNEE INSTRUCTIONAL 

COURSE: Satisfaction in Total 

Knee Arthroplasty 


INSTRUCTIONAL COURSE: Soft 

Tissue Injuries of the Elbow and 

Adolescent hyper-use injuries of 

the shoulder 

12h30-13h00 

Plenary lecture Canadian Orthopaedic Association (Audi 1) 

An Integrated Approach to Quality and Access in a Universal Healthcare System 

James P. Waddell 

13h00-13h30 

ARTHREX ISS: Meniscal repair 

through arthroscopic posterior 

portal 

ARTHREX ISS: How I treat 

instabilities 

LUNCH 

13h00-14h00 LUNCH LUNCH 


14h00-14h30 

14h30-15h30 

KNEE FREE PAPERS 

SHOULDER AND ELBOW FREE 

PAPERS (Rotar cuff) 


16h00-17h00 


SHOULDER AND ELBOW - FREE 

PAPERS (Instability) 

17h00-17h30 

17h30-18h00 

SHOULDER AND ELBOW DEBATE 

19h00 GALA DINNER GALA DINNER GALA DINNER 

9


08h00-10h00 

Debates 


THURSDAY 14 

APRIL 2016 

Free Papers 


THURSDAY 14 

APRIL 2016 

THURSDAY 14 

APRIL 2016 





OSTEOMED: Ankle Fusion Plating - 

The ExtremiLOCK Plating System 


10h00-10h35 

TEA 

TEA 

TEA 

10h30-11h00 


11h00-12h00 



12h00-12h30 

12h30-13h00 

Plenary lecture Canadian Orthopaedic Association (Audi 1) 

An Integrated Approach to Quality and Access in a Universal Healthcare System 

James P. Waddell 

13h00-14h00 

LUNCH 

SMITH & NEPHEW: Hip 

Arthroscopy for DJD. 

Hip Arthroscopy Lateral Position 

with capsule-sparing sub-capsular 

approach for FAI The Role of 3D 

CT Scans in Hip Arthroscopy and 

Hip Preservation 

DEPUY SYNTHES ISS: Minimally 

Invasive Vs Open Latarjet 

Technique (lunch will be served) 

VENUE: ROOF TERRACE 


14h00-14h30 

14h30-15h30 



PAPERS 

14h00-14h30: ABC Fellow 

feedback 

14h30-14h45: Current State of 

DVT Prophylaxis in Total Joint 

Replacement. 


16h00-17h00 

17h00-17h30 


PAPERS 

17h30-18h00 

19h00 GALA DINNER GALA DINNER GALA DINNER 

10



Symposia 





FRIDAY 15 APRIL 

2016 


2016 


2016 


08h00-10h00 

South African Orthopaedic 

Association (SAOA) Symposium: 

ARTHROPLASTY FREE PAPERS 

First World Surgeon in a third 

world environment: the milieu 

TUMOURS INSTRUCTIONAL 

COURSE: New concepts in 

genetics and novel treatment in 

bone tumours 


10h30-12h30 


Association (SAOA) Symposium: 

First World Surgeon in a third 

world environment: the clinical 

challenge 


TUMOURS INSTRUCTIONAL 

COURSE: Metastatic bone disease 

12h30-13h00 

Plenary Lecture GT du Toit, South African Orthopaedic Association (Audi 1) 

Access to quality Orthopaedic services in Low to middle income countries 

Mkhululi Lukhele 

13h00-14h00 

LUNCH 

LUNCH 

LUNCH 

14h00-14h30 

Plenary Lecture JJ Craig South African Orthopaedic Assocation (Audi 1) A walk 

along the path of clubfoot management in South Africa 

Mark Eltringham 

14h30-15h30 KNEE FREE PAPERS TUMOUR FREE PAPERS 


16h00-16h30 

16h30-17h00 


TUMOUR MEET THE EXPERTS 

17h00-17h30 

17h30 

CLOSING CEREMONY - 

Venue 4 - 1.61 


Venue 4 - 1.61 


Venue 4 - 1.61 

NOTE: Programme subject to change Programme subject to change Programme subject to change 

11


08h00-10h00 

Debates 



2016 

Free Papers 



2016 


2016 


SHOULDER FREE PAPERS 



10h30-12h30 

SHOULDER & ELBOW FREE 

PAPERS 

12h30-13h00 

Plenary Lecture GT du Toit, 


Association: (Audi 1) Access to 

quality Orthopaedic services in 

Low to middle income countries 

Mkhululi Lukhele 

SAOA Plenary lecture, Audi 1 

13h00-14h00 

13h00- 13h30 ARTHREX ISS: 

How I treat massive cuff tears 

LUNCH 

DEPUY SYNTHES ISS: Achieving 

long-term and superior patient 

outcomes in Shoulder Fractures 

(Lunch will be served) 

14h00-14h30 

Plenary Lecture JJ Craig South 

African Orthopaedic 

Assocation: (Audi 1) A walk 

along the path of clubfoot 

management in South Africa 

Mark Eltringham 

14h30-15h30 

15h30-16h00 

ELBOW FREE PAPERS 

TEA 

16h00-17h30 


INSTRUCTIONAL COURSE: New 

Concepts in Shoulder Surgery 

17h30 

CLOSING CEREMONY 

NOTE: Programme subject to change Programme subject to change Programme subject to change 

12

13 

NOTES

PLENARY LECTURES 

MONDAY 

12H30: American Orthopaedic Association (AOA): 

Certification of Competency Throughout an Orthopaedic Surgeons Career, 

T. Peabody. 

14H00: American Academy of Orthopaedic Surgeons (AAOS): 

The Evidence Base for the Prognosis and Treatment of Adolescent idiopathic 

Scoliosis, Stuart Weinstein. 

TUESDAY 

12H30: Australian Orthopaedic Association (AuOA): Initiatives in Orthopaedic 

Education and Training, Ian Incoll. 

14H00: New Zealand Orthopaedic Association (NZOA): Paediatric 

Orthopaedics in the 21st Century, Sue Stott. 

WEDNESDAY 

14H30: Robert Jones, British Orthopaedic Association (BOA): 

The use and abuse of data and evidence in Orthopaedics, Tim Wilton. 

THURSDAY 

12H30: Canadian Orthopaedic Association (COA): An Integrated Approach 

to Quality and Access in a Universal Healthcare System, J. Waddell. 

PLENARY LECTURES 

FRIDAY 

12H30: GT du Toit, South African Orthopaedic Association (SAOA): 

Access to quality Orthopaedic services in Low to middle income countries, 

Mkhululi Lukhele. 

14H30: JJ Craig, South African Orthopaedic Association (SAOA): 

A walk along the path of clubfoot management in South Africa, 

Mark Eltringham. 

14

15 

NOTES

SYMPOSIA 

AMERICAN ORTHOPAEDIC ASSOCIATION (AOA) SYMPOSIUM 1 

S01 Forging Partnerships: Multidisciplinary Teamwork to Enhance Patient Care 

Moderator: Peter M. Murray, MD 

Panelists: 

Peter M. Murray, MD 

Galen M. D. Perdikis, MD 

Terrance D. Peabody, MD 

Overview 

The objective of this symposium is to provide an overview of a multidisciplinary team. 

The multidisciplinary microsurgical team at Mayo Clinic in Florida which treats complex 

reconstructive problems will be used as an example for our discussion. Developed 

collaboratively through the Department of Orthopedic Surgery and Division of Plastic 

Surgery, this highly functioning microsurgical team benefits from the collective yet 

diverse knowledge and experiences of its members to forge a partnership that 

enhances patient care through surgical innovation, OR process redesign, advanced 

communication skills, and cultural change including a commitment to patient safety. 

At the end of this symposium, the attendee will be familiar with the complex surgical 

problems encountered in the treatment of limb sarcomas, breast carcinoma and head 

and neck cancer. The key components on how to build and sustain a multidisciplinary 

team will be discussed. The attendee will also take away a new appreciation for 

the potential synergy that can be developed by working closely with colleagues from 

other disciplines. 

1. Introduction: Why Build a Team? Peter M. Murray, MD (10 minutes) 

2. Evidenced Based Medicine Terrance D. Peabody, MD (20 minutes) 

3. Systems and Procedures Peter M. Murray, MD (20 minutes) 

4. Culture of Safety Galen M. D. Perdikis, MD (30 minutes) 

5. Case Discussion/Questions and Answers Drs. Murray, Perdikis and Peabody 

(10 minutes) 

AMERICAN ORTHOPAEDIC ASSOCIATION (AOA) SYMPOSIUM 2 

S02 Orthopaedic Workforce Needs: Challenges in a Changing Environment 

Moderator: Stuart L Weinstein, MD 

University of Iowa Hospitals & Clinics, Iowa City, IA 

Panelists: 

S. Weinstein 

J. L. Marsh 

R. Leighton 

SYMPOSIA 

16

We are in the midst of an “age quake,” the aging of the population around the world. 

Coinciding with that, there is an increasing burden of disease for musculoskeletal 

conditions, with these conditions currently ranked as the second leading cause of 

disability around the world. What changes will be necessary in the workforce in 

North America to address this increasing burden of disease? In the United States, 

we are in the midst of a fundamental change in how health care is paid for and 

delivered. The United States is also seeing traditional physician roles assumed by 

mid-level providers and others. GME funding is also at risk. Canada, on the other 

hand, has already adapted to another system of health care payment and delivery, 

which may yet serve as a model for the United States. How each nation deals with 

medical education, specialty training, and the identification of workforce needs will 

be the subject of this symposium. 

AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS (AAOS) 

SYMPOSIUM 1 

S03 An International Perspective on Value-Based Healthcare 

Moderator: Kevin Bozic 

Panelists: 

David Teuscher 

Kevin Bozic 

Gillian Hawker 

Stephen Graves 

Across the world, payers, providers and policymakers are increasingly focused on 

identifying delivery and payment models to align incentives among stakeholders to 

improve the value (outcomes and patient experience divided by cost) of care for 

orthopaedic patients. While each country has a different approach to achieving these 

goals, some common themes include using registries to track and increase transparency 

around outcomes/cost data, reorganizing delivery and payment around non-fee-forservice 

models, and strong leadership from the medical profession. The Australian 

Orthopaedic Association’s National Joint Replacement Registry (AOANJRR) was one 

of the first (established in 1999) and has since played an important role in monitoring 

longitudinal arthroplasty outcomes by publishing data on survivorship of prostheses. 

Other countries have similarly founded national registries in recent years, such as 

the American and Canadian Joint Replacement Registries (AJRR, CJRR). In the United 

States, bundled payments in which the care team and hospital are accountable for 

outcomes, care utilization, and costs up to 90 days post-discharge have become very 

popular. Medicare recently finalized the Comprehensive Care for Joint Replacement 

model which mandates bundled payments for primary TJR in 900 hospitals across the 

U.S. In CJR, hospitals are incentivized to collect patient-reported outcomes such as 

change in pain and functional status, with the ultimate goal of determining how PROs 

can be used to assess TJR appropriateness and value. Canada has introduced several 

alternative payment models including Alternative Relationship Plans (Alberta) which 

17

provide clinical full-time equivalent based or capitated per-member-per-year payment 

models, and quality-based incentive payments to encourage physician-integrated 

networks (Manitoba). As almost all value-based delivery and payment models are 

in their infancy, the international healthcare community must work together to design, 

test, iterate on, and disseminate these models. 

AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS (AAOS) 

SYMPOSIUM 2 

S04 Hot Topics and Controversies in Total Hip Replacement 

Moderator: K. Saleh 

Panelists: 

K. Saleh 

K. Bozic 

Young-Min Kwon 

J. Callaghan 

C. L. Nelson 

Primary total hip arthroplasty (THA) is considered as one of the most successful 

interventions in the medical field in regards to its high functional outcomes and low 

complication rates. It is projected that there will be as many as 610,582 primary 

and 99,898 revision THA procedures annually by 2020 in the United States. Over 

the past decade, and in an ever-evolving healthcare environment, multiple advances 

and changes occurred that had direct and indirect impact on the delivery of hip 

arthroplasty. In this symposium, we present the impact of recent policy changes on 

the practice of hip replacement in the US, share the advances in implant design 

and procedure techniques, highlight the consensus in risk-stratifications in evaluating 

patients with metal-on-metal and modular neck stems, present the results of long-term 

follow-up studies in THA, and provide an update on the current knowledge in wear 

and tribocorrosion. Finally we discuss potential methods and approaches to improve 

outcomes following revision THA. 

AUSTRALIAN ORTHOPAEDIC ASSOCIATION (AuOA) SYMPOSIUM 1 

National Joint Replacement Registry 

S05 The Australian Orthopaedic Association, the Registry and the Orthopaedic 

Community 

PRESENTER: A. Loefler 

AUTHORS: Loefler A a , Graves SE b , de Steiger RN b , Lewis PL b , Turner C b , Rainbird 

S b , Lorimer M c , 

& Cuthbert A c . 

a 

Australian Orthopaedic Association (AOA) 

b 

Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) 

c 

South Australian Health and Medical Research Institute (SAHMRI) 

SYMPOSIA 

18

There are a number of contributing factors crucial to the quality and success of a 

registry. A quality registry is dependent on ownership within the orthopaedic 

community, the quality of the data, the availability and and delivery of information 

to all stakeholders, transparent governance, its integration into the health care system, 

and its optimised ability to bring about beneficial change. 

The Australian Orthopaedic Association National Joint Replacement Registry 

(AOANJRR) is owned by the Australian Orthopaedic Association (AOA). The AOA 

supports and encourages the AOANJRR to strive in its commitment to the orthopaedic 

and wider community to improve the outcome of joint replacement surgery. 

An important benefit of the Registry to the Australian Orthopaedic community has been 

the ability to influence policy and health care decision making using an evidence 

based approach. 

The AOANJRR has recently begun a new collaboration with the South Australian 

Health and Medical Research Institute (SAHMRI) and the University of South Australia 

(UniSA). The underlying principle of collaboration and innovation is providing new 

opportunities for developing better outcomes for patients receiving joint arthroplasty. 

A major recent focus of the AOA has been to examine approaches to enhance 

support to surgeons to achieve the best possible outcomes. This includes encouraging 

surgeons to review and compare their own outcomes to colleagues and develop 

strategies to ensure reducing rates of revision. 

S06 Update: Primary Hip Replacement 

PRESENTER: P. Lewis 

AUTHORS: Lewis PL a , Graves SE a , de Steiger RN a , Turner C a , Rainbird S a , Lorimer 

M b , & Cuthbert A b . 

a 


b 


ABSTRACT 

In the 2015 Annual report, the AOANJRR reported for the first time on the outcomes 

of mini stems, dual mobility acetabular prostheses, and constrained acetabular 

prostheses used in primary total conventional hip replacement (THR). 

There were 1,778 mini stem procedures undertaken for osteoarthritis, representing 

less than one percent of all primary THR procedures. There was no difference in the 

overall rate of revision of mini stems, but revision for loosening/lysis was over twice 

that of other femoral stems at 10 years (3.9% and 1.5% respectively). 

There were 1,789 procedures using constrained acetabular prostheses for primary 

THR. Of these, there were 611 constrained acetabular inserts and 1,178 constrained 

cups. When all primary diagnoses are considered, there is no difference in the 

rate of revision when constrained prostheses are compared to other acetabular 

prostheses. When used for fractured neck of femur, constrained prostheses have a 

lower rate of revision compared to other acetabular prostheses. 

19

Dual mobility prostheses were used in 1,702 primary THR procedures. When all 

primary diagnoses were considered, there was no difference in the rate of revision of 

dual mobility prostheses compared to other acetabular prostheses. 

The revision burden following hip replacement in Australia continues to decline. The 

revision burden was 10.2% in 2014, compared to 12.9% in 2003. Most of this 

improvement can be directly linked to change in practice due to information provided 

by the AOANJRR. 

S07 Update: Primary Knee Replacement 

PRESENTER: P. Lewis 

AUTHORS: Lewis PL a , Graves SE a , de Steiger RN a , Turner C a , Rainbird S a , Lorimer 


a 


b 


In the 2015 Annual Report the AOANJRR identified the continuation of a number of 

major trends in primary conventional total knee replacement (TKR). These included 

increasing use of patella resurfacing, cement fixation, and cross-linked polyethylene. 

The proportion of primary TKR procedures using computer navigation also continued 

to increase. 

There were 47,476 primary TKR procedures performed in Australia in 2014. This 

was 5.2% increase compared to the previous year and 115.1% increase since 2003. 

TKR is more commonly undertaken for females (56.1%) and in the 65-74 age group. 

Patella resurfacing has increased from a low of 41.5% in 2005 to 59.3% in 2014. 

The use of patella resurfacing for most prostheses is associated with a reduced rate of 

revision. Cementing both femoral and tibial components has increased from 44.8% in 

2003 to 58.6% in 2014. The outcome of fixation is dependent on whether the knee 

replacement is minimally or posteriorly stabilised. Minimally stabilised primary TKR 

has the lowest revision rate if the tibial baseplate is cemented. Posteriorly stabilised 

primary TKR have the best outcome when both the tibial and femoral components 

are cemented. The use of cross-linked polyethylene has increased proportionally from 

7.1% in 2003 compared to 49.2% in 2014. For some but not all prostheses, this is 

associated with a lower rate of revision. Computer assisted navigation has increased 

from 2.4% in 2003 to 26.8% in 2014. There is a reduced rate of revision for 

loosening, particularly in patients aged less than 65 years of age. 

The revision burden following knee replacement in Australia continues to decline. In 

2014, the revision burden was 7.7%, gradually decreasing from 8.8% in 2004. Most 

of this improvement can be directly linked to change in practice due to information 

provided by the AOANJRR. 

SYMPOSIA 

20

S08 Analysis of Revision Hips and Knees 

PRESENTER: S. Graves 

AUTHORS: Graves SE a , de Steiger RN a , Lewis PL a , Turner C a , Rainbird S a , Lorimer 


a 


b 


This presentation reports the outcome of revision hip and revision knee replacement 

procedures. The AOANJRR analysed 11,320 1 st revisions of primary total conventional 

hip replacements (THR) and 15,232 1 st revisions of primary total conventional knee 

replacements (TKR). 

The 10 year cumulative percent revision (CPR) of a 1 st revision THR is 21.6%. There 

is a higher rate of 2 nd revision if the 1 st revision is undertaken within five years of the 

primary procedure (7 year CPR ≤5 year is 18.6% compared to 13.8% >5 years). 

Patients that are older at the time of the primary hip procedure have a lower rate of 

2 nd revision. Minor revisions have a much higher rate of 2 nd revision but only if they 

are undertaken within 5 years of the primary procedure. Fixation of the primary hip 

procedure did not affect the outcome of the 1 st revision. 

The 10 year CPR of a 1 st revision TKR is 22.6%. As with hips, there is a higher rate of 

2 nd revision if the 1 st revision is undertaken within five years of the primary procedure 

(7 year CPR ≤5 year is 20.1% compared to 10.1% >5 years). Patients that are 

older at the time of the primary knee replacement have a lower rate of 2 nd revision. 

Minor revisions have a lower rate of 2 nd revision but only if they are undertaken 

within 5 years of the primary procedure, otherwise there is no difference in outcome 

compared to other types of revision procedures. Cemented primary procedures have 

a lower rate of revision but only when the 1 st revision is undertaken within 5 years of 

the primary procedure. 

S09 Outcomes of Total Shoulder Replacement 

PRESENTER: Richard Page, Shoulder Representative, AOA NJRR 

The AOA National Joint Replacement Registry (AOA NJRR) commenced shoulder 

data collection in 2004, with full national data collection from 2007. The registry 

is the largest shoulder replacement registry internationally and has data on over 

32,000 joint replacements, with 4692 procedures recorded in 2014. Total shoulder 

replacement (TSR) surgery is one of the fastest growing forms of joint replacement 

surgery internationally. In Australia the number of procedures has grown 70.9% since 

2008. 

Data collection is undertaken at the point of surgery and cross validated with the 

hospital separation data in each state to reach a high level of data accuracy. Data 

includes patient demographic, diagnostic and prosthesis related information. The 

AOA NJRR currently classifies shoulder procedures as partial (partial and hemi 

21

esurfacing, hemi mid head, hemi stemmed and humeral ball), total (total resurfacing, 

mid head, conventional and reverse) and revision. Minor revisions are those where a 

component is exchanged that is not fixed to bone, major partial where a component 

fixed to bone is exchanged and major total where a complete revision procedure is 

undertaken. The components implanted are recorded and tracked by the AOA NJRR. 

Standardised outcome assessment methodology has lead to the withdrawal of one 

conventional uncemented TSR and one conventional / reverse component from the 

market. In addition it has identified two partial, two conventional and one reverse 

shoulder replacement as having higher than anticipated revision rates compared 

to their class. The data enables surgeons to make informed decisions in prosthesis 

selection, which reduces the potential revision risk nationally. 

S10 The Identification of Implant Outliers 

PRESENTER: R. de Steiger 

AUTHORS: de Steiger RN a, Graves SE a , Lewis PL a , Turner C a , Rainbird S a , Lorimer 


a 


b 


Joint Replacement Registries play a significant role in monitoring arthroplasty outcomes 

by publishing data on survivorship of individual or combinations of prostheses. The 

difference in outcomes can be device or non device related and these factors can be 

analysed separately. Although Registry data indicate that most prostheses have similar 

outcomes some have a higher than anticipated rate of revision when compared to all 

other prostheses in their class. The Australian Orthopaedic Association National Joint 

Replacement Registry (AOANJRR) has developed a method to report prostheses with 

a higher than expected rate of revision. These are referred to as “outlier” prostheses. 

This is based on a transparent and accountable three stage process comprising an 

automated algorithm, an extensive analysis of individual prostheses or combinations by 

Registry staff and finally a meeting involving a panel from the Australian Orthopaedic 

Association Arthroplasty Society. Prostheses are listed in the Annual Report as (i) 

identified but no longer used in Australia, (ii) those that have been re-identified and 

are still used and (iii) those that are being identified for the first time. 

Since 2004, the Registry has identified 118 prostheses or combinations using this 

approach. In the year following their notification in the Annual Report, over half of all 

these prostheses have no usage and 95% have reduced usage. 

S11 How does the Surgeon influence the results of joint replacement surgery? 

PRESENTER: R. de Steiger 

AUTHORS: de Steiger RN a, Graves SE a , Lewis PL a , Turner C a , Lorimer M b , & Cuthbert 

A b . 

a 


b 


SYMPOSIA 

22

ABSTRACT 

Patient, surgeon and prosthesis factors may affect the outcome of hip and knee 

replacement and the relative importance of each of these elements is yet to be 

established. 


(AOANJRR) has undertaken an analysis to determine if the rate of revision for joint 

arthroplasty is related to the number of procedures a surgeon performs per year, or the 

number of years a surgeon has been in practice. For the volume of surgery analysis 

four groups were identified: surgeons who performed ≤10 procedures per year, 

>10 ≤25, >25 ≤70 and >70 per year. For the experience analysis, surgeons were 

grouped into those surgeons who had been operating for < 3 years post fellowship, 

3-7 years and ≥ 8 years. 

Surgeons averaging >70 procedures per year had a lower rate of revision than 

surgeons performing less than 70 procedures for primary THA and TKA. However, 

surgeons who do perform a lower number of procedures can still have a low rate of 

revision when choosing well performing prostheses, whereas surgeons undertaking a 

large number of procedures do not improve the outcome of a prosthesis that has been 

identified as having a higher than expected rate of revision. 

In general, for both THA and TKA, the most experienced surgeons have a lower 

rate of revision than the less experienced surgeons, but this does not apply over all 

time periods. When a prosthesis specific analysis was performed using the two most 

commonly implanted THA recorded in the registry there was no effect of experience, 

once again suggesting choice of prosthesis is important. There was some prosthesis 

specific variation with regards to experience and TKA. 

S12 Achievements of the Australian Registry 

PRESENTER: S. Graves 

AUTHORS: Graves SE a , de Steiger RN a , Lewis PL a , Turner C a , Rainbird S a , Lorimer 


a 


b 


ABSTRACT 

The use of community based data by National Arthroplasty Registries play a critical 

role in improving the outcome of joint replacement surgery. National Arthroplasty 

Registries can simultaneously compare the effect of multiple factors on the outcome of 

joint replacement surgery. Clinicians are able to use this data to identify best practice 

that is relevant to their own approach to arthroplasty. 


(AOANJRR) has been one of the most effective National Arthroplasty Replacement 

Registries. It has continually reduced the revision burden of both hip and knee 

replacement. The savings associated with this reduction is approaching AUD $630 

million. This has been achieved by identifying best and worst practice in prosthesis, 

patient, and procedure selection leading to changes in surgical practice. 

23

The AOANJRR was the first arthroplasty registry to establish a prosthesis outlier 

detection strategy. Using this approach, it has identified 118 prostheses or prosthesis 

combinations that have a higher than anticipated rate of revision. Most of these have 

been removed from the Australian market. In addition, the AOANJRR was the first 

arthroplasty registry to identify problems with large head metal on metal conventional 

total hip replacement and the use of exchangeable neck femoral stems. 

The AOANJRR has identified patient populations that do best with particular 

procedures: e.g. resurfacing males

CONCLUSION: There is a reduced rate of revision for navigated TKA in patients less 

than 65 years of age, an overall reduction in the rate of revision for loosening/lysis 

and also a reduction in major revisions. This may be as a consequence of improved 

alignment. 

S14 Objective measures of outcome after CAS TKR 

PRESENTER: J. Stoney 

Knee replacement is a proven and highly effective operation. Achieving a successful 

prosthesis outcome with conventional instrumentation is effective in most cases but 

failures can occur due to issues with prosthesis alignment. Poor alignment has been 

associated with stiffness, pain, excessive polyethylene wear, early loosening, extensor 

mechanism dysfunction and knee instability. 

The first computer assisted total knee replacement was performed by Picard and 

Saragaglia in France in 1997 1 . The advent of computer navigation bought with it the 

promise of better alignment and subsequent improvement in patient satisfaction, knee 

function and prosthesis survivorship. 

A number of studies have shown that computer navigation is effective in improving 

radiological measures of prosthesis alignment 2 . Unfortunately, it has been difficult to 

extrapolate this improvement in alignment to better prosthesis outcomes and enhanced 

patient satisfaction. Recent studies have failed to demonstrate a reproducible link 

between improved alignment and measurable outcomes of prosthesis performance 3 . 

New technology such as computer navigation adds costs to the procedure and 

increases the duration of surgery. In this age of spiraling healthcare expenditure and 

an aging population, it is incumbent on the Orthopaedic Community to critically 

appraise the outcomes of new technology and justify its continuing use. 

This paper will review the evidence for computer-assisted knee arthroplasty with a 

focus on the objective measurement of outcomes. 

1. M. Fosco, R. Ben Ayad, R. Fantasia, D. Dallari and D. Tigani (2012). 

Concepts in Computer Assisted Total Knee Replacement Surgery 

Recent Advances in Hip and Knee Arthroplasty, Dr. Samo Fokter (Ed.) 

2. Choong PF, Dowsey MM, Stoney JD (2009) 

Does accurate anatomical alignment result in better function and quality of 

life? Comparing conventional and computer-assisted total knee arthroplasty. 

J Arthroplasty. Jun;24(4):560-9. 

3. Young-Hoo Kim, Jang-Won Park, Jun-Shik Kim (2012) 

Computer-Navigated Versus Conventional Total Knee Arthroplasty: 

A Prospective Randomized Trial. 

Journal of Bone and Joint Surgery, Nov 21;94(22):2017-24. 

S15 Computer guided tumour surgery – future directions 

PRESENTER: Prof. Peter F.M. Choong, MBBS MD FRACS FAOrthA 

Sarcoma management is an exciting area of oncology not only because of the 

possibility to control disease with multimodal therapy, but also to preserve or reconstruct 

25

limbs following tumour resection. Coordinated and expert multidisciplinary care has 

afforded patients of all ages improved survival and better function. 

Advances in chemotherapy have seen dramatic improvement in disease free survival 

of primary bone sarcoma over the last 2 decades. Radiotherapy has been successfully 

integrated with surgery to provide excellent local control of soft tissue sarcoma. 

Advances in medical imaging have enabled surgeons to delineate more clearly and 

plan more accurately the appropriate surgical margins while avoiding vital structures. 

Computer assisted surgery has facilitated accurate translation of planning information 

into surgical practice. Precision margins now allow safer approaches to tumour and 

preservation of tissues previously sacrificed because of the uncertainty of whether 

such margins could be achieved. Input of CT and MRI based images has been a 

significant step forward. Addition of functional imaging will be of greater benefit. 

Future progress in the development of robot assisted surgery with input from 

preoperative imaging will usher in a new paradigm of computer assisted surgery with 

the goals of safer and more frequent limb sparing surgery even for tumours previously 

thought to be unresectable without amputation. 

S16 Computer Navigation in Orthopaedic Trauma 

Bucknill A and De Steiger R 

Computer navigation is a tool that can assist with fracture reduction and implant 

placement in orthopaedic trauma. 

Purported benefits include; Improved planning; Improved accuracy of implant 

placement; Reduced radiation dose; More efficient surgery. 

Computer navigation is most often used for percutaneous screw placement (particularly 

in pelvic and acetabular trauma), intramedullary nailing and pedicle screw placement 

in spinal trauma. 

We present an overview of the current the capability and utility of this developing 

technology as well as our research, experience and results using the technology over 

the last 10 years. 

S17 Navigation: It’s Role in Surgery of the Hip 

PRESENTER: William Donnelly 

INTRODUCTION 

The association between suboptimal implant position and poor surgical outcome has 

been well documented. Over the years many instruments have been developed in an 

attempt to increase the accuracy of component placement in total hip arthroplasty. 

Computerized navigation for total hip arthroplasty has been used in Australia over 

the last 15 years. Computer navigation is designed to allow the surgeon to insert the 

acetabular and femoral components with greater accuracy, thus theoretically resulting 

in better component performance and an increased survival rate. In this presentation 

the history and development of computerised navigation in total hip arthroplasty and 

its application to other forms of hip surgery such as FAI will be presented. Data from 

the Australian Orthopaedic Association National Joint Replacement Registry for total 

hip arthroplasty and hip resurfacing arthroplasty will also be presented. 

SYMPOSIA 

26

METHODS 

Data from the AOANJRR was used to review the outcome of all navigated total 

hip arthroplasty and hip resurfacing arthroplasty cases performed in Australia and 

compared these with non-navigated cases. Trends in usage, outcomes and reasons 

for revision were analysed for both groups. 

RESULTS 

3588 navigated total hip arthroplasty procedures have been performed in Australia 

since 2002 as compared to 292944 non-navigated cases. The incidence of 

navigation in THR although increasing remains low with 2.1% of cases being navigated 

in 2014. There was no significant difference in the revision rate between the two 

groups at 10 years although the revision rate for dislocation in the navigated group 

03.% was lower than that of the non-navigated group 0.8%. The cumulative percent 

revision of primary total resurfacing hip replacements to 8 years was significantly 

higher in the navigated group 18.6 as compared to the non-navigated group 7.8. 

DISCUSSION 

The use of computerised navigation in primary total hip arthroplasty in Australia has not 

significantly decreased the overall revision rate although the incidence of revision for 

dislocation is lower in navigated cases. However of more concern is the significantly 

higher revision rate of navigated primary total resurfacing hip replacements when 

compared to non-navigated cases 

S18 Navigation in Spine Surgery 

PRESENTER: Davor Saravanja FRACS FAOrthA BMed 

Navigation or Image Guided Surgery (IGS) represents the use of tracked surgical 

instruments with either pre-operative or intra-operative imaging. Stereotactic cranial 

surgery was developed by Kirchner (1933), Leksell (1949), and Brown Roberts 

Wells (1977), utilising rigid frames attached to the skull. In the 1980s and 90s the 

development of frameless stereotactic surgery allowed IGS to be applied to Spinal 

Surgery. 

Today multiple computerised instrument tracking systems are available allowing high 

precision IGS to assist in Spine Surgery. Whilst surgeons continue to require precise 

anatomic and surgical training and knowledge, IGS has aided in increased accuracy 

and ease of complex surgeries including instrumented spinal fusion, and complex 

osteotomies. 

Publications for IGS in the spine literature have focused on assessing accuracy 

of instrumentation, radiation exposure, radiation safety, applications in trauma, 

applications in minimally invasive spine surgery, utilisation of fiducial screws, and 

complex congenital deformity surgery. Further applications include utilisation in 

training, complex revision surgeries, and spine tumour surgery. 

NEW ZEALAND ORTHOPAEDIC ASSOCIATION (NZOA) SYMPOSIUM 1: 

S19 Clinical Prioritisation of Elective Orthopaedic Surgery 

Chairman Clinical Prioritisation Symposium - Jean-Claude Theis 

27

Speakers: 

J - C Theis 

A. Panting 

R. Keddell 

R. Rowan 

This symposium will present the evolution and current state of elective orthopaedic 

surgery in New Zealand. 

In the 1990’s New Zealand was faced with increasing surgical waiting lists in the 

public sector and the government introduced maximum waiting times and clinical 

prioritisation systems. The initial tools were very crude, intuitive and lacked validation. 

Working with surgical specialty societies the Ministry of Health set up a series of 

clinical prioritisation working groups tasked with developing scientifically validated 

scoring tools. 

The challenge faced by orthopaedic surgery was the large number of surgical 

procedures, compared to cardiac surgery for example, and the issue of painful 

conditions outscoring those with mainly functional impairment. As result 2 tools were 

developed one for joint arthroplasty and one for all other orthopaedic procedures. 

Each individual hospital had to determine in advance their capacity within the limits 

of the maximum waiting time and set an access threshold for surgery (minimum clinical 

priority score). This led to 2 access scores for joint replacements and other procedures. 

The effect of setting a maximum waiting time, in the presence of limited resources, 

resulted in explicit rationing of elective surgery which caused significant concern 

amongst orthopaedic surgeons. This resulted in ‘gaming’ by surgeons which made 

the system prone to outside pressure. 

Over the years a tool development methodology was developed using clinical 

vignettes ranked on the basis of clinical priority by a group of experts using a Delphi 

type consensus process. The weighting of the different items of the scoring tool was 

carried out using a decision analysis tool called 1000Minds. The tools were then 

trialled clinically in a number of hospitals before being implemented on a national 

basis. 

The latest orthopaedic tool has a patient derived component, applies universally to all 

orthopaedic procedures, is web based and will be discussed during the symposium. 

Clinical prioritisation is not rationing but basically lines up the patients in order of 

priority. If resources are limited then a line will be drawn at some stage between 

those who will get their surgery and those who won’t. Regular audit and feedback of 

surgeon scoring is essential to identify outliers and clamp down on gaming. 

NEW ZEALAND ORTHOPAEDIC ASSOCIATION (NZOA) SYMPOSIUM 2: 

S20 The Orthopaedic Practice and a No Fault Accident Compensation 

Environment 

Chairman: Denis Atkinson 

Panelists: 

J.C Theis Michael Barnes 

B. Krause 

SYMPOSIA 

28

It is forty years since New Zealand instituted a No Fault system for personal injury 

by accident. The legislation bars civil proceedings in tort law for claims of damages 

resulting from personal injury by accident. This Symposium explores the influence 

of the No fault legislation on the practice of Orthopaedic surgery in New Zealand. 

The history of legislation is presented. The amendments to the Act and the current 

focus on injury prevention and rehabilitation are discussed. 

The legislation is unique in providing cover for personal injury sustained as a result of 

treatment by a Medical Practitioner. 

Medicolegal aspects and the legislation relating to Orthopaeeic surgery will be 

explored. Entitlement for the injured person in a background of pre-existing conditions 

and the aging process are discussed. 

The influence of the No Fault system in determining functional outcome following 

spinal surgery is explored. 

There will be ample time for questions and discussion to explore the value of a No 

Fault Compensation system in relation to orthopaedic practice. 

BRITISH ORTHOPAEDIC ASSOCIATION (BOA) SYMPOSIUM 1 

S21 The International Musculoskeletal Time Bomb – Better outcomes, lower cost 

Panelists: 

S. Weinstein 

S. Graves 

J. Jacobs 

J. de Vos 

P. Choong 

T. Briggs 

There is a burgeoning demand for trauma and orthopaedic interventions that is 

confronting health care systems around the world. In the developed world - as 

people are living longer - the main demand arises from ageing populations for 

life transforming joint replacement and hip fracture repair. This presents significant 

challenges of affordability and service sustainability. In the developing world the 

rising demand for orthopaedic trauma services is inexorable, often due to road traffic 

accidents and inadequate health and safety practice in the work place. In essence 

we are facing an international musculoskeletal time bomb. This session scopes the 

scale of the problem from a range of different countries’ perspectives and the potential 

evidence based solutions that may be required to deliver affordable and sustainable 

health care delivery services. 

BRITISH ORTHOPAEDIC ASSOCIATION (BOA) SYMPOSIUM 2 

S22 Creating an evidence based cost effective arthroplasty service 

Panelists: 

T. Wilton 

C. Howie 

R. Parkinson 

F. Haddad 

29

W. Jackson 

D. Sochart 

All trauma and orthopaedics procedures lend themselves to evidence based quality 

improvement, which is an essential, patient-focused ingredient of contemporary 

professional practice. This applies particularly to arthroplasty. The session will set 

the scene from a UK perspective, drawing on the extensive hip and knee arthroplasty 

evidence available from the National Joint Registry for England and Wales, the 

Scottish Arthroplasty Project, and the broader transparency agenda that is a feature of 

the information age. In doing so it will focus on the importance of accurate, validated 

registry data, the key role of effective analysis, and the over-riding requirement for 

transparent surgeon and inter-hospital peer review as a means of implementing and 

sustaining quality improvement at unit level. 

This will be illustrated with reference to the difference that might be made by ensuring 

the correct surgeon, the correct implant, and the correct approach to both hip and 

knee replacement 

CANADIAN ORTHOPAEDIC ASSOCIATION (COA) SYMPOSIUM 1 

S23 “The Role of a Competency Based Curriculum in Orthopaedic Training: 

Bridging the Gap between Theory and Clinical Practice” 

Panelists: 

Kevin Black 

Simon Hadlaw 

Robert Dunn 

Ian Incoll 

Philip Turner 

Markku Nousiainen 

The current paradigm of residency training is ill-equipped to address the issues 

facing medical education in the 21 st century. These issues include: (i) a diminution 

of work experience in resident trainees stemming from a variety of causes, including 

reduced work hours, a stronger move towards patient safety, and a move towards 

fiscal efficiency in hospitals (all of which minimize the ability for trainees to operate 

independently); (ii) a move in postgraduate medical education accreditation bodies 

towards requiring training programs to clearly document how curricula are taught 

and assessed; and (iii) a move in postgraduate medical education accreditation 

bodies towards ensuring that graduates from training programs are competent in 

performing the key tasks of the specialty that they trained in. In response to these 

issues, an international movement towards implementing competency based medical 

education (CBME) has begun. This symposium will discuss how postgraduate 

education in orthopaedic surgery is changing to meet the requirements of CBME. 

Representatives from the participating countries in the Congress will present an update 

on their experience in how CBME has begun to be implemented into their residency 

SYMPOSIA 

30

training programs. Discussion, focusing on lessons learned and how the participating 

countries can work together in making the implementation of CBME more efficient, 

will follow. 

CANADIAN ORTHOPAEDIC ASSOCIATION (COA) SYMPOSIUM 2 

S24 Title: Clinical Trials (and Tribulations): The Promise of Multinational Research 

MODERATOR: Mohit Bhandari, McMaster University, Hamilton, Canada 

SPEAKERS: 

Mohit Bhandari, McMaster University, Hamilton, Canada 

Ross Leighton, Dalhousie University, Canada 

Brad Petrisor, McMaster University, Hamilton, Canada 

SUMMARY: 

Evidence-based orthopaedics posits the integration of surgeon expertise with patient 

preferences incorporating the best available research evidence. Randomized trials 

sit atop the hierarchy of evidence, representing the standard by which surgical 

innovations are evaluated. The last decade in orthopedic surgery has experienced 

a dramatic shift in culture favoring the conduct of clinical trials. Moreover, evolving 

methodological approaches in their design and execution has led to bigger, greater 

complexity trials with larger sample sizes. Inherent in this new culture is a global 

mandate for collaboration with increased surgeon engagement. This symposium will 

highlight the opportunities and challenges of large, multinational trials integrating 

practice changing trials in orthopedics that have fueled major advances in patient 

care worldwide. 

SOUTH AFRICAN ORTHOPAEDIC ASSOCIATION (SAOA) SYMPOSIUM 

1S25 First World Surgeon in a third world environment: the milieu 

Speakers: 

Robert Dunn 

Mike Marshall 

Johan Davis 

Mthunzi Ngcelwane 

Michael Held 

The SAOA will present a range of topics describing the unique nature of Orthopaedic 

practice at the southern tip of Africa where we are challenged by a massive burden 

of disease compounded by a migrating medical population seeking care which 

may not be readily accessible near their homes. The environment will be described 

by Prof Dunn and the cost drivers and need / strategies for cost containment will 

be addressed by Dr Marshall from a large private medical funding administration 

company. The need to re-organise as professionals will be highlighted by Dr Davis. 

The burgeoning public health sector with all its challenges and promise of national 

coverage will be addressed by Prof Ngcelwane. Dr Held will discuss appropriate 

research to benefit our region. 

31

SOUTH AFRICAN ORTHOPAEDIC ASSOCIATION (SAOA) SYMPOSIUM 2 

S26 First World Surgeon in a third world environment: the clinical challenge 

Panelists: 

Sithombo Maqungo 

Graham McCollum 

Greg Firth 

Len Marais 

Stephen Roche 

South Africa is unique in that it has a massively diverse population where well trained, 

highly skilled surgeons are frequently faced with severe advanced pathology due to 

poor access to care and high burden of disease resulting in fierce competition for 

resource. This results in extreme surgical challenges and a need for local adaptation 

to “first world” solutions. This session will present the management of some of these 

challenges by local leaders in their fields. 

SYMPOSIA 

32

33 

NOTES

INSTRUCTIONAL COURSE LECTURES 

HIP ARTHROPLASTY INSTRUCTIONAL COURSE (ICHAP) 

ICHAP01 Short Stay THA 

Brian J. McGrory, MD, MS 

Short stay and outpatient THA has become very topical over the last few years, at least 

in North America. Pressures from patients and third party payers have incentivized 

surgeons to consider surgical and perioperative strategies to minimize length of stay 

in the hospital before and after THA. At the same time, expectations for no increase in 

complications, readmissions or patient dissatisfaction remain high. Anterior minimally 

invasive THA as well as discharge pathways of coordinated care have permitted 

this agenda to succeed, but require surgeon and institutional buy-in and dedication. 

Appropriate patient selection and education, in conjunction with facility preparation, 

have allowed 85% of all primary THAs at my institution to be discharged to home 

within 24 hours over the last 5 years. During this time frame, our institution was in 

the top 2 percent of United States hospitals in regard to in-house complications and 

30 day readmission. Short stay THA can be a safe and efficient intervention, and is 

associated with high patient satisfaction. 


ICHAP02 (P506) 

Presenter: B. Masri 

Authors: B. Masri 

Disclosure: No 

Abstract title: Short and Medium Sized Stems 

At least in North America, they has been a substantial change in femoral implant 

philosophy over the past two decades, with an increasing use of cementless fixation. 

In addition, there has been a substantial increase in the use of proximally porous 

coated tapered stem. While outcomes of these traditional devices has been excellent, 

there has been a trend with manufacturers to offering a shorter, primarily metaphyseal 

loading stem, by shortening the distal segment of the traditional tapered stem, or 

by introducing unique metaphyseal loading designs. Some stems are designed to 

preserve most of the femoral neck and are inserted into the femoral neck only. These 

have not been popular and have little in the way of peer-reviewed results. Others are 

designed to be inserted up to the metaphyseal-diaphyseal junction and have been 

better reported in the literature. These were initially marketed as a more conservative 

or bone preserving stem to maintain non-violated bone for the revision, should that 

be necessary down the road. To date, there have been a number of retrospective 

reviews of these short stem, showing no substantial difference in survivorship between 

short and traditional stems. Also, biomechanical and RSA studies have shown that 

shortening the stem does not lead to substantial increase in migration that would 

compromise long term stability. 

34

35 


Presenter: G Hooper 

Authors: G Hooper 


Abstract title: Cementless Total hip Arthroplasty 

Introduction: 

Uncemented total hip replacement (THR) was introduced to improve the long term 

results and in particular the results in younger, higher functioning patients. There 

has been general acceptance of uncemented acetabular fixation but there remains 

controversy about the value of uncemented femoral fixation. 

Methods: 

We used the results from the 14 year NZJR report to compare the all-case revision 

rate and the reasons for revision between uncemented and cemented fixation in THR. 

These results were stratified into age bands further comparing younger and older 

patients. Early revision (


Presenter: F. S. Haddad 

Authors: F. S. Haddad 


Abstract title: Bearing Surfaces 

A multitude of different bearing combinations exist to recreate the artificial hip joint. 

To date, there is no particular ‘gold-standard’ total hip arthroplasty (THA) couple since 

none is faultless. Strategies to improve performance are aimed either at modifying 

the shape and design of components or their material properties. Wear particle 

generation is a well-recognised as a cause of aseptic loosening 1which consistently 

features amongst the most common indication for revision THA and thus minimising 

wear lies at the cornerstone of developing bearing couples. However history has 

shown the use of supposed newer and improved materials have not been without 

occasional catastrophic failures. Hard on hard bearings are theoretically more resistant 

to wear but component fracture and squeaking has been witnessed with ceramic on 

ceramic articulations whilst metal on metal articulations have been plagued by reports 

of pseudotumour and ALVAL formation. This has all led to resurgence in the hard on 

soft couple. 

At present, it is fair to say that there is no single bearing that is ideal for all patients. 

There are hard-on-hard, hard-on-soft, and novel bearings that are available, and each 

has to be applied in the appropriate setting. 

Metal-on-metal arthroplasty was very popular a few years ago. Hip resurfacing 

remains an excellent metal-on-metal alternative in young men with large femoral 

heads. However, there are now contraindications in females and in a variety of 

disorders such as dysplasia which will narrow the indications. The sequelae of these 

narrow indications may be that training in this technique will be difficult, and that 

metal-on-metal resurfacing may see a further decline. Metal-on-metal bearings outside 

resurfacing no longer really have a role to play as the outcome of large head metalon-metal 

have been unacceptable. It has been an unfortunate journey in that it has 

opened our eyes to the difficulties of translating from the laboratory into clinical 

practice, and into the study of local debris production and its systemic effects, the 

advanced imaging of hips, and a renewed interest in tribocorrosion. 

In terms of hard-on-hard bearings for hip arthroplasty, the most viable option available 

at present is ceramic-on-ceramic. This has excellent tribological properties which have 

withstood the test of time in many series. It is also associated with lower risks of 

late instability. The problem with ceramic-on-ceramic, like any other potential hard 

bearing, is that we do not yet have an understanding of the perfect position for the 

acetabular component in gait, and thus edge loading and metal transfer can still 

occur. The problems that are still seen include chipping/fracture and squeaking. 

Fracture of the ceramic component is a significant problem associated with relatively 

poor outcomes after revision. Ceramic-on-metal has been tried and tested in a number 

of studies, but there is no data to show its superiority over standard bearings. 

The great advance of the last two decades has been the advent of highly cross-linked 

polyethylenes. There are a variety of these, but multiple prospective randomised studies 

and registry data all show improved wear properties, decreased osteolysis and better 


36

survivorship. There are many interfaces that can be applied against the highly crosslinked 

polyethylene. Cobalt chrome is becoming less popular due to concerns about 

corrosion, although that is a rare complication. Ceramic is increasingly popular as a 

counterface, as is oxidised zirconium which has excellent clinical results, and good 

results in the Australian registry. There are no good long-term comparative studies that 

differentiate between these counterfaces. The decision making will at present be as 

much based on corrosion potential as it is on wear or revision rates. 

The other issue that must of course be factored in in the modern era is that of cost 

effectiveness. A modern bearing may well be appropriate for a younger patient 

with a life expectancy of 20 years or more, whereas the elderly patient with a very 

poor life expectancy would not risk the expense, or indeed the complication risks 

associated with the modern bearings that are designed for longevity. 

There are of course other issues to consider with bearings such as head size, which is 

an important issue for many surgeons who hope to decrease dislocation rates. There 

is also the flexibility that is seen with polyethylene and metal or ceramacised metal 

bearings that is not seen with ceramics. Ultimately each surgeon will need to carefully 

decide on the bearings that should be available in their hospital. These should cover 

the full breadth of patient population treated, should be safe and reproducible, and 

should of course be cost effective. 

37 


Presenter: B Masri 

Authors: B. Masri 


Abstract title: Trunnionosis and ARMD 

Adverse reactions to metal debris (ARMD) has become very topical over the past five 

years and has been associated with failed metal on metal hip implants, particularly 

those with large metal heads. The metal ion levels of such patients has been reported 

to be much higher than in patients with metal on metal hip resurfacing. Because of 

this difference, attention moved away from the articular surface to other reasons for 

the generation of metal debris. The trunnion of a morse taper has been shown to 

have significant corrosion in patients with ARMD. While corrosion of the tunnion is 

not a new phenomenon, its effect on the failure mechanism of hip replacement is 

relatively new. With micromotion at the taper, crevice corrosion facilitated by the 

galvanic phenomenon due to the typical use of dissimilar metals (Titanium for the stem 

and Cobalt Chrome for the femoral head in most cases) can lead to damage to the 

female portion of the taper at the femoral head, leading to release of Cobalt and 

Chromium ions which may cause the phenomenon of ARMD, leading to pseudotumor 

formation and ultimate failure. This phenomenon has also been observed in metal 

on polyethylene hip replacement, which may lead to pain, delayed dislocation due 

to soft tissue loss and ultimately to failure of the arthroplasty. The prevalence of this 

phenomenon is currently unknown in metal on polyethylene hip replacement, but 

it seems to be rare based on the small number of reported cases in the literature. 

However, arthroplasty surgeons need to be aware of this potential complication, 

and need to investigate it in patients presenting with pain of unknown origin or with 

delayed dislocations after a total hip replacement.


Presenter: T. Munting 

Authors: T. Munting 


Abstract title: Hip Resurfacing: Is this still an option? 

The demands of the modern highly functional, often younger patient, on their hip 

replacement are quite substantial. At the same time newer hard on hard bearings 

for these patients demand more from the surgeon. This presentation reviews the joint 

registry data highlighting the higher revision rates for total hip replacements in the 

younger population and then looks at the survival of resurfacing hip replacements, 

specifically the Birmingham Hip Resurfacing. Evidence from these numerous sources 

point towards better survival for the BHR as well as functional outcomes when looking at 

scores emphasizing functional demand. This data has also crystalized the indications 

for BHR use, which if adhered too appear to result in better long term outcomes. Thus 

concluding that hip resurfacing should still be considered in the right patient. 


ICHAP07 

Prevention of Infection in THA 

Brian J. McGrory, MD, MS The incidence of deep infection has declined since the 

early years of joint replacement and the average rate of infection is less than 1 

percent in primary hip arthroplasty. Paradoxically, deep infection accounts for up to 

one quarter of early revisions and the revision burden attributable to infection appears 

to be increasing. When considering infection prevention, it is helpful to understand 

that elimination of deep infection after THA is not possible, because surgical exposure 

and implant presence disrupts the patient’s natural immune protections. On the other 

hand, intervention to minimize infection is effective and includes not only actions that 

decrease contamination but also factors that bolster the patient’s natural protections. 

Ultimately, the risk for infection in a given population hinges on these interventions. 

Some risk factors are mutable, and others are not. Evidence based medicine is 

zeroing in on these selection, preparation, surgical and follow-up strategies to avoid 

the expensive and devastating complication of deep periprosthetic infection. Finally, 

monitoring of infection rates on a local, national, and even an international scale is 

prudent in order to be able to identify strengths and weaknesses in current infection 

prevention practices. 



Authors: G Hooper 


Abstract title: Perioperative management in THA 

Perioperative risks in THA can be thought of as being related to both the patient and 

the environment. 

Patient risks: 

As total hip arthroplasty has been shown to reliably improve pain and function in 

disabled and frail patients, coupled with the marked increase in the ageing population, 

there have been an increased number of patients with multiple co-morbidities 

38

presenting for replacement. Despite this, the overall mortality rate has continued to 

drop with the estimated 90 day rate of 0.7%. The ASA physical activity rating is an 

active predictor of patient mortality and function following THR. We have shown a 

6 month mortality rate of 0.90% with a significant difference (p

The presence of internal fixation implants on either the femoral or acetabular side will 

require removal either prior or at the same time as the arthroplasty procedure. 

Complex primary hip conditions are diverse and each of them poses different 

challenges for the surgeon. Obesity can make a standard hip arthroplasty difficult 

and extra care has to be taken when positioning the patient on the operating 

table. Common complex conditions include hip dysplasia, neurological diseases, 

hip ankylosis, coxa vara, protrusio acetabulae, post proximal femoral fracture or 

osteotomy etc. 

Careful selection of femoral and acetabular implants is essential particularly in 

cases of severe bony abnormalities. Constraint or double mobility cups should be 

considered in case of abductor weakness and neurological conditions. Occasionally 

custom implants are required. 

Intra operative fluoroscopy and sciatic nerve monitoring can be helpful in cases of 

high dislocation secondary to dysplasia. 



Presenter: D.R. van Der Jagt 

Authors: D.R. van der Jagt 


Abstract title: Avascular Necrosis of the Hip. A Review of the Pathophysiology 

and Treatment. 

Avascular necrosis of the hip remains a challenging problem in orthopaedic surgery. 

The causes are varied and often obscure. Risk factors commonly include steroids and 

alcohol, as well as coagulation disorders. The high rate of avascular necrosis due to 

HIV infections as well as the long-term therapy with anti-retrovirals is highlighted. The 

natural progression of the disease is discussed. 

The management is discussed. A review of procedures aimed at preserving the 

natural hip is detailed. Future possibilities including stem cell therapies are explored. 

Failure of conservative strategies to preserve the femoral head usually results in hip 

arthroplasties being done. The results of such hip replacements are reviewed. 


Presenter: R McLennan-Smith 

Authors: R. McLennan-Smith 


Abstract title: Hip Dysplasia 

90% of patients younger than 50years of age who develop osteoarthritis of the hip 

have an underlying developmental structural problem – 50 % of these being dysplasia 

(DDH – Developmental Dysplasia of the Hip) 

80 % of DDH’s are female, with 40% being bilateral. Dysplasia may have other 

aetiologies and these may influence the surgical management, especially with 

myopathies. 

Dysplasia is present in 7 % of patients undergoing Hip Arthroplasty 

THA for DDH is challenging as the anatomical differences can be difficult to predict 

and CT 3D reconstruction can be very useful in pre-operative planning. Deformities 

40

include acetabular hypoplasia with anterior and lateral deficiency, femoral head 

deformity and short femoral necks with excessive anteversion, narrow straight femoral 

canals, leg length discrepancy and high deformed trochanters., 

The Crowe Classification may not be helpful in pre-operative planning with regards 

to the necessity of a femoral osteotomy and this should be anticipated in cases where 

angulatory or rotational correction may be required as well as when shortening is 

necessary. 

Soft tissue problems are common and extensive releases are frequently required, thus 

the risk of dislocation is much higher than uncomplicated THA. This is compounded 

by the smaller size implants and head sizes in these patients. COC bearings allow 

for smaller size cups without the problem of thin poly liners 

THA for DDH also has a higher incidence of polyethylene wear due to the smaller 

sizes and component loosening with cemented implants is more frequent. 

Surgery may be complicated by previous osteotomies, especially femoral and 

retained hardware 

Restoring the normal hip centre of rotation is one of the most important goals of 

reconstruction as this gives the best long term results. This is usually done with 

uncemented shells with femoral head autograft or acetabular metal augments. The 

acetabular bone may be osteopaenic in Crowe 3 & 4’s and fixation can be difficult 

The choice of femoral implant is dictated by the femoral canal width, femoral neck 

version and the need for an osteotomy. Modular uncemented sleeve/stem implants 

have been widely used to address these problems. Good results have also been 

reported with cemented Exeter stems. 

DDH surgery is demanding and carries a much higher complication rate – including 

sciatic and femoral nerve injuries and intraoperative femoral fracture. 


Presenter: I Learmonth 

Authors: I. D. Learmonth 


Abstract title: The Painful Total Hip Replacement 

Persistent pain after total hip replacement (THR) is clinically challenging, and is more 

prevalent than is commonly reported. Adequate assessment requires a sympathetic 

surgeon, a careful history detailing any pre-operative problems, as well as the onset, 

character and severity of the pain. Pain at rest is suggestive of infection, while activity 

related pain implies implant loosening. The pain can arise locally from inflammation 

(trochanteric or ilio-psoas bursitis/tendonitis), and from the implant, or it can be 

referred from the spine. 

Careful examination will usually differentiate the local causes of pain from referred 

pain. Imaging will then be required to determine the exact cause of the pain. This 

would include AP and lateral X-rays of the hips, nuclear scans, and A CT scan. 

Ultrasound and MRI are used to identify soft tissue lesions such as effusions, synovitis, 

iliopsoas tendonitis etc. 

41

Clearly infection remains the greatest concern after THR. A normal CRP and a normal 

sedimentation rate are virtually 100% specific for excluding infection. Remember that 

an aspiration has a very high false positive rate. Polymerase chain reaction analysis 

could be useful in identifying bacterial DNA sequences which, if present suggest 

infection, but has a low specificity. Alpha Defensin is one of several new molecular 

tests currently being tested, and shows promise to deliver increased diagnostic 

accuracy. 

If a definitive cause for the pain is diagnosed with confidence, then it is reasonable 

to proceed to treat the pathology- component revision, injection of cortico-steroids, or 

release of the ili-psoas tendon etc. Neurogenic pain and regional pain. 


Presenter: F. S. Haddad 

Authors: F. S. Haddad 


Abstract title: Dislocations 

Instability after total hip replacement is a devastating complication for both the surgeon 

and the patient. It is a complication that has driven a great deal of innovation over the 

past few decades including modification of approaches, a better understanding of 

soft tissue balancing, and the use of increased offset implants, increased use of larger 

head sizes, and improved soft tissue repair. 

Once a patient suffers a dislocation their perception of the hip arthroplasty is never the 

same again, and an ultimate outcome is compromised. More significantly for many 

surgeons, dislocation is seen as a surgeon-specific complication rather than one that 

has occurred as a result of chance. 

The best management of potential hip instability is to avoid it by careful appropriate 

surgical technique, through the choice of best approach, the best implants, and the 

best surgical technique for that individual patient. Modern techniques that include 

less muscle damage in the approach, improved soft tissue repair, and improved 

biomechanics with larger femoral heads have decreased the dislocation rate. There 

is nevertheless a significant number of patients who continue to present with this 

complication. This increases over time from arthroplasty, particularly in the elderly 

population. 

If dislocation does occur, then the cause needs to be identified at an early stage and 

a decision made between non-operative and operative management. The workup of 

dislocations should include consideration of other secondary associated pathologies 

such as infection or metal-on-metal disease that render the capsule vacuous. There 

are a number of factors that come into play including soft tissue damage, component 

malposition, patient compliance and local anatomy. Intervention should reverse the 

reason for the instability, and may include the use of dual mobility or constrained 

liners, although this should not be at the expense of appropriate component position. 

Dislocation remains one of the feared problems of hip arthroplasty. We need to redouble 

our efforts to avoid this whenever possible, to evaluate and intervene early 

when it occurs, and to optimise our management options for recurrent instability, 

which are at present unsatisfactory. 


42

ICHAP14 Surgical management of periprosthetic hip fractures 

Jean-Claude Theis 

Periprosthetic hip fractures are increasing and their management remains challenging. 

Mortality and morbidity is high and successful outcome depends on the surgeon’s 

trauma and hip arthroplasty revision skills. We reviewed 30 patients (1 bilateral) 

with a periprosthetic hip fracture obtained from our local audit database between 

2004 and 2014. All fractures were graded according to the Vancouver classification 

and outcome assessed based on failures as documented in the notes. Patients were 

divided into those who underwent internal fixation and those who had an arthroplasty 

revision. Outcome was correlated to Vancouver type and operative procedure. Of the 

30 patients half were female and the median age was 78.5 years. There were 14 

cemented and 17 uncemented stems of which over 50% were of the CLS variety. We 

found 23 type 1, 7 type 2, 0 type 3 and one type C fracture. Internal fixation was 

carried out in 20 cases and arthroplasty revision in 11 cases. In the internal fixation 

group there was a 35% failure rate combining revision of fixation and arthroplasty 

conversion. This compared to a very low failure rate in the revision arthroplasty group 

of 9% only. Arthroplasty conversion in the fixation group was either for failure of 

fixation (2 cases) or revision of a loose stem after the fracture had healed (5 cases). 

In those patients were a long revision stem was used primarily there was one revision 

for early subsidence of the stem and dislocation. This study has shown a high failure 

rate in patients with periprosthetic hip fractures if internal fixation was chosen over 

arthroplasty revision with a distally fixed long stem. 

ICHAP15 Improving outcomes after THA surgery. 

I.Learmonth 

43

FOOT AND ANKLE INSTRUCTIONAL COURSE (ICFA) 

The Adult Flat Foot Deformity – where do we stand? 

ICFA01 Etiology and classification. 

N. Willis 

ICFA02 The deltoid ligament and the Spring Ligament. 

D. Muir 

ICFA03 Joint sparing procedures 

K. Wapner 

ICFA04 Why do extra articular reconstructions fail. 

T. Lee 

ICFA05 When and what to fuse. 

C. Coetzee 

ICFA06 Ankle replacement in stage IV adult acquired flat foot deformity. T. Judet 

A 10mm Osteochondral Lesion of the Talus in a 26 y/o Rugby Athlete: 

ICFA07 Microfracture is Tried and True and Here’s the Data 

N. van Dijk 

ICFA08 Autologous Osteochondral Transplantation is the Way to Go 

J. Kennedy 


ICFA09 Navicular Stress Fractures in the Athlete 

MaCalus V. Hogan, MD 

Assistant Professor of Orthopaedic Surgery and Bioengineering 

Associate Residency Program Director 

University of Pittsburgh Medical Center 

Navicular stress fractures represent complex injuries, especially in the athletic 

population. Treating physicians must be knowledgeable of and co-manage 

contributing factors such as underlying metabolic bone disorders (i.e. osteoporosis, 

vitamin D deficiency), and the role of foot type on outcomes (i.e. cavus). Conservative 

and surgical management can each be complicated by delayed or nonunion, as well 

as recurrence upon return to activity. Surgical management also comes with a risk 

of fixation failure. There is additional controversy as it pertains to the utility of bone 

graft (autologous and allograft), biologic augmentation, screw fixation technique, and 

return to play recommendations. This discussion will review current concepts on the 

treatment of navicular stress fractures in the athlete. 

ICFA10 Fifth Metatarsal Stress Fractures 

C. Pearce 

Stress fractures of the 5 th metatarsal tend to occur in the same area of the bone as 

the ‘Jones fracture’ where there are the greatest shear forces and the poorest blood 

supply. 

Biomechanical factors such as a cavus foot and hindfoot varus, shift peak stresses in 

the foot to the lateral column therefore patients with cavovarus feet are more prone 

to this injury. Those patients involved in sports that involve cutting and turning are 

perhaps most at risk. Footwear, training/playing surfaces, training errors and the 

global pandemic of vitamin D deficiency, amongst others, also have their contribution 

and should be considered in the assessment and addressed in the treatment of 5 th 

metatarsal stress fractures. 

Treatment will be discussed and involves correcting contributory factors and altering 

the biomechanical environment to allow the fracture to heal. In the athlete, there should 

44

e a low threshold for surgical intervention. There also needs to be an emphasis on 

the provision of adequate time for recovery before the resumption of activity as reinjuries 

are not uncommon and can result in a significantly increased time away from 

training and playing. 

ICFA11 Syndesmosis Injuries in the Athlete 

MaCalus V. Hogan, MD 

Assistant Professor of Orthopaedic Surgery and Bioengineering 

Associate Residency Program Director 

University of Pittsburgh Medical Center 

Injuries to the ankle syndesmosis are commonly seen in the general and athletic 

population. However, no clear guidelines exist to help providers in diagnoses, 

grading, and management of these injuries. Despite widespread biomechanical 

and clinical research, no consensus exists regarding fixation technique. There is 

significant variability regarding screw size, number of screws, number of cortices, 

location of fixation, and implant removal. The use of suspensory fixation continues to 

increase, especially in the athletic population. Despite this debate remains regarding 

the biomechanical profiles and long-term outcomes of suspensory versus traditional 

screw fixation for these injuries. There is additional controversy as it pertains to 

the utility of arthroscopic debridement, the management of associated fractures (i.e. 

the posterior malleolus, high fibula), as well as questions regarding management of 

other commonly associated ligamentous injuries (i.e. deltoid, lateral ankle ligament 

complex), and return to play. Consensus data specific to the athletic population is 

lacking. This discussion will review current concepts and treatment recommendations 

for syndesmotic injury management in the athlete. 

ICFA12 Turf Toe 

C. Pearce 

The term turf toe was coined by Bowers and Martin in 1976, describing the injury in 

500 American football players. The mechanism is usually hyperdorsiflexion of the first 

MTP joint and seems more common when playing on artificial turf. 

The first MTP joint complex has little inherent stability. The plantar plate, collateral 

ligaments and joint capsule act as static stabilizers while the dynamic stabilizers are 

the short flexors, adductor hallucis and abductor hallucis tendons. 

Injuries may present acutely or may be chronic. 

A suggested treatment algorithm as below will be discussed: 

45


46

47 

NOTES

MEDICOLEGAL SESSION (ML) 

ML01 SAMLA - Medicolegal Session Negligence in Spinal Surgery and 

how to stay out of trouble. 

H.Edeling (Neurosurgeon) 

It is trite to say that there is a medical negligence crisis in South Africa. This crisis is 

responsible for many kinds of harm to multiple victims, including patients, surgeons, 

the national and provincial departments of health, the workforce and the economy. 

The paper will address the following: - 

Questions. What is negligence? When is a mistake negligent? What places a 

surgeon in the crosshairs of lawyers? Who is to blame for negligence? Answers to 

these questions will be discussed. 

Problems. Experience of recurring trends in indefensible negligence claims against 

spinal surgeons in South Africa. This will include examples of recurring negligent acts 

in the pre-operative, intra-operative and post-operative periods, as well as others that 

span all times of doctor-patient interaction. Differences between negligence patterns 

in private practice and State practice will also be noted. 

Solutions. Recommendations will be made for practical and meaningful interventions 

to curb the harm and the costs. This will include immediate coal-face interventions and 

remote interventions for future generations. Specific recommendations will be made 

for practising surgeons, specialist associations, state health institutions, universities, 

colleges and the HPCSA. 

ML02 SAMLA - Medicolegal Session: The current clinical negligence 

crisis and considering mediation as an alternative form of dispute 

resolution to litigation 

R. Sutherland (Attorney and Mediator) 


Medical negligence disputes are very human in nature as factually they are always 

complex. 

In litigation, the primary goal is to put the injured party back where they would 

have been had the injury not occurred, by way of monetary compensation. 

Mediation gives the parties an opportunity to actually talk to each other and provide 

a platform for the doctor to explain why something was done the way it was. This 

creates a safe environment which requires all the parties, with the assistance of the 

mediator, to actively listen and communicate effectively with the goal of reaching a 

resolution to the dispute which is mutually acceptable to both parties. 

48

Mediation is effective because it moves the parties away from a “blame and 

punishment” narrative to a more conciliatory place. This is specifically effective 

in medical negligence cases because of the overwhelming recognition that a 

breakdown in communication is the foremost cause for a patient suing his/her doctor. 

Unlike litigation, mediation shares many of the same goals as medicine, including the 

promotion of healing. It is therefore a great fit for the dynamic that exists between 

a patient and his/her doctor and the importance they attach in cementing and 

preserving the qualities of trust and caregiving. 

In my presentation I will discuss how the so called “clinical negligence crisis” can be 

addressed by the implementation of mediation at any stage of a dispute. I will also 

discuss a successfully mediated medical negligence matter which I was personally 

involved in whilst highlighting the structure and process of mediation and the results 

which can be obtained thereby. 

ML03 SAMLA - Medicolegal Session: Eggshell cases and negligence in 

Orthopaedic Treatment 

Dr & Adv Anton van den Bout (Orthopaedic and Spinal Surgeon and Advocate) 

Abstract 

Talem Qualem, Latin for “as it is”, is the principle which has to be applied in persons 

who have a certain congenital or acquired abnormality which make them more 

vulnerable to damage because of that abnormality. 

Treating doctors like Orthopaedic Surgeons should always be familiar with all 

the details of the patients they are going to treat but sometimes can be put into a 

situation whereby they find an abnormality which make the treatment more particular, 

sometimes more difficult and sometimes dangerous. 

That particular abnormality of the patient however can never be held as an excuse 

when something goes wrong in the treatment. In other words “You have to take your 

patient as he comes”. 

Whether bad or disastrous results are negligent will totally depend on the specific 

circumstances of that case and the standard of practice of that surgeon is going to 

be measured up to. 

Always be on guard as treating Orthopaedic Surgeon that the patient could have 

some known or unknown condition which could make the treatment difficult or even 

impossible. 

ML04 BOA Medicolegal Session: Litigation Trends in the UK 

2016. 

M. Foy 

Review and comment upon the upsurge of medical negligence claims in orthopaedic 

practice in the UK from review of the National Health Service Litigation Authority 

(NHSLA) and private insurer’s data. Discussion of the recent changes in the law as 

they relate to informed consent in the UK and its potential impact in this area. Brief 

consideration of topical issues in personal injury litigation. 

49

Michael Foy has been a consultant orthopaedic & spinal surgeon for 26 years. He 

is chairman of the medico-legal committee of the BOA. Author/Co-editor of textbook 

“Medico-Legal Reporting in Orthopaedic Trauma” now in its 4th edition. Author of 

various papers on general orthopaedic, spinal and medico-legal issues. Extensive 

experience of expert witness work in negligence and personal injury practice. Still in 

active clinical/surgical practice. 

ML05 COA Medicolegal Session: The Medical-Legal Environment: A 

Canadian Perspective. 

R. Richards 

The Canadian Medical Protective Association is the largest medical organization 

in Canada. It was incorporated by an Act of Parliament in 1913 and currently has 

86,000 members. The organization provides legal defense, liability protection and 

risk management education for physicians and compensation to patients and their 

families who have been harmed by negligent clinical care. 

The number of legal actions initiated has decreased over the past decade, although 

the cost of individual actions has increased. One of every fourteen Canadian 

orthopaedic surgeons are named in a civil legal action annually whereas only one in 

one hundred family practitioners are named. 

Over the last five years 63% of actions against orthopaedic surgeons have been 

dismissed, 31% have been settled, 5% have received a judgment for the physician 

and 1% have received a judgment for the plaintiff. Sixty percent of serious medical 

errors relate to communication issues. 

A current focus of the CMPA is to advocate for the development of safe systems and 

processes of care in an effort to reduce unanticipated outcomes. Informed consent 

and discharge, implementation of the surgical safety check list, simulation-based 

skills training and education, communication protocols for handoffs and decreased 

distraction in the operating room are important initiatives. Risk management conferences 

and symposia including 400 “customized” conferences for specific physician groups 

are organized annually. The CMPA has partnered with the Canadian Patient Safety 

Institute to develop programs and tools aimed at improving patient safety. 


In a publicly funded health care system adequate resources are required to maintain 

quality and access to care. With respect to orthopaedic surgical care access issues 

exist and patient expectations are very high. Orthopaedic surgeons have an important 

role to play in publicly advocating for both safety and access to care. Transparent 

discussion is required with respect to the differential allocation of resources within the 

system to maintain the standard of care. 

50

ML06 AuOA Medicolegal Session: Percentage thresholds and their 

effects on injury assessment. 

Ian Dickinson 

Medicolegal assessment within Australia varies from jurisdiction to jurisdiction and 

usually also within jurisdictions. The differences between third party injury, worker’s 

compensation and statutory claims can be significant. 

The rules in relation to performing medicolegal assessments have become much more 

proscribed than in the past and surgeons have been expected to fit within very strict 

guidelines. 

The effect of being an expert “for the Court” as opposed to being an expert in 

independent practice is significant. 

Most Australian jurisdictions use AMA 5, some with prescribed modifications and 

some jurisdictions use AMA 4. Some have no threshold for purposes of paying 

damages, and others have thresholds that are as high as 15%. 

The question of whether to “run a case” depends very much on the expectations in 

relation to the jurisdiction. 

The definitions of injury and disease vary considerably and can make a significant 

difference in the surgeon’s finding of whether a particular event has caused or not 

caused a particular outcome. 

Where there is little if any impairment, there is significant interest in minor variations 

in assessment particularly the spine and particularly in relation to activities of daily 

living and to scarring. 

While the Courts are interested in obtaining expert opinions, the attempts to provide 

legal boundaries for what is in essence medical “opinion” have at times proved to be 

confusing or even fruitless for the medical expert point of view. 

ML07 AOA Medicolegal Session: US Healthcare in the New Era: 

Consolidate, Integrate, Perpetuate 

K.J. Saleh 

The United States healthcare system has existed in a fragmented nature for more 

than 40 years. The disjointed model of medical access and payment created a 

great need for modification in the US healthcare system. For the first time, the United 

States has a universal healthcare system brought about by the Patient Protection and 

Affordable Care Act. While this unique state brings solutions to many of the old 

problems of access to care, it also reveals new issues of cost and quality of care that 

must be addressed as new provisions are implemented. A closer look at the legislative 

provisions of the ACA allow the orthopaedic provider to better understand how these 

changes can impact their practice, and subsequently the care and outcomes of 

patients. In this session, we will explore some of these key issues including healthcare 

economics (price transparency, healthcare costs, healthcare reimbursements), 

healthcare regulation (competition in the marketplace, business mergers, anti-trust 

laws, liability of managed care organizations, issues of informed consent), and 

healthcare technology (HIPPA, EMR implementation), and how healthcare reform is 

51

shaping the future of medical provision in the United States (Tort Reform, the Patient 

Protection and Affordable Care Act, Accountable Care Organizations). Finally, we 

will discuss the future of healthcare in America and the cultural quest for a “right to 

healthcare” for all people on US soil. 

ML08 NZ Medicolegal Session: Patient Compensation and Surgeon 

Accountability following Surgery Error in a No Fault System 

D. Atkinson 

New Zealand’s No Fault system bars civil proceedings in tort law for damages 

resulting from personal injury by accident. 

The Legislation is unique in providing cover for personal injury sustained as a result of 

treatment by a Medical Practitioner. 

This Paper explores the issues of patient compensation and Surgeon accountability 

following a knee replacement procedure which results in a catastrophic complication 

with below knee amputation. The patient’s compensation and ongoing entitlesments 

are explained. The Surgeon’s accountability and the role of regulatory bodies and 

injyry prevention are discussed. 


52

53 

NOTES

EDUCATION AND RESEARCH (ER) 

ER01 EFORT’s work in Education and Standardization in Europe 

Stephen Cannon 

The European Federation of National Associations of Orthopaedics and Traumatology 

(EFORT) was founded in 1992. At that time it was considered that there were three 

major obstacles to its success. The multiplicity of languages, the differing concepts of 

“Orthopaedics” and the diversity of health care systems. Since this early beginning 

EFORT has evolved in its mission to “Work with the European Orthopaedic Community 

to restore and secure mobility, musculoskeletal health and quality of life for the European 

population. This has been achieved by the exchange of scientific knowledge and 

experience in the field of prevention and both conservative and surgical treatment of 

diseases and injuries concerning the musculoskeletal system. 

To achieve these ends EFORT organizes Instructional Courses at various levels, Fora 

within the meetings of the National Associations and a large number of fellowships 

for both trainees and consultants. The highlight of the educational program however 

remains the annual congress which attracts over 6000 delegates. Educational 

pathways however remain very variable and EFORT has now introduced an 

Education Platform to facilitate the training and assessment of all surgeons within 

Europe. We invite colleagues from around the globe to contribute to these goals. 

ER02 BRITISH BONE AND JOINT JOURNAL: Getting your work 

published and achieving the highest impact 

Professor Fares Haddad (Chairman) 

Miss Deborah Eastwood 

Professor Hamish Simpson 

Introduction 

The process of developing a research idea into a formal hypothesis and a research grant 

submission followed by ethical/IRB approval and the setting up of the infrastructure 

to do the research are difficult enough in their own right. There is then the issue of 

collecting, collating and analysing the data which can be very time consuming and 

at times complex and riddled with unexpected problems. It is therefore a surprise 

to many that once they have overcome all of these hurdles, that there are still great 

difficulties in translating all this hard work into a creditable, readable, attractive output 

that journals will accept and that will be looked upon favourably and subsequently 

cited. This instructional is designed to take you through one perspective on how to 

publish your research more easily in a high impact journal. 

There are many facets to this including the basic quality of the research, the way the 

information is transmitted and the ability to respond to queries and challenges. 

EDUCATION AND RESEARCH (ER) 

54

This instructional course will summaries current thinking on research methodology and 

the best way to ensure that your study provides an output that is acceptable to peer 

review. It will highlight some of the key issues around the ethics of research and how 

to navigate what are increasingly complex regulations. We hope to also provide a 

guide as to how the material should be laid out and presented. 

We would advise considering how an editor/reviewer will view your work. It must be 

presented in a well written and concise format, carefully checked by all the authors. 

The title is critical as that will rapidly give an impression of a study that may or may 

not be suitable for a specific journal. The abstract is also key as it is most read part 

of a paper, will have the most impact and rapidly gives the sense of the key issues. 

It must therefore be set out in a clear way expressing the purpose of the study, the 

methodology and the important findings. We would strongly recommend that the 

instructions to authors are always carefully followed. Deviations, no matter how minor, 

can lead to rejection of good material. 

ER03 (P515) 

Presenter: M Swiontkowski 

Authors: M. F. Swiontkowski, C. R. Clark 


Abstract title: Advance Your Career Through Participation in Scholarly 

Publications: the Why and How of Reviewing for an Orthopaedic 

Journal and Being Selected for an Editorial Board 

This session will start with an overview of the rapidly changing field of orthopaedic 

scholarly publication, including the trend toward relationships with large publishers and 

the status of the open-access publication movement. We will then move to a detailed 

interactive session on how to review a manuscript for a peer-reviewed orthopaedic 

publication, complete with examples of what not to do as well as exemplary practices 

that endear the reviewer to the editorial board. We will conclude with a discussion 

of the advantages of serving on an editorial board and how to work toward being 

selected for such a board. Audience members who have participated in orthopaedic 

editorial boards are encouraged to bring examples of their experiences, both positive 

and negative. 

55


HAND INSTRUCTIONAL COURSE (ICH) 

Total Wrist Arthroplasty 

ICH01 The Maestro experience 

G. Packard 

ICH02 Australian National Joint Replacement Registry; Initial Review of Wrist 

Replacements. 

G. Bain 

ICH03 Arthroplasty of the DRUJ. 

G. Bain 

ICH04 Motec technical tips and results. 

G. Packard 

ICH05 The Cape Town Experience with Total Wrist Arthroplasty. An evolution? 

M. Solomons 

ICH06 Role of hemi-arthroplasty 

G. Packard 


Management of radiocarpal arthritis 

ICH07 Wrist arthroscopy in management of arthritis 

(i.e. Midcarpal fusion how I do it) 

A. Atzei 

ICH08 3 Vs 4 Corner fusions. 

G. Bain 

ICH09 PRC vs Midcarpal fusion. Also, is there a role for total wrist fusion? 

G. Packard 

ICH10 STT OA 

A. Atzei 

ICH11 Kienbock’s Disease; Pathoanatomy, assessment and a new treatment 

algorithm. 

G. Bain 

ICH12 Wrist arthroscopy in decision making on TFCC repair / Reconstruction. 

A. Atzei 

ICH13 Role of arthroscopy in decision making. 

G. Packard 

PAEDIATRICS INSTRUCTIONAL COURSE (ICP) 

ICP01 (P336) 

Presenter: B Willis 

Authors: Dr R.B. Willis 


Abstract title: Advanced Clubfoot and Vertical Talus Management 

1. Overview and Historical Perspectives 

The evaluation and treatment of congenital clubfoot has undergone a momentous shift 

in the last 15-20 years. Robert Jones in 1923 stated ‘he had never met with a case 

where treatment has been started in the first week where the deformity could not be 

completely rectified by manipulation and retention in 2 months”. Unfortunately, his 

results could not be duplicated in many centres resulting in various forms of treatment 

with far from perfect feet. 

56

The modern era of conservative management of clubfeet was made popular by Hiram 

Kite of Atlanta, although he treated each component of the deformity separately and 

he failed to understand the concept of correction of the hindfoot varus by abduction 

before eversion could be obtained. 

In the 1970’s, surgical correction as popularized by Vincent Turco ( posteromedial 

release ) and George Simons ( comprehensive subtalar release ) resulted in plantigrade 

feet but often with overcorrection, joint damage, stiffness and eventual arthrosis, 

muscle weakness and pain. 

Ponseti outlined his treatise on the management of clubfeet in 1948 but it was not 

until the 1990’s that his treatment protocol became widely accepted. His specific 

manipulative technique will be demonstrated in detail and results from a number of 

centres will be reviewed. 

Recent work by Dobbs utilizing the same principles employed by Ponseti by in a 

reverse order has suggested that congenital vertical talus may be managed in a 

similar fashion. 

ICP02 (P332) 

Presenter: D Eastwood 

Authors: Dr D. M. Eastwood 


Abstract title: Club Feet: How to pick the winners from the losers. 

Not all club feet are the same and the skill lies in identifying those that are truly 

idiopathic from those that are not. We have already identified the complex and 

atypical idiopathic feet but there are other clues in the history and examination 

and in the response to treatment that might warn you that care must be taken. 

The accelerated programme may work in some feet but not in others – why? The 

phenotype must be described so that we can work towards identifying the relevant 

genotypes too. 

The stiffness of the foot – hind foot and forefoot, the neurological status and muscle 

power are factors mentioned in the Bensahel-Dimeglio classification but ones which 

perhaps deserve more consideration. 

Poor evertor power and/or significant hindfoot stiffness and calf wasting can 

be identified clinicially. The question for the future might be: are there any 

investigations that might improve our understanding of the individual foot to allow us 

to define our treatment plan on a more individual basis: surely, in the future, not ALL 

idiopathic feet will have to be braced for such a long time? 

We may not have all the answers but if you keep your eyes and ears open, it is 

possible to pick up some of the ‘winners’ and identify some of the ‘losers’ from an 

early stage. 

ICP03 Management of neglected as well as syndromic and neglected clubfoot 

Dr Matthew Dobbs 

The Ponseti Method has been widely shown to be successful for treating infants and 

young children with isolated clubfoot deformity. There is less data on the use of the 

57

Ponseti method to correct the rigid severe clubfeet associated with neuromuscular or 

genetic disorders. I will illustrate the efficacy of the Ponseti method in this difficult 

group of patients as well as the successful correction of neglected clubfeet up to the 

age of 21 years. I have expanded the use of the Ponseti method to patients that 

have undergone prior extensive soft-tissue releases and have developed relapse. 

There are essentially no clubfeet for which the Ponseti method should not be utilized 

for it always allows at minimum partial correction leaving any surgical interventions 

to an “a la carte” approach. 

ICP04 (P331) 

Presenter: M Ramachandran 

Authors: Dr M. Ramachandran 

Abstract title: Technical and non-technical factors in CTEV and CVT treatment 

This talk will explore both clinician- and non-clinician factors in the outcomes of CTEV 

and CVT treatment. Variations in treatment technique and their effect on outcome will 

be explored. In addition, non-technical factors such as adherence, parental factors, 

psychological and socioeconomic issues will be discussed. 


ICP05 Congenital vertical talus – Update and management 

Dr Matthew Dobbs 

My treatment method for congenital vertical talus evolved from the Ponseti method 

for clubfoot management. A key to my vertical talus minimally invasive technique 

lies in the ability to palpate the head of the talus just as it is clubfoot. This can be 

challenging in the small infant foot. The principle of manipulation relies on the fact 

that the talus is fixed in the ankle mortise but the rest of the foot including the subtalar 

joint complex can rotate around the head of the talus. The method is gentle and 

serial casting is performed in the clinic on a weekly basis. It takes an average of 

5 casts to achieve correction. Once correction achieved it is maintained with pin 

fixation of the talonavicular joint and a tendo Achilles tenotomy. While clubfoot uses 

the head of the talus as a fulcrum to externally rotate the foot, my method for vertical 

talus correction uses the head of the talus as a fulcrum to reduce the talonavicular joint 

while bringing the foot into plantar flexion and adduction. It is key to apply both a 

dorsal and lateral force on the talus to correct not only the lateral plane deformity, 

but also the coronal plane deformity. The other keys to the technique are to cast 

gradually into maximal equinovarus deformity to reduce the talonavicular joint. This 

is analogous to achieving 70˚ of external rotation in the final Ponseti cast for clubfoot 

correction. The maximal equinovarus position is essential to overcorrect the deformity 

in order to adequately stretch the dorsal and lateral soft tissues. If this is not done, 

there will either be lack of full correction or high relapse risk. My method has been 

shown to be effective for both isolated vertical talus and vertical talus associated with 

neuromuscular and genetic disorders and results in better long-term outcomes than 

vertical talus treated with extensive soft-tissue release surgery. 

58

ICP06 (P335) 

Presenter: B Willis 

Authors: Dr R.B. Willis 


Abstract title: Slipped Capital Femoral Epiphysis 

The treatment of Slipped Capital Femoral Epiphysis (SCFE) had changed very little in 

the time from the 1940’s until the last 5-10 years when specifically the treatment of 

unstable slipped epiphysis has been altered by early work, originally by Ganz and 

Swiss surgeons and more recently by Sucato (TSRH-Dallas ), Millis and Kim (Boston) 

and Little (Sydney). 

The classification of Loder is universally accepted and forms 2 distinct groups with 

quite different prognoses. 

Stable slips are universally treated by in-situ stabilization (smooth pins in Europe, 

screws in North America and Australasia ) and the complication rate is very low. 

Femoroacetabular impingement may occur in more severe stable slips leading to 

labral degeneration and eventual degenerative joint disease. 

This has led to management of FAI by arthroscopic and open techniques + or – femoral 

neck realignment osteotomies or intertrochanteric osteotomies with encouraging 

results. 

On the other hand, unstable slips with a high rate of avascular necrosis have continued 

to be problematic. Recent work which involves “safe surgical hip dislocation“ , femoral 

neck trimming with realignment of the capital femoral epiphysis has demonstrated 

encouraging results in some centres with AVN rates of 10-20 %. 

This begs the question whether this form of management should be undertaken in all 

centres or only in centers of special expertise. 

ICP07 (P333) 

Presenter: D Little 

Authors: Prof D. Little 


Abstract title: Update on pathophysiology of SCFE and AVN. 

Slipped Capital Femoral Epiphysis is a mainly idiopathic condition, which seems to 

be increasing in incidence. As one major risk factor for SCFE is obesity, and obesity 

incidence is rising, this makes sense. While known hormonal risk factors for SCFE 

include growth hormone deficiency (and perhaps growth hormone treatment), as well 

as hypothyroidism and renal failure, it is unknown if subtle hormonal effects in obese 

patients also contribute. 

Once retroversion commences, the force required to further retrovert the femoral head 

decreases. At some point the repetitive forces on the growth plate cause widening and 

disorganisation of the physis, also seen in other paediatric overuse syndromes. From 

around 15-20 degrees it is likely that the deformity will continue to progress. Some 

patients continue to slip slowly until the femoral head abuts the posterior neck, with 

resultant impingement, loss of motion and gait disturbance. Others acutely progress 

usually after minor trauma leading to an unstable slip and the risk of avascular necrosis. 

59

Urgent treatment can save some but not all unstable slips from undergoing loss of 

blood supply and AVN. AVN will lead to collapse and destruction of the hip in the 

majority of cases. Current efforts at treating AVN involve a period of weight relief, 

anti-catabolic therapy (bisphosphonates, denosumab) and anabolic therapies of 

either bone grafting or BMP. Animal studies are showing some success but in clinical 

practice AVN remains a huge challenge. 

ICP08 (P334) 

Presenter: J Schoenecker 

Authors: Dr J.G Schoenecker 


Abstract title: SCFE 

SCFE predominantly leads to an external rotation deformity of the femur and 

incongruence of the femoral head/neck junction. Together these abnormalities 

prohibit a functional range of motion of the hip without impingement. It is thought 

that these deformities significantly contribute to the often rapid deterioration and pain 

in the hip of these patients. In order to restore the functional range of motion of 

the hip in these patients an orthopedic surgeon must correct abnormalities without 

compromising the precarious vascularity of the proximal femoral epiphysis. The safest 

mode of reconstruction of the proximal femur is through osteotomies that do not put 

the epiphyseal vascularity at risk. This can be accomplished through combinations of 

an intertrochanteric osteotomy and osteochondroplasties. An alternative method of 

proximal femoral reconstruction is through an osteotomy of the epiphyseal metaphyseal 

junction, often referred to as a capital realignment. These osteotomies provide the 

most direct restoration of the anatomy but carry the greatest risk of iatrogenic avascular 

necrosis which can lead to devastating consequences. The objective of this lecture 

will be to discuss the most common deformities caused by SCFE and how to address 

these deformities without compromising epiphyseal vascularity. 

ICP09 (P330) 

Presenter: M Ramachandran 

Authors: Dr M. Ramachandran 


Abstract title: Contemporary techniques in SCFE treatment 

This talk will explore stable and unstable SCFE and the current approaches to 

treatment. For stable SCFEs, screw-related factors will be explored along with surgical 

techniques. For unstable SCFEs, surgical approaches such as anterior, anterolateral, 

surgical dislocation and arthroscopic approaches will be discussed.This talk will 

explore stable and unstable SCFE and the current approaches to treatment. For 

stable SCFEs, screw-related factors will be explored along with surgical techniques. 

For unstable SCFEs, surgical approaches such as anterior, anterolateral, surgical 

dislocation and arthroscopic approaches will be discussed. 


60

SPINE INSTRUCTIONAL COURSE (ICS) 

ICS01 Where 3rd and 1st worlds collide 

Speakers: 

Tuberculosis of the spine - when and how to intervene. 

Pyogenic and other infections of the spine. 

The challenge of post-traumatic delayed presentation. 

Complex paediatric deformity. 

SCI - a death sentence in Africa? 

J. Davis 

P. Polley 

A. Puddu 

R. Dunn 

N. Kruger 

South African spine practice is unique as there is an interface between well trained 

surgeons with first world benchmarks and a high burden of disease population, 

competing for care in an under resourced environment. This results in delayed 

presentation with advanced disease required challenging surgery. The health system 

and the surgeons are frequently overwhelmed and need to find local solutions for the 

local challenges. This session will address some of these challenges. 

ICS02 Spine sports injuries 

Speakers: 

When does spondylolysis need a spine surgeon? 

The professional rugby player and the acute cervical radiculopathy 

The school boy rugby player with cervical facet dislocation 

Return to play 

E. Coetzee 

D. Welsh 

R. Dunn 

R. J. Ramlakan 

Spine injury or surgery can be devastating to a sportsman’s’ career. This may be as 

innocuous as pars lysis which often manifests in parental anxiety demanding quick 

fix solutions from the surgeon to cervical dislocation. There is little consensus on 

management of these conditions or even return to play criteria. This session will 

discuss these challenging issues. 

AO FOUNDATION INSTRUCTIONAL COURSE (ICAOF) 

AOTrauma Europe Symposium—Lower limb trauma: All things considered 

ICAOF01 AOTrauma global objectives and perspectives 

Kevin Smith 

This short talk will provide an overview of the Structure of AOTrauma and its place 

within the AO foundation. 

The role of AOTrauma and the scope of its international educational activities will 

be outlined, as will a summary of the objectives of the organisation going forward. 

Developments in way in which AOTrauma delivers education, adapting to 

technological advances will also be highlighted. 

ICAOF02 - Pelvic fractures - strategies in the developing world 


The phrase ’islands of excellence in a sea of need’ aptly describes the status of pelvis 

61

fracture care in South Africa. The management of pelvis fractures in the developing 

world represents two opposite ends of the treatment spectrum. Patients who sustain 

trauma close to the major metropolitan areas receive medical care that rivals the best 

in the world. These patients are treated in state of the art theatres using the latest 

imaging techniques and intra-operative fluoroscopy as well as the availability of the 

latest orthopaedic implants and anaesthetic expertise. 

On the other end of the spectrum are patients who are injured in remote villages 

who have no ready access to high quality health care. Vast geographical distances 

between hospitals makes patient transfer difficult and they often present with delayed 

fractures or neglected injuries requiring major reconstruction. These patients often 

have life-long morbidity tha impacts on both the health and social security services. 

There is also a wide-spread perception that pelvis fractures are to be treated 

non-operatively as their surgical treatment is lengthy, complex and fraught with 

complications. Our education efforts need to be directed at correcting this perception 

as well as training the next generation of orthopaedic surgeons in the field of pelvic 

fracture surgery. 

The widespread use of pelvis binders in the pre-hospital setting is to be encouraged 

as this is an efficient and cost effective way of reducing transfusion requirements and 

saving lives. 


ICAOF03 Implant related infection abstract 

Iain McFadyn 

Infection can lead to terrible outcomes following fracture fixation or arthroplasty. 

Bacterial biofilm formation on implants regulates infection and can occur within hours 

of contamination. Diagnostic and treatment strategies have to be directed at the 

biofilm. Diagnostic tests have varying levels of sensitivity and specificity. Treatment 

algorithms have been developed by consensus and are becoming increasingly well 

validated in clinical practice. Implant related infection places an enormous burden on 

hospital resources accounting for around 20% of acute orthopaedic bed occupancy 

in NHS teaching hospitals. Consequently many UK and European hospitals are 

developing specialist bone infection teams to manage the problem. 

ICAOF04 Truth and reconciliation commission 

Brian Bernstein 

One of the most positive aspects of the transition from an Apartheid state to the 

Rainbow Nation Democracy in which we now live in South Africa, was the Truth and 

Reconciliation Commission. 

It was here that we faced the demons of our past, to forge our future in peace and 

harmony. All our perceived realities were laid bare for all to see and dissect, and we 

did reconcile! 

The controversies around optimal management of complex Tibia fractures are many, 

and most surgeons will have their preferential management plan. 

As one of the most common bones fractured, often with associated soft-tissue 

62

complications, and associated high incidence of infection / infected non-union, we 

will discuss the treatment options in the form of a case based debate. The panel 

will present their own perceived realities, and we will dissect this with audience 

participation to try to find some truth and reconciliation.” 

ICAOF05 The Case for Tibial Nail 

Kevin Smith 

An evidence based case for treating the fracture by intra-medullary tibial nailing 

ICAOF06 The case for Tibial Plate 

ICAOF07 The case for External Fixation 


Franz Birkholtz 

AOTRAUMA/AORECON SYMPOSIUM - PERIPROSTHETIC FRACTURES AROUND 

THE HIP AND KNEE 

ICAOF08 AORecon initiative 

N. Haas 

AORecon is an initiative of the AO Foundation focusing on education and the 

exchange within a global community to improve patient care in joint preservation 

and replacement. 

Prof Haas, founder of AORecon, will give a short introduction of the initiative and 

an overview of the current activities. 

ICAOF09 Unified Classification System for Peri-Prosthetic Fractures 

Professor Fares S. Haddad, BSc, MD (Res); MCh (Orth), FRCS (Orth) 

Consultant Orthopaedic Surgeon, University College London & Princess Grace 

Hospitals, 

Director, Institute of Sport, Exercise & Health, UCL, London, UK. 

Periprosthetic fractures lead to considerable morbidity in terms of loss of component 

fixation, loss of bone and subsequent functional deficits. We face an epidemic of 

periprosthetic fractures as the numbers of prosthetic procedures increases in an elderly 

population with poor bone stock and the number of cementless implants inserted 

continues to rise and the number of revisions continues to increase. The appropriate 

management of such fractures is therefore critical. 

The management of periprosthetic fractures requires careful preoperative imaging, 

planning and templating, the availability of the necessary expertise and equipment, 

and knowledge of the potential pitfalls so that these can be avoided both intraoperatively 

and in follow-up. There is a danger that these cases fall between the 

expertise of the trauma surgeon and that of the revision arthroplasty surgeon. 

The past decade has afforded us clear treatment algorithms based on fracture location, 

component fixation and the available bone stock. These are now newly categorized 

in the Universal Classification System that will be presented. This presentation will 

introduce the United Classification System, the universal classification system which has 

been developed on the background on the Vancouver system in order to encompass 

all periprosthetic fractures across all bones and joints. This provides a guidance 

63

system for the classification and management of periprosthetic fractures including the 

less common types which have previously been under recognized. The system, its 

validation, and its use will be described. 

REFERENCES: 

Duncan CP, Haddad FS. The Unified Classification System (UCS): improving 

ourunderstanding of periprosthetic fractures. Bone Joint J. 2014 Jun;96-B(6):713-6. 

Van der Merwe JM, Haddad FS, Duncan CP. Field testing the Unified Classification 

System for periprosthetic fractures of the femur, tibia and patella in association with 

knee replacement: an international collaboration. 

Bone Joint J. 2014 Dec;96-B(12):1669-73. 

Vioreanu MH, Parry MC, Haddad FS, Duncan CP. Field testing the Unified 

Classification System for peri-prosthetic fractures of the pelvis and femur around 

a total hip replacement : an international collaboration. Bone Joint J. 2014 

Nov;96-B(11):1472-7. 


ICAOF10 Osteosynthesis of periprosthetic fractures after THA 

Chris Frey 

Arthroplasty implants are ever improving. So are the indications for total hip arthroplasty 

(THA) in the ageing population as in younger patients. Periprosthetic fractures around 

hip arthroplasty are often a devastating complication. Periprosthetic acetabular 

fractures are rare. Fractures around the femoral stem are common. Treatment is guided 

by classifications. Decisions are made by assessing the stability of the implant, the 

bone stock and the fracture pattern. Open reduction and internal fixation in feasible 

femoral fractures can be done with load bearing devices. On the load bearing 

devices the new pre-contoured locking plates with bi- and uni-cortical screws, cable 

attachments to the plate and specific cement fixating screws in combination with 

or without bone graft have improved results. The principles for locking plates, long 

working length, compression screws close and locking screws far from the fracture 

must be followed. The main local complications are high non-union rates and high 

re-fractures. This is related to the decreased biological vascularity and osteopenia of 

the bone. 

ICAOF11 Periprosthetic Femur Fracture in Total Hip Arthroplasty 

Michael H. Huo, MD 

UT Southwestern Medical Center. Dallas, TX 

The volume of total hip arthroplasty (THA) is expected to reach nearly 1 million per 

year by 2030. Epidemiology estimates indicate that >2.5 million living Americans 

have a THA. The prevalence of periprosthetic femur fracture around a THA is on the 

rise. The fracture can occur intraoperatively or after surgery. Significant challenges 

and resource utilization are involved in the clinical management of these fractures. 

64

The outcome of the patients with this complication has not been uniformly successful. 

Bhattacharyya et al. reported 11% mortality within the first years in 106 patients. They 

compared the data to a group of 309 patients with fragility hip fractures (mortality 

rate= 16.5%), and 311 primary THAs (mortality rate= 2.9%). One interesting finding 

was that the mortality rate was higher for those patients with ORIF (mortality rate= 

33%) than for those patients who underwent revision THA for their peri-prosthetic 

fracture. (mortality= 12%) (p

B3: These are technically challenging as there is either poor quality or insufficient 

quantity of bone. Similar techniques used for major bone deficiencies associated with 

femoral revisions can be utilized. Allograft-prosthetic composite and proximal femoral 

replacement are two of the options. 

Type C: These can be treated by ORIF or by indirect reduction and limited incision 

technique (LISS). 

Outcome 

Springer et al. reported on revision THA for 118 periprosthetic femur fractures. 

Survival was 90% at 5 years, and 79.2% at 10 years. Lindahl et al. reported on 

321 fractures over a 2-year period in the Swedish Joint Registry. The survival rate was 

poor: 74.8% at 66-month. Fuchtmeier et al. reported on 121 patients. The one-year 

mortality rate was 13.2%. Even more importantly, the implant failure rate was 16.5% 

within the first year. Colman et al. reported on 97 fractures treated at one institution 

over 11 years. Three treatments methods were utilized: ORIF (57), revision THA 

(19), and proximal femoral replacement (21). There was no statistically significant 

difference in the mortality rate among the 3 groups. Implant survival at 5-year interval 

was less successful (p=0.03) in the proximal femoral replacement group in contrast 

to the other two groups. 


ICAOF12 Osteosynthesis of periprosthetic fractures after TKA 

Chris Frey 

Periprosthetic fractures around total knee arthroplasty (TKA) are increasing due to 

increasing numbers of patients undergoing TKA. Periprosthetic distal femur fractures 

are the most common fractures followed by patella and tibia fractures. Classification 

systems are useful guides for the treatment choice. Decisions are made by assessing 

the stability of the implant, the bone stock and the fracture pattern. Open reduction 

and internal fixation in feasible femoral fractures can be done with load shearing, 

IM nails or load bearing devices. On the load bearing devices the new precontoured 

locking plates with bi- and uni-cortical screws, cable attachments to the 

plate and specific cement fixating screws have improved results. Preferred treatment 

for patella fractures are non surgical, provided parts of the extensor mechanism are 

intact. Periprosthetic tibia fractures follow the same open reduction guidelines as 

femur fractures. The main local complications are high non-union rates and high refractures. 

ICAOF13 Carsten Perka - Revision TKA after periprosthetic fractures 

Periprosthetic fractures after primary TKA show an incidence of 0.3-2.5% at the femur, 

0.3-0.5% at the tibia, and 0.2-0.6% at the patella. In revision TKA the incidence is 

increasing. The Unified Classification system (UCS) allows to classify periprosthetic 

fractures based on the anatomic localisation in relation to the TKA implant, the fixation 

of the implant and the quality of the host bone, which are representing the most 

important factors for decision making in the surgical treatment of these fractures. 

In case of a loosened implant, insufficient bone stock or missing possibility of an 

osteosythesis, revision TKA is recommended. Surgical key points are: careful implant 

66

emoval without further dislocation of the fracture and bone loss, anatomical reposition 

of the fracture, and adequate fixation of the new implant predominantly in combination 

with an osteosynthesis. Therefore basic principles of TKA revision and osteosythesis 

have to be combined. In case of larger bone loss modular implants and additional 

constructs like bone grafts, metal augments, metaphyseal sleeves, and metaphyseal 

cones have to be available. If possible, larger resection of bone and implantation 

of a megaprosthesis should be avoided due to a decreased long-term survival and 

missing options in re-revision. 

AORECON SYMPOSIUM (ICAOR) 

Controversies in Knee Replacement Surgery 

ICAOR01 Consensus Statement on the Indications for Medial Unicompartmental 

Knee Arthroplasty 

Jean-Noel Argenson, Sebastien Parratte, Matthieu Ollivier, Xavier Flecher 

The Institute for Locomotion, Aix-Marseille University, Sainte-Marguerite Hospital, 

Marseille, France 

Unicompartmental knee arthroplasty (UKA) has been described as a conservative and 

minimally invasive alternative to total knee arthroplasty (TKA) in selected patients for 

the treatment of osteoarthritis of the knee. UKA Survivorship of various implant designs 

has been reported to be as high as 98% at 10 years 3 and 91% through the second 

decade. Advocates of UKA cite a faster recovery, improved postoperative range of 

motion, a higher activity level, and fewer complications when compared to TKA. 

The primary indication includes bone-on-bone, Grade IV disease, or greater 

than 75% loss of medial compartment joint space, eburnated bone on the medial 

femoral condyle and tibial plateau. This includes also a functionally, ligamentously 

normal knee with intact anterior cruciate ligament, correctable varus deformity, and 

functionally intact lateral compartment. AVN involving and isolated to the medial 

compartment is a secondary indication for medial UKA. 

The cautious expansion of indications to obesity relates to survivorship which 

appears to be unaffected by increasing BMI, and a higher improvement in knee 

scores may be obtained with UKA in the more obese patients. Although increased 

BMI is no longer a contraindication to medial metal-backed UKA, concern remains 

with any arthroplasty in active, mesomorphic males. 

The cautious expansion of indications to age: age is no longer considered as a 

contra-indication to UKA. There exists a bias towards performing UKA in younger 

patients with less severe disease and higher expectations. 

The cautious expansion of indications to patellofemoral disease: in the presence 

of anteromedial OA, full thickness cartilage loss within the lateral facet of the patella 

and/or lateral trochlea with eburnation, grooving, with or without the presence of 

lateral patellar subluxation is a contra-indication to medial UKA. All other conditions 

of the patellofemoral joint are acceptable and not to be considered as contraindications. 

67

The cautious expansion of indications to ACL deficiency: While the presence of a 

functionally intact ACL is one of the hallmarks of AMOA, there are certain cases like 

sedentary patients in which ACL deficiency may be safely ignored or concomitant 

ACLR may be performed with medial UKA. 

Over the past decades the indications for UKA have been widely reported and 

debated since the classic selection criteria. 1 The purpose of this paper was to present 

a focused consensus statement updating the primary indications and contraindications 

for medial UKA. 2 

1. Kozinn SC, Scot RD. Unicondylar knee Arthroplasty: current concepts review. 

J Bone Joint Am. 1989; 71:145-150 

2. Berend KR, Berend ME, Dalury DF, Argenson JN, Dodd CA, Scott RD. 

Consensus statement on indications and contraindications for medial 

unicompartmental knee Arthroplasty. Journal of Surgical Orthopaedic 

Advances 2015;24:252-256 


ICA0R02 Patellofemoral replacement for patellofemoral arthritis 

Bas Masri 

While patellofemoral pain is a very common condition, and is commonly treated 

non-operatively, when there are degenerative changes in the patellofemoral joint, 

the success of non-operative treatment is reduced. While total knee replacement is 

accepted treatment for end-stage patellofemoral arthritis, this may be overkill for some 

patients. 

In highly motivated patients, patellofemoral arthritis can be treated with isolated 

replacement of the patellofemoral joint. 

In this session, the controversies, surgical techniques and outcomes of patellofemoral 

replacement will be explored. 

Controversies in Knee Replacement 

ICAORO3 One Stage vs Two Stage Exchange 

Professor Fares S. Haddad, BSc, MD (Res), MCh (Orth), FRCS (Orth) 

Consultant Orthopaedic Surgeon, University College London & Princess Grace 

Hospitals, 

Director, Institute of Sport, Exercise and Health, UCL, London, UK. 

The infected joint arthroplasty continues to be a very challenging problem. Its 

management remains expensive, and places an increasing burden on health care 

systems. It also leads to a long and difficult course for the patient, and frequently a 

sub optimal functional outcome. The choice of a particular treatment program will 

be influenced by a number of factors. These include the acuteness or chronicity of 

the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to 

manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the 

available bone stock; and the particular philosophy and training of the surgeon. 

68

69 

For most patients, antibiotics alone are not an acceptable method of treatment, and 

surgery is necessary. The standard of care for established infection is two stage 

revision with antibiotic loaded cement during the interval period and parental 

antibiotic therapy for six weeks. Single stage revision may have economic and 

functional advantages however. We have devised a protocol that dictates the type of 

revision to be undertaken based on host, organism and local factors. 

Our protocol has included single stage revision using antibiotic loaded cement 

in both THA and TKA. This was only undertaken when sensitive organisms were 

identified preoperatively by aspiration and appropriate antibiotics were available 

to use in cement. Patients with immunocompromise, multiple infecting organisms or 

recurrent infection were excluded. Patients with extensive bone loss that required 

allograft reconstruction or where a cementless femoral component was necessary 

were also excluded. 

Our algorithm was validated first in the hip and extended to infected TKA in 2004. 

This protocol has now been applied in over 200 TKA revisions for infection between 

2004 and 2014 that have a minimum 2 year follow-up. Our single stage revision 

rate is now over 25%. We continue to see a lower reinfection rate in these carefully 

selected patients, with high rates of infection control and satisfaction and better 

functional and quality of life scores than our two stage revision cases. 

Whilst our indications are arbitrary and not based on specific biomarkers, we present 

excellent results for selective single stage exchange. Our experience suggests that 

these patients have shorter hospital stays, higher satisfaction rates and better knee 

scores. An ongoing evaluation is in place. One stage revision arthroplasty for infection 

offers potential clinical and economic advantages in selected patients. 

1: George DA, Gant V, Haddad FS. The management of periprosthetic infections in 

the future: a review of new forms of treatment. Bone Joint J. 2015 

Sep;97-B(9):1162-9. doi: 10.1302/0301-620X.97B9.35295. Review. PubMed 

PMID: 

26330580. 

2: Parvizi J, Haddad FS. Periprosthetic joint infection: the last frontier. Bone 

Joint J. 2015 Sep;97-B(9):1157-8. doi: 10.1302/0301-620X.97B9.37018. 

PubMed PMID: 

26330578. 

3: Haddad FS, Sukeik M, Alazzawi S. Is single-stage revision according to a strict 

protocol effective in treatment of chronic knee arthroplasty infections? 

Clin Orthop Relat Res. 2015 Jan;473(1):8-14. doi: 10.1007/s11999-014-3721- 

8. 

PubMed PMID: 24923669; PubMed Central PMCID: PMC4390922. 

4: George DA, Haddad FS. Surgical management of periprosthetic joint infections: 

two-stage exchange. J Knee Surg. 2014 Aug;27(4):279-82. doi: 

10.1055/s-0034-1376881. Epub 2014 May 12. Review. PubMed PMID: 

24819519. 

5: Gulhane S, Vanhegan IS, Haddad FS. Single stage revision: regaining momentum. 

J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):120-2. doi: 

10.1302/0301-620X.94B11.30746. PubMed PMID: 23118398.

6: Vanhegan IS, Morgan-Jones R, Barrett DS, Haddad FS. Developing a strategy to 

treat established infection in total knee replacement: a review of the latest evidence 

and clinical practice. J Bone Joint Surg Br. 2012 Jul;94(7):875-81. doi: 

10.1302/0301-620X.94B7.28710. Review. PubMed PMID: 22733939. 

7: El-Husseiny M, Patel S, MacFarlane RJ, Haddad FS. Biodegradable antibiotic 

delivery systems. J Bone Joint Surg Br. 2011 Feb;93(2):151-7. doi: 

10.1302/0301-620X.93B2.24933. Review. PubMed PMID: 21282751. 

8: Ashby E, Haddad FS, O’Donnell E, Wilson AP. How will surgical site infection be 

measured to ensure “high quality care for all”? J Bone Joint Surg Br. 2010 

Sep;92(9):1294-9. doi: 10.1302/0301-620X.92B9.22401. PubMed PMID: 

20798451. 

9: Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement 

for infection after grading according to a standard protocol. J Bone Joint Surg 

Br. 2010 Sep;92(9):1222-6. doi: 10.1302/0301-620X.92B9.23663. PubMed 

PMID: 

20798438. 

10: Haddad FS, Adejuwon A. The management of infected total knee arthroplasty. 

Orthopedics. 2007 Sep;30(9):779-80. PubMed PMID: 17899936. 


ICAOR04 Trabecular metal vs. allograft in revision TKR 

Rob McLennan-Smith 

Bulk allograft has for many years been the main option for reconstructing large bony 

defects in revision TKR but has many problems including availability, incorporation 

and collapse. 

The advent of metal augments, especially the trabecular metal cones and sleeves, has 

significantly improved the ability to reconstruct these defects with excellent long term 

results. Latest studies show significantly better results with these augments compared 

to bulk allografts. 

The augments have allowed surgeons to rely more on a bony metaphyseal fixation 

with shorter stems and less cement and this results in less diaphyseal pain, stress 

sheilding and easier revision. 

They also provide a much better fixation in the metaphyseal region for the use of the 

more constrained and hinged implants which do not do well with allografts. 

The sleeves are implant specific whereas the cones can be used with various implant 

designs. 

The downside of these metal augments is the high cost and the difficulty of removal 

of a well ingrown implant in the face of infection or re- revision for whatever reason. 

HIP ARTHROSCOPY INSTRUCTIONAL COURSE (ICHAS) 

Hip Scope Basics 

ICHAS01 Labral Function our current understanding 

ICHAS02 Pincer FAI and OA Evidence How I Treat it then and now 

ICHAS03 CAM FAI and OA Evidence How I treat it then and now 

ICHAS04 Capsular function and Instability How I treat it then and now 

J. O’Donnell 

R. Field 

J. O’Donnell 

T. Andrade 

70

Advanced Hip Arthroscopy 

ICHAS05 Chondral Preservation through the scope Who and how D.Griffin 

ICHAS06 Labral reconstruction who and How 

R. Field 

ICHAS07 Lateral compartment surgery - My Approach 

F. Bataillie 

ICHAS08 The FAIT Study: an RCT looking at physiotherapy and arthroscopic hip 

surgery for the treatment of FAI 

T. Andrade 

ICHAS09 What hip arthroscopy has done for hip preservation J. O’ Donnell 

ICHAS10 First 100 years of hip arthroscopy-a global perspective. T. Andrade 

ICHAS11 Do all athletes with FAI benefit from hip arthroscopy. 

D. Griffin 

ICHAS12 The Internal Snapping Hip My approach then and now. V. Ilizaliturri 

ICHAS13 Groin Pain, making sense of it all. 

D. Griffin 

ICHAS14 Hamstring origin pathology. Presentation and Management. F. Bataillie 

ICHAS15 Assessing paediatric and young adult patients with hip pain and the role 

of Hip Arthroscopy. 

R. Buly 

SOUTH AFRICAN LIMB LENGTHENING AND RECONSTRUCTION SOCIETY 

INSTRUCTIONAL COURSE (ICLL) 

ICLL01 Approach to bone defects 

Phillip de Lange 

Abstract: Bone defects remain a challenging problem for the Orthopaedic surgeon. 

A stepwise approach can aid in determining treatment options, duration and 

prognosis. In this lecture we would try to summarise an approach to Bone defects 

looking specifically at location, size and cause of bone defects. 

ICLL02 Management of Bone Defects: Distraction Osteogenesis and Classic 

Masquelet 

Franz Birkholtz 

Abstract: The management of long bone defects remains a significant clinical 

problem with a variety of approaches being advocated. In this twenty minute talk 

we will explore two management strategies namely the Masquelet technique and 

distraction osteogenesis. We will look at some case examples and try and juxtapose 

the two strategies to try and see in which clinical cases it would be appropriate to use 

which technique. This should provide the limb reconstruction surgeon with a rational 

approach to decision-making in this challenging field of orthopaedics. 

ICLL03 Vascularized fibula graft for the management of bone defects 

Nando Ferreira 

Abstract: The treatment of skeletal defects is a challenging problem. Various treatment 

options have been proposed including bone transport, the induced membrane 

technique, limb shortening and free vascularized fibular graft. While small to medium 

defects are successfully treated by various techniques, the management of massive 

defects still remains controversial. We investigate the use of free vascularized fibular 

grafts for the treatment of skeletal defects and explore the indications, complications 

and outcomes associated with this treatment option. 

71

ICLL04 Post-infective bone defects 

Leonard Charles Marais 

The extent of the debridement of necrotic infected bone is an important consideration 

when treating patients with chronic osteomyelitis. Wider resection margins increase 

the chance of achieving remission of infection. Aggressive debridement is, however, 

frequently complicated by the creation of large bone defects. While acute shortening 

of the limb remains an option, it should be used with extreme care in the setting 

of scarred soft tissues. The use of antibiotic-impregnated PMMA spacers, as a 

customized dead space management tool, has recently grown in popularity. In 

addition to certain biological advantages, the spacer also offers a therapeutic benefit 

by serving as a vehicle for delivery of local adjuvant antibiotics. The classic Masquelet 

technique, involving cancelous bone grafting into the induced membrane, is useful 

in certain small defects with a good muscular envelope. Bone transport through the 

induced membrane is emerging as the procedure of choice for larger defects. While 

vascularized fibula bone grafting has certain drawbacks it remains an option for 

massive bone defects, particularly in the upper limb. 


ICLL05 Management of bone defects in children 

Nando Ferriera 

Abstract: Long bone defects in children due to trauma and infection present a significant 

treatment challenge. Prognosis is dependent on the quality and activity of remaining 

periosteum. Described treatment options include vascularised and non-vascularised 

free fibula graft, fibula bypass graft, the induced-membrane technique and distraction 

osteogenesis with the Ilizarov technique. There are unique considerations in the 

paediatric skeleton. We will review the literature on the management of bone defects 

after trauma and chronic osteomyelitis with case examples demonstrating the decision 

making process and complications of various methods. 

TRAUMA INSTRUCTIONAL COURSE (ICTR) 

ICTR01 Trauma care delivery debate 

Brian Bernstein 

“The delivery of orthopaedic trauma care has long been poorly prioritised in most 

countries, however, as Trauma has increased in our industrialised world we have 

been forced to evolve and many initiatives have been formulated to deal with this. 

South Africa is facing an endemic trauma problem, and finds itself in the unenviable 

position of bridging the “first world” with the “third world”. 

Our Department of Health is proposing, and currently piloting, a National Health 

Insurance plan, and we have perhaps a small window in which to influence the 

delivery of care protocols with respect to the victim of trauma. 

The UK have recently rolled out a Trauma Centre Plan, and this has long been in 

effect in the USA and to a large extent in Canada, and there is much experience to 

learn from. 

We will present the positives and the negatives of the various trauma care delivery 

systems with the aim of learning from each other’s experiences, and perhaps 

formulating an ideal proposal for our department of Health. 

Audience participation will be welcome”. 

72

ICTR02 The UK Experience 

Iain McFadyn 

The NHS has seen two massive projects in the provision of trauma care adopted 

in recent years - in hip fracture treatment and in major trauma. Both were based on 

independent national audits and supported by financial incentives. 

Regional Trauma Networks were launched across England, each centred on a Major 

Trauma Centre (MTCs). Triage criteria were used to guide which patients within 45 

minutes of an MTC should bypass other hospitals to be transported directly to the 

MTC. MTC hospitals are required to meet criteria such as an all-hours consultantled 

trauma team and rapid CT scanning capability. The project has seen changes 

to hospital case mix , workloads, clinical processes, and surgical training. Early 

indicators suggest a reduction in mortality. 

The standards in hip fracture treatment have seen a marked decrease in mortality and 

impressive lowering of costs. 

ICTR03 The USA Experience. 

L. Marsh 

ICTR04 Canadian Perspective on trauma care 

R. Leighton 

This Canadian perspective presentation on trauma care will enlighten the attendee 

as to the beginnings of the trauma system in Canada and how and why it functions 

as it does at this time (2016). It will also show some short comings to this particular 

provincially run system with its good news and bad news stories. As in many other 

countries, what works in one jurisdiction may NOT work in another BUT can usually 

plant seeds of what may work elsewhere and how to methodically make this happen 

in your environment. We all want our trauma patients to have the best of care and 

attain maximal recovery to assume their place in society. How we can predictably 

make this happen, is really the topic of the day! 

ICTR05 Choosing Residents - Advice for all 

Rick Buckley 

Every program director in an orthopedic program hopes to choose the perfect group 

of residents so that their program can become strong and develop into a good 

program. Is there a secret to this process? 

Selection of good resident candidates can be based upon some science in the field 

and sometime invested. 

Decisions need be made upon all aspects of a candidate’s portfolio with emphasis 

on the affective characteristics of a candidate and on their consistent achievements 

within their academic record. Experience for this talk is based on 25 years within a 

department of surgery educational portfolio and as an orthopedic program director 

at the University of Calgary. 

73

ICTR06 UK Multi-centre Trauma Trials 

Nigel Rossiter 

“Six years ago there were very few well conducted multi-centre randomised clinical 

trials answering fundamental clinical questions in Orthopaedic Trauma. Almost 

none of these were conducted in the UK. Since the advent of the Orthopaedic 

Trauma Society in the UK linking with the National Institute of Health Research the UK 

“Traumapods” have now completed and published three major trials - DRAFFT (distal 

radius), PROFHER (proximal humerus) and AIM (ankle fractures in the over 60s). At 

last year’s Orthopaedic Trauma Association meeting the plenary session on multi 

centre randomised trials had four out of the six papers from the UK. A further three 

studies will be reporting shortly, two other studies are on-going, five more are about 

to start recruiting and a further five are in planning. A real sea change in the attitude 

to research in UK Orthopaedic Trauma has occurred. A short summary of these trials 

will be presented.” 


ICTR07 Damage-control orthopaedics vs. early total care vs. early appropriate 

care 

Gregory J. Della Rocca, MD, PhD, FACS 

Within recent years, orthopaedic multiple-trauma patients were treated as early as 

possible with fixation of as many fractures as possible. The adage “the patient is 

too sick NOT to treat” was commonplace, but the results were suboptimal. Multiple 

research studies revealed higher rates of acute respiratory distress syndrome (ARDS), 

blood transfusion requirements, and poorer outcomes with this “early total care”. 

With improved understanding of the multiply-injured patient’s physiology, a move 

away from early total care towards “damage control orthopaedics” was instituted. 

This involved provisional stabilization of long-bone fractures with devices such as 

external fixators, and then awaiting definitive stabilization of these fractures until 

improvement in the patient’s physiology was noted. However, external fixators were 

not perfect in allowing for patient mobilization out of bed for improved pulmonary 

toilet, and occasionally patients would do poorly for many days, obviating a return 

to the operating room for definitive stabilization for many days or even weeks. The 

concept of “early appropriate care” has been advocated by some institutions. In 

such a case, patients with appropriate physiologies are treated with definitive, 

yet rapid, fixation of some major musculoskeletal injuries, followed by staged 

management of other fractures based upon how the patient’s physiology responds 

or improves. At some centers, this has resulted in expedited patient care without 

increasing complications or mortality. This discussion will focus on the evolution 

of polytrauma care and the emerging debate about early appropriate care vs. 

damage control orthopaedics. 

74

ISAKOS ORTHOPAEDIC SPORT MEDICINE INSTRUCTIONAL COURSE (ICI): 

Welcome and Announcement of MEASAKOS/How to develop World Class Sport 

Medicine Facility 

ICI01 Welcome and Information of MAKASS 

ICI02 History and Why ISAKOS relevant in 2016 

ICI03 Future of Orthopaedic Journals 

W. van der Merwe 

F. Fu 

N. van Dijk 

Whats new and what is coming in Orthopaedic Sport Medicine 

ICI04 Pittsburge experience 

F. Fu 

ICI05 ASPETAR experience 

P. Landreau 

ICI06 Australia Institute of Sport - Is there place for Orthopaedics G. Bain 

ICI07 Amsterdam 

van Dijk 

ICI08 New way to look at ACL Injury mechanism 


ICI09 Double Bundle ACL recon where we are 

F. Fu 

ICI10 Extra Articular tennodesis ALL 

P. Landrau 

ICI11 Shoulder instability in Rugby Players 

M. Ferguson 

ICI12 AC Joint Where are we now 

S. Roche 

ICI13 Approach to lateral ankle instability in the athlete 

N van Dijk 

ICI14 Syndesmosis injuries: Assessing stability and the need for arthroscopy 

G. McCollum 

Surgical Technique 

Knee: 

ICI15 PF Instabilty 

S. Erasmus 

ICI16 Meniscal Repair techniques in Prof Athlete Werner van der Merwe 

Surgical Technique: Shoulder 

ICI17 Rotator Cuff Tears: Anatomy, Function and Repairs 

G. Bain 

ICI18 Multi-center results of arthroscopic Latarjet 

P. Favorito 

Surgical Technique: Foot and Ankle 

ICI19 Arthroscopic Groove deepening and peroneal tendonoscopy N. Van Dijk 

ICI20 Hindfoot endoscopy- Indications, Techniques, tips and pearls N. Van Dijk 

KNEE INSTRUCTIONAL COURSE (ICK) 

ICK01 Biology of ACL 

B Sonnery-Cottet 

Revascularization and synovialization are known to be important for the biological 

integration and mechanical properties of the ACL graft. Histologic studies showed that 

human ACL remnants contain a cellular capacity and vascularity for healing potential. 

Evidence suggests that preservation of the ACL remnant is beneficial in terms of 

vascularity and proprioception, which may improve recovery of joint positioning and 

enhance revascularization and integration of the graft. With the goal of preserving 

the properties of the ACL remnant and the vascularity of the auto-graft, we describe an 

ACL reconstruction and preservation technique using a minimally invasive approach. 

75

The tibial attachment of the semi-tendinosus (ST) graft is kept attached to the tibia to 

prevent avascular necrosis and is passed though the ACL remnant from the tibia to 

the femur. 4 This technique is performed through standard portals without the need for 

any special equipment. 

ICK02 ACL Mechanism of injury 

ICK03 ACL repair - my technique and results 

ICK04 Biological ACL reconstruction and my results 

ICK05 (P58) The Anterolateral Ligament; an anatomical, histological and 

radiological study. 


A. De Vlieg 

H. Hobbs 

M. Hirner 

Presenter: M Hirner 

Authors: D Lees, M Hirner, E Swanton, K Scott, A Mirjalili 


Abstract title: The Anterolateral Ligament; an anatomical, histological and 

radiological study. 

Purpose of study: 

There is renewed interest in the anterolateral ligament (ALL) of the knee as a secondary 

stabiliser. Both historic and recent studies have provided descriptions of this structure. 

Yet there is little published on how to identify this ligament with modern imaging. The 

aim of this study was to dissect this structure, to establish anatomical guides that may 

aid reproducible identification on MRI scans. 

Methods: 

14 cadaver knees were dissected to identify anatomical guides for ALL identification 

on MRI. 90 knee MRI scans were subsequently reviewed by four observers, who 

were paired and blinded to each other’s findings. 

Results: 

The ALL was identified in 13 of the 14 cadaver specimens. The ALL originated 

from the lateral epicondyle in conjunction with the lateral collateral ligament before 

becoming discrete on approach to its insertion. Proximally it would not be recognised 

as discrete on MRI scans. It consistently inserted as a discrete ligament into the mid 

coronal region of the lateral tibial plateau, rather than the anterolateral region of the 

tibia. The lateral geniculate vessels passed deep to this structure. It ran on average 

14 degrees anterior to that of the lateral collateral ligament. Histology of this tissue 

showed regular dense connective tissue, consistent with a ligament. Following 

these dissection findings, 90 MRI scans (45 ACL intact and 45 ACL deficient) were 

reviewed. The ALL was identified in 96% of MRI scans, with consensus in 92% of 

findings between paired observers. 

Conclusion: 

The ALL is a discrete anatomical structure that can be identified on MRI. 


76

ICK06 The ACL and ALL 

B Sonnery-Cottet 

Lesions of the ACL and the anterolateral structures of the knee are known to induce 

rotational instability with a positive pivot shift test. There is still controversy whether the 

cause of a positive pivot shift is due to only an ACL rupture or a combined lesion to 

the ACL and anterolateral structures. 

The purpose of this study was to further define the involvement of the anterolateral 

knee structures, including the iliotibial band (ITB) and the ALL, in the internal rotational 

control of the knee. Twelve fresh-frozen, cadaveric knees were tested in internal 

rotation at 20 and 90° of flexion and pivot-shift test at 30°. A serial section of the 

ACL, ALL and ITB were performed. Measurements were collected using a surgical 

navigation system before and after each section. 

This study demonstrated that the anterolateral structures play a critical role in the 

rotational control of the knee. The ALL doesn’t work in isolation but in combination with 

the ITB and/or ACL in the rotational control of the knee. 

ICK07 The Extra-articular tenodesis - the French experience 

P. Landreau 

ICK08 My ALL reconstruction technique and results 

Dr M Barrow 

Our Techniques and Results of an Anterolateral Ligament Reconstruction 

Doctor Michael S. Barrow 

ABSTRACT 

Background: The Anterolateral Ligament has recently been identified as an important 

ligament in controlling rotational laxity of the knee. 

Purpose: To report our technique and outcome of a combined Anterior Cruciate 

Ligament (ACL) and Anterolateral Ligament reconstruction (ALL). 

Method: Our indications for doing an Anterolateral Ligament reconstruction are: 

(1) revision ACL reconstruction, (2) ligamentous hyperlaxity, and (3) chronic ACL 

instability with a grade three pivot. A total of 17 patients were enrolled in this study. 

All patients underwent an ACL reconstruction, or revision ACL reconstruction, as well 

as an Anterolateral Ligament reconstruction. A gracilis graft was used in 9 cases, and 

synthetic fibre tape was used in 8 cases to reconstruct the Anterolateral Ligament. 

Results: The mean follow up was 13 months. The Lysholm scores, and subjective and 

objective IKDC scores were all improved. Pre-op 4 patients had a grade one pivot 

shift, 5 had a grade two pivot shift, and 8 had a grade three pivot shift. Post-op 15 

had negative pivot shifts and 2 had a grade one pivot shift. 

Conclusion: This study shows that adding an Anterolateral Ligament reconstruction 

to an Anterior Cruciate Ligament reconstruction is a safe and effective procedure to 

control rotational stability. 

ICK09 All Facts and Fiction 

F. Fu 

77

Satisfaction in Total Knee Arthroplasty 

ICK10 (P355) 

The Orthopaedic Quality Score 

Presenter: J Waddell 

Authors: J.P. Waddell, E. Hellsten, R. McGlasson, K. Doresco 


Abstract title: The Orthopaedic Quality Score 

Purpose: 

To evaluate the effect of the orthopaedic quality scorecard on total joint replacement 

performance in a provincial model. 

Methods & Materials: 

MOHLTC of Ontario mandated the development of a standardized model of care for 

total joint replacement (hip and knee). Health Quality Ontario developed a consensus 

derived handbook for total knee replacement and total hip replacement focused on 

pre-operative assessment, in-hospital care and post-operative rehabilitation setting 

goals for wait times, length of stay, discharge disposition, re-admission rates and 

revision rates. Hospital performance is continually measured and reported quarterly. 

Results: 

WTIS reports quarterly on wait times and surgical volumes; MOHLTC reports on 

length of stay, discharge disposition, revision rates and re-admissions. 

The wait times remain constant although volume has increased 2% a year since the 

implementation of the scorecard. Discharge disposition has changed dramatically 

with over 90% of patients being discharged directly home avoiding inpatient rehab. 

Length of stay has fallen on average from 6.2 days to 3.8 days. Re-admission rates 

remain below target at under 3% and one year revision rates remain at or just above 

target at 1%. 

Conclusion: 

The use of an orthopaedic quality scorecard promotes practice change in the context 

of improved patient care and optimized resource utilization. 


ICK 11 (P264) A patient’s perception of their hospital stay influences the functional 

outcome and satisfaction of total knee replacement 

Presenter: C Howie 

Authors: ND Clement, D MacDonald, R Burnett, AHRW Simpson, CR Howie 


Abstract title: A patient’s perception of their hospital stay influences the functional 

outcome and satisfaction of total knee replacement 

This study assessed whether patient satisfaction with their hospital stay influences the 

early outcome of total knee replacement (TKR). 

During a five year period patients TKR at the study centre had prospectively outcome 

data recorded (n=2264). Patients with depression (p=0.04) and worse mental 

wellbeing (p

knee (OKS) (p

arthroplasty with a Brainlab system. Deformity as well as passive range of motion was 

captured before and after release of the posterior cruciate ligament. 

Findings: 6 out of 10 valgus knees were passively correctable before PCL release 

and this improved to 8 out of 

10 knees after PCL release. 13 varus knees out of 17 varus knees improved to 17 of 

17 knees after PCL release. The gain in extension ranged from 0,5 to 7,5º ( average 

4º ) and gain in flexion ranged from 0 to 10º ( average 5º ) 

Conclusion: PCL release improved the ability to passively correct deformity in 50% of 

uncorrectable valgus knees and 

100% of uncorrectable varus knees. PCL release also increased extension and 

surprisingly also increased flexion. 


ICK16 (P150) Knee OUTcome study: a comparison of outcomes between 

Osteotomy, UKA, TKA for medial compartment osteoarthritis in males under 55 

years. 

Presenter: R Maxwell 

Authors: A R Maxwell, A Johnston 

Disclosure: Yes: Institutional research funding from Zimmer Biomet Author is 

Consultant for ZimmerBiomet 

Abstract title: Knee OUTcome study: a comparison of outcomes between Osteotomy, 

UKA, TKA for medial compartment osteoarthritis in males under 55 years. 

Introduction 

Managing medial compartment osteoarthritis (OA) in the younger male patient 

is challenging because these patients tend to be physically high demand. 

Traditionally, High Tibial Osteotomy (HTO) has been the favoured surgical option, 

but Unicompartmental (UKA) and Total (TKA) knee replacements have been more 

recently utilized. Our aim was to compare patient satisfaction with these treatments 

and establish a revision and reoperation comparison. 

Method 

Using our hospital data bases we retrieved the names of male patients under 55 

years who had one of the three procedures performed between 2005-2013, for 

medial compartment OA. The TKA group had all patients who did not meet the 

criteria for HTO/UKA excluded. These patients then had their satisfaction assessed 

retrospectively using the Forgotten Joint Score (FJS), information on occupation, 

reoperation, and duration of satisfaction were also questioned. Hospital records and 

Registry data were reviewed for the reoperation and revision rate on all of the patients 

identified. 

Results 

We identified 117 TKA in patients under 55, 33 TKA which met our criteria, 73 

HTO’s (all MOW) and 97 UKA’s (all Cementless Oxford). Of the HTO group, 4 were 

revised early for nonunion, and 9 have been converted to TKA and one to UKA. Of 

the UKA, 4 have had revision surgery. None of the TKA group have been revised to 

date. 

80

FJS results show statistically significant differences between HTO and TKA (p=0.05), 

between TKA and UKA (p=0.005), and highly significant difference between HTO 

and UKA (p=0.0001) favouring UKA. 

From a survivorship point of view, the UKA group were 69% less likely to require 

revision than the HTO group (p=0.046) 

Conclusion 

These early results favour the use of UKA over HTO in this group of patients, for both 

patient reported outcome and survival. UKA is also favoured over TKA for patient 

reported outcome. However, it is early to give a definitive answer with respect to 

survivorship and we intend to repeat the study in a further 5 years. 

ICL01 Current State of DVT Prophylaxis in Total Joint Replacement 

Robert D’Ambrosia 

The current state of DVT Prophylaxis has been in constant flux over the past few 

decades with the American College of Chest Physicians (ACCP) advocating for 

treating all asymptomatic Deep Vein Thrombosis which has been at odds with 

the American Academy of Orthopedic Surgeons (AAOS) who have emphasized 

treating symptomatic DVT’s. Prevention of symptomatic DVT’s is a balancing act 

between safety and efficacy. The variables associated with a higher incidence of 

Pulmonary Emboli are weighed against the various agents currently available and 

what patient risk factors are most important for predictors of a serious event. Taking 

the ACCP and the AAOS recommendations into consideration the best prophylaxis 

for the prevention of systematic DVTs and subsequent Pulmonary Embolus is 

summarized. Emphasis is put on the fact that Venous Thromboembolisms is not a 

never event despite the current state of the art prophylaxis. 

SHOULDER AND ELBOW INSTRUCTIONAL COURSE (ICSE) 

Approach to Shoulder Instability 

ICSE01 Anterior Instability - Soft Tissue. 

ICSE02 Anterior Instability - Bone Deficiency. 

ICSE03 Capsular injuries HAGL and GLAD lesions 

ICSE04 Posterior Intability. 

ICSE05 Approach to the Fist Time Dislocator 

Trauma around the Shoulder: 

ICSE06 Acromioclavicular Joint Instability. 

ICSE07 The Floating Shoulder - ring injuries 

ICSE08 Clavicle Fractures. 

ICSE09 Major Neurovascular Complications after Clavicle Fractures 

P. Hardy 

J. de Beer 

M. Ferguson 

S. Osman 

G. Greeff 

P. Favorito 

P. Hardy 

C. Breckon 

G. Bain 

81

ICSE10 (P182) Deltoid Exposure for Fractures. 

Presenter: K Cutbush 

Authors: K Cutbush, L Anderson, K M Hirpara 


Abstract title: Fracture Deltoid Reflection for Exposure of the Proximal Humerus 

Purpose of study: Different techniques have been described for surgical exposure of 

the shoulder and proximal humerus. The neurovascular and muscular anatomy impedes 

the use of a truly safe fully extensile approach. The deltopectoral approach continues 

to be the most widely used. Methods of extending the deltopectoral approach have 

been reported, namely the use of either an acromion or clavicle osteotomy. Nonunion 

rates of such osteotomies have been described in the literature and we had three 

cases of such, one of which was symptomatic. As a result, the senior author changed 

his personal practice from a clavicle osteotomy for extensile exposure of the shoulder 

to utilising a deltoid reflection technique, as described by Charles Neer (JBJS, 1970). 


Description of methods: A single surgeon performed twenty-four extensile approaches 

to the proximal humerus and shoulder joint with anterior deltoid reflection off the 

clavicle between January 2011 and September 2014. Retrospective review of 

patient’s charts was conducted to confirm the surgical procedure and identify any 

complications. Patients were contacted for follow-up with specific reference to scar 

and deltoid contour. 

Summary of results: There were no complications for the anterior deltoid reflection off 

the clavicle as an extensile approach to the proximal humerus and shoulder joint. We 

report three nonunions from clavicle osteotomies during that same time period. 

Conclusion: Charles Neer described his approach to the proximal humerus in his 

landmark paper “Displaced Proximal Humerus Fractures” (part II 1970 JBJS). In this 

paper he described approaching proximal humeral fractures with a reflection of the 

anterior 7.6cm of the deltoid from the clavicle. This approach has been used by 

the senior author to increase the exposure available in a deltopectoral approach 

for internal fixation of proximal humeral fractures and difficult joint replacement 

surgery. The deltoid reflection used by the senior author has varied from a reflection 

of the clavicular attachment to a complete deltoid detachment for a case of humeral 

nonunion. No complications were identified in this retrospective review of twenty-four 

cases. The technique is presented for discussion. 

ICSE11 Proximal Humeral Fractures and Osteoporosis 

P. Webster 

Soft tissue injuries of the elbow 

ICSE12 Approach to Elbow Instability. 

ICSE13 Management of Elbow Dislocations. 

ICSE14 Complex Elbow Instability 

ICSE15 Tennis Elbow Syndrome. 

ICSE16 Sport Related Injuries of the Biceps and Triceps. 

A. Smit 

B. Vrettos 

G. Bain 

D. Kastanos 

G. Bain 

82

Adolescent hyper-use injuries of the shoulder 

ICSE17 Sports Injuries - The Physician’s Approach. 

J. Suter 

ICSE18 Apohyseal injuries in Adolescents. 

S. Dix-Peek 

ICSE19 Overhead Injuries in Young Athletes. 

S. Roche 

ICSE20 Approach to instability with open physes. 

P. Hardy 

ICSE21 Hyper-use injuries in Adolescents 

P.Favorito 

ICSE22 The STOP programme 

P. Webster 

New Concepts in Shoulder Surgery 

ICSE23 Arthroscopic assessment of IGHL in stable versus unstable shoulders: 

A prospective controlled study 

S. Desai 

ICSE24 Arthroscopy findings, classification and results of arthroscopic Bankart repair 

in 400 cases of recurrent anterior dislocation of shoulder 

S. Desai 

ICSE25 (P404) Short term outcome following arthroscopic capsular release for 

adhesive capsulitis 

S.Osman 

SR Baba 

SA Osman 

Abstract 

1. Purpose 

The purpose of the study was to investigate the efficacy of arthroscopic capsular release in 

the management of pain in patients with adhesive capsulitis. 

2. Methods 

Circumferential arthroscopic capsular release was performed by a single surgeon on 29 

patients (33 

shoulders) with painful adhesive capsulitis over a one year period. Patient reported pain 

scores and 

range of movement(ROM) were documented pre-op, 2 week and 6 week follow up. 

3. Results 

79% of patients presented with idiopathic adhesive capsulitis with the mean time to 

surgery from first presentation was 133 days(3-339). Subacromial decompression 

and acromioplasty was simultaneously performed on 51.5% of patients and 2 

patients also had a lateral clavicle excision procedure performed. 

All 29 patients had pre-op pain with a mean VAS of 6. At 2 week follow-up only 

7(21.2%) of patients still had pain (78.2% no pain), and at 6 weeks 8(24.2%) of 

patients experienced pain (2 patients whom were pain free at 2 weeks developed 

pain and one patient with pain at 2 weeks resolved at 6 weeks). 

ROM improved from pre-op levels: flexion 75* to 84*, abduction 56* to 66*, 

and external rotation 15* to18*. No further significant improvement was noted 

at the 6 week follow up. No complication were reported viz instability, infection, 

axillary nerve injury. 

83

4. Conclusion 

Circumferential arthroscopic capsular release is a safe and effective procedure 

for the short term management of pain in adhesive capsulitis. Though the range of 

motion did not significantly improve in the short term, there was no further limitation 

in ROM as a result of the surgery. 

5. Level of study 

Retrospective case series, Level IV 

ICSE26 Kinematric and Radiographic Analysis of a Synthetic Ligament for AC 

reconstruction C. Roth 

ICSE27 (P105) Glenohumeral Internal Rotation Deficits in the Overhead Collegiate- 

Level Athlete can be Reliably Detected through Measurement of Glenohumeral 

Rotation and Horizontal Adduction Range of Motion. 

Presenter: D Sheps 

Authors: J. Chepeha, D. Magee, D.M. Sheps, L. Beaupre 



Abstract title: Glenohumeral Internal Rotation Deficits in the Overhead Collegiate- 

Level Athlete can be Reliably Detected Through Measurement of Glenohumeral 

Rotation and Horizontal Adduction Range of Motion. 

Background: 

Alterations in glenohumeral range of motion have been linked to shoulder pathologies, 

particularly in the overhead athlete. Knowing which shoulder motions can be reliably 

measured, and are clinically meaningful for specific patient populations, could 

provide clinicians with a frame of reference for monitoring and preventing shoulder 

pathology. The purpose of this study is to determine if glenohumeral rotation and 

horizontal adduction range of motion can be reliably measured and used to distinguish 

clinically meaningful differences in shoulder motion between overhead athletes and 

students not involved in overhead activities. 

Methods: 

Phase I - Standard goniometric assessments of glenohumeral rotation and horizontal 

adduction were conducted on 30 men and women (16-55 years). Two physical 

therapists performed blinded assessments to determine the intraclass correlation 

coefficient, standard error of measurement, and minimal detectable change values 

for intra- and inter-rater shoulder range of motion. Phase II - Glenohumeral rotation and 

horizontal adduction range of motion values were compared between 66 overhead 

athletes in volleyball, swimming and tennis and 30 students not involved in overhead 

activities. Independent t-tests determined whether range of motion differences were 

statistically significant and clinically important, based on Phase I’s findings. 

84

Results: 

Minimal detectable change values were less than or equal to 12° for all glenohumeral 

motions measured within and between therapists. All motions were statistically different 

between overhead athletes and students; the greatest difference being internal rotation 

(p=

Conclusion: Arthroscopic Latarjet provides a safe and effective alternative technique 

to stabilise patients with high-grade instability. With modification to the initial exposure 

concomitant labral repair may be routinely performed. 

ICSE30 (P361) Performance of preknotted suture vs 3 conventional sutures 

Presenter: P Favorito 

Authors: Favorito, P.J., Rodes, S.R., Piccirillo, J.P., Spivey, J.T. 

Disclosure: Yes: I am a concultant for DePuy and Mitek Sports Medicine. I received 

no funding for this presentation or preparation of the manuscript 

Abstract title: Performance Comparison of a Pre-Tied Suture Knot to Three 

Conventional Arthroscopic Knots 

Purpose: To compare the knot characteristics of a pre-tied suture knot to three of the 

most commonly utilized arthroscopic knots tied with various high-strength sutures 


Methods: Three commonly used arthroscopic knots (Surgeon’s knot, SMC, and 

Duncan loop) tied with #2 high strength sutures were compared to a pre-tied knot 

secured with either 1, 2 or 3 reversed half hitches (RHAPS). An orthopaedic sports 

medicine surgeon and fellow tied a total of 120 knots. All knot combinations were 

tested for strength, knot bulk, cyclic loop elongation, ultimate loop elongation, and 

ultimate strength. 

Results: All pre-tied configurations had statistically significant improved strength 

(p=0.048, p=

TUMOURS AND INFECTION INSTRUCTIONAL COURSE (ICTU) 

New concepts in genetics and novel treatment in bone tumours 

ICTU01 Advances in Sarcoma Treatment “From machines to molecules”. P. Choong 

ICTU02 Minimal invasis cryotherapy in bone tumours, 

B. Lindeque 

ICTU03 Genetics in osteosarcoma metastasis and implications in treatment H. Luu 

ICTU04 Targeted therapy for primary osteosarcoma: Implications for 

chemoprevention and maintenance treatment 

R. Haydon 

ICTU05 “Extreme Orthopaedics” - Oncology solutions to bone loss. K. Hosking 

ICTU06 Innovations in limb sparing surgery. 

K. Hosking 

ICTU07 Non invasive lengthening endoprosthetic replacement/joint sparing 

endoprosthetic replacement 

W. Aston 

ICTU08 Navigation in Tumour resection 

L. Jeys 

Metastatic bone disease 

ICTU09 Metastatic lesions of the proximal femur. 

L. Marais 

ICTU10 Renal carcinoma metastasis. 

B. Lindeque 

ICTU11 Management of metastatic disease - tips for the general orthopaedic 

surgeon. 

T. Peabody 

ICTU12 Metastatic pathological fracture - New biomechanical superior fixation to 

allow early weight bearing and early mobility. 

R. Leighton 

ICTU13 Prophylcatic fixation - when and why? 

R. Leighton 

ICTU14 My approach to soft tissue sarcomas 

L. Jeys 

87

NOTES 


88

89 

NOTES

FREE PAPERS 

All Abstracts that were submitted have been published as they were received. Typing or other errors made 

by the authors are not corrected. Abstracts that were not submitted to the Organisers are not included. 

Paper 1 

Presenter: P Walmsley 

Authors: J Maempel, N Clement, A Ballantyne, I Brenkel, P Walmsley 


Abstract title: Range of movement correlates with the Oxford knee score after 

total knee replacement: a prediction model and validation. 

Purpose: Patient reported outcome measures are widely used in the evaluation of 

outcomes after Total Knee Replacement (TKR) in joint registries and large studies. The 

aim of this study was to assess the relationship between the Oxford knee score (OKS) 

and range of motion (ROM) after TKR, and to construct and validate a prediction 

model of ROM from the measured OKS. 

Methods: We analysed 808 patients with complete followup data from our institutional 

database, which included OKS and ROM, 5 years after their TKR. Mulrivairiate 

analysis was undertaken to determine predictors of ROM and derive formulae to 

estimate ROM. These formulae were then validated on a group of patients 9 to 10 

years after their TKR by calculating the estimated ROM from their OKS. The estimated 

ROM was compared to clinically measured ROM 9 to 10 years postoperatively and 

Bland Altmann plots and intraclass correlation coefficients used to assess the validity 

of the prediction models. 

FREE PAPERS 

Results: Multivariate linear regression analysis demonstrated a significant correlation 

between the 

OKS and ROM (r=0.38, p

Paper 2 

Presenter: P Walmsley 

Authors: Maempel J, Wickramasinghe N, Clement N, Dunstan E, Brenkel I, 

Walmsley P 


Abstract title: Preoperative Haemoglobin Concentration can be used to predict a 

reduced risk of allogenic blood transfusion after TKR 

Purpose: Preoperative haemoglobin concentration is the strongest predictor of 

perioperative blood transfusion after total knee replacement (TKR), yet there are no 

studies reporting a concentration that should be targeted preoperatively. The study 

aims to identify a preoperative threshold haemoglobin concentration that would identify 

patients at risk of blood transfusion when undergoing TKR. Our secondary aim was 

to describe the post-operative complications associated with blood transfusion after 

TKR in our institution. 

Methods: Receiver operator characteristic (ROC) curve analysis of 2287 consecutive 

patients undergoing unilateral TKR was used to determine gender specific threshold 

concentrations predicting perioperative blood transfusion with the highest combined 

sensitivity and specificity. 

Results: The area under ROC curve was 0.78 for males; 0.76 for females, indicating 

that use of preoperative haemoglobin alone is effective in predicting transfusion 

risk. Threshold concentrations of 13.85g/dl for males and 12.75g/dl for females 

were identified. Transfusion rates (in males and females respectively) above these 

concentrations were 3.4% and 7.0% while below the thresholds, they were 14.9% 

and 25.7%. Blood transfusion was associated with increased incidence of early 

postoperative confusion (odds ratio (OR) 3.59), cardiac arrhythmia (OR 6.15), 

urinary catheterisation (OR 1.61), one year deep prosthetic infection (OR 4.19) and 

increased length of stay (8 days versus 6, p

Updated - Background and purpose: Total knee replacement (TKR) is being increasingly 

performed in elderly patients, yet there is little information on specific requirements 

and complication rates encountered by this group. We assessed whether elderly 

patients undergoing TKR had different length of stay, requirements, complication rates, 

and functional outcomes compared to younger counterparts. 

Patients and methods: We analyzed prospectively gathered data on 3,144 

consecutive primary TKRs (in 2,092 patients aged less than 75 years, 694 patients 

aged between 75 and 80 years, and 358 patients aged over 80 years at the time 

of surgery). 

Results: Incidence of blood transfusion, urinary catheterization, postoperative confusion, 

cardiac arrhythmia, and 1-year mortality increased with age, even after adjusting for 

confounding factors, whereas the incidences of chest infection and mortality at 1 

month were highest in those aged 75–80. Rates of thromboembolism, prosthetic 

infection, and revision were similar in the 3 age groups. All groups showed similar 

substantial improvements 

in American Knee Society (AKS) knee scores, which were maintained at 5 years. 

Older patients had smaller improvements in AKS function score, which deteriorated 

between 3 and 5 years postoperatively, in contrast to the younger group. 

Conclusions: Elderly people stand to gain considerably from TKR, particularly in 

terms of pain relief, and they should not be denied surgery based solely on age. 

However, they should be warned that they can expect a longer length of stay, a 

higher requirement for blood transfusion and/or urinary catheterization, and more 

medical complications postoperatively. Mortality was also higher in the older age 

groups. The risks have been quantified to assist in perioperative counselling, informed 

consent, and healthcare planning. 

Paper 6 

Presenter: N Kruger 

Authors: N Kruger, E McNally, S Al-Ali, R Rout, JL Rees, AJ Price. 


FREE PAPERS 

Abstract title: 3D Reconstructed magnetic resonance scans: Accuracy in identifying 

and defining knee meniscal tears 

Purpose 

Knee meniscal tears occur in multiple configurations. Conventionally, radiologists 

use preoperative MRI to describe their site, morphology and plane of rupture. 

This information aids clinical understanding and affects patient management. 3D 

Reconstruction presents this MRI data in a visiospatially simple format, simplifying 

pathological identification and description. The aim was to determine whether 3D 

reconstruction from conventional MRI was able to define the meniscal tear presence 

and configuration. 

92

Materials and methods 

33 patients’ 3T MRI scan data were collected and sagittal uni-planar 3D reconstructions 

performed. There were 24 meniscal tears in 24 patients, and nine controls. All 

patients had arthroscopic corroboration of MRI findings. Two independent observers 

prospectively reported on all 33 reconstructions. Meniscal tear presence or absence 

was noted, and tear configuration subsequently categorised as either radial, buckethandle, 

parrot beak, horizontal or complex. 

Results 

Identification of control menisci or meniscal tear presence was excellent (Accuracy: 

observer 1 = 90.9%; observer 2 = 81.8%). Of the tear configurations, bucket handle 

tears were accurately identified (Accuracy observer 1 and 2 = 80%). The remaining 

tear configurations were not accurately discernable. 

Conclusion 

Uni-planar 3D reconstruction from 3T MRI knee scan sequences are useful in identifying 

normal menisci and menisci with bucket-handle tears. Advances in MRI sequencing 

and reconstruction software are awaited for accurate identification of the remaining 

meniscal tear configurations. 

Paper 8 

Presenter: O laurent 

Authors: L Obert, V Morris, A Tchurukdichian, F Loisel, I Pluvy, D Cheval, F 

Gindraux, N Zwentienga 


Abstract title: induced membrane technique (masquelet technique) to treat bone 

defect at hand level proscpective multicenter evaluation 

Introduction: 26 cases of bone defect have been treated by the induced membrane 

technique avoiding allograft, microsurgery and amputation 

Methods: 23 patients (mean age 51,7 – 85% of male- 65% of work accident) with 26 

cases of bone defect at the hand have been included in this multicentric prospective 

evaluation (3 centers). 19 cases were traumatic, and 7 cases were septic. Size of 

bone defect reached at least “one phalanx” with an average of 2cm (0,5-7). 38% of 

injury were extra articular. All cases were treated by the induced membrane technique 

which consists in stable fixation, flap if necessary and in filling the void created by 

the bone defect by a cement spacer (PMMA). This technique needs a second stage 

procedure (3,7 months (1-14) after the 1rst stage) where the cement is removed and 

the void is filled by cancellous bone (from distal radius in 22/26 cases). The key 

point of this induced membrane technique is to respect the foreign body membane 

which appeared around the cement spacer and which create a biologic chamber 

93

after the second time. Bone union was evaluated prospectively in each case by an 

surgeon not involved in the treatment by Xray and CT scan if necessary. Failure was 

defined as a non union at 1 year, or an uncontrolled sepsis at 1 month. 

Results: 2 cases of bone defect failed to achieve bone union. No septic complications 

occured and all septic cases werre stopped. Bone union was achieved with a delay 

of 5 months (1-14) in 92% of cases. 2 biopsies allowed to proove us that osteoid 

tissue was created by the technic. TAM of injuried fingesr reached 114 (20-250), 

Quick dash 19 (4-40), return to work was effective in 6 months (1-24), all fingers 

have were included. 

Conclusion Masquelet first reported 35 cases of large bone defect of tibia non 

union treated by the induced membrane technic which allow to fill bone defect with 

cancellous bone alone. The cement spacer allows to induce a foreign body membrane 

(neo periosteum) which constitute a biological chamber. Works on animal model 

reported by Pellissier and Viatteau showed the properties of the membrane: secretion 

of growths factors (VEGF, TGFbéta1, BMP2) and osteoinductive activitie of the cells. 

Using this technic is possible in emergency or in septic condition where bone defect 

can not been solved by shortening. This technic avoids to use microsurgical technic 

and the limit is the quantity of avalaible cancellous bone. 

Using induced membrane technique is possible in emergency or in septic condition 

where bone defect can not been solved by shortening. This technic allow an early 

mobilisation depending on associated injuries and avoids to use microsurgical technic 

to achieve bone union. 

Paper 9 

Presenter: Radu Moldovan 

Authors: Hughes A, Heidari N, Livingstone J, Jackson M, Atkins R, Monsell F 


FREE PAPERS 

Abstract title: Computerised Hexapod Assisted Femoral Deformity Correction, The 

Bristol Experience 

Updated - Computer Hexapod Assisted Orthopaedic (CHAOS) Surgery is a surgical 

technique incorporating a Taylor Spatial Frame intraoperatively to correct complex 

femoral deformities before definitive fixation with minimally invasive stabilization 

techniques. All patients who underwent a CHAOS procedure for femoral deformity at 

our institution between 2005 and 2011 were retrospectively reviewed. The purpose 

of the study was to determine the accuracy of deformity correction, assess the safety 

of the procedure and to define patients that may be suitable for this procedure. 

The clinical and radiographic records were available for 55 consecutive procedures 

undertaken in 49 patients. The mean age at surgery was 40.1 years (Range 15 – 78 

years) and patients were assessed at a mean interval of 44 months following surgery 

(range 6 to 90 months). The most common indications were vitamin D resistant rickets 

94

(VDRR), growth plate arrest and post-traumatic deformity. Multi-planar correction was 

required in 30 cases and was achieved at a single level in 43 cases. Locking plates 

used to stabilize the osteotomy in 33 cases and intramedullary nails in the remainder. 

Additional procedures were required on the ipsilateral limb in 29 patients; 20 for 

tibial deformity correction, 4 knee replacements, 4 trochloeplasties and 1 femoral 

lengthening. Complications included two non-unions, which have subsequently 

united with further intervention, one death, one below knee DVT and one revision 

CHAOS procedure due to initial under correction. There were no neurovascular 

injuries or compartment syndromes. 

This series demonstrates that precise intraoperative realignment is possible with an 

external fixator prior to definitive stabilization with contemporary internal fixation and 

this combination allows satisfactory correction of complex femoral deformity. 

Paper 10 

Presenter: J de Beer 

Authors: J. de Beer, M. Winemaker, D. Petruccelli, D. Harris, D. Mertz 


Abstract title: Prosthetic Joint Infections: Patterns of Practice for Diagnosis, 

Management and Outcome 

Purpose 

Current data demonstrate an overall prosthetic joint infection (PJI) incidence of 1.4% 

(1.6% hip, 1.2% knee). Although these rates are low, the absolute number is significant 

and continues to grow with the increased number of total joint replacements (TJR) 

being performed. The relative lack of well accepted guidelines in the field may result 

in inconsistent approaches in how PJI is diagnosed and managed. 

Method 

A retrospective cohort study of a consecutive series of hip and knee arthroplasty 

patients diagnosed with subsequent deep or organ/space PJI (NHSN/CDC criteria) 

at one tertiary care arthroplasty centre over a 5 year period was conducted to 

determine diagnostic strategies, infecting organism, clinical management strategies, 

and outcomes. 

Results 

Of 8,505 hip and knee arthroplasty cases completed over the study period, 288 

(3.4%) were diagnosed with subsequent PJI including 63 (0.7%) deep infections. Of 

deep PJIs, 22 (35%; PJI rate of 0.2%) were knees and 41 (65%; PJI rate of 0.5%) 

hips, with 67% occurring after primary TJR. Infectious diseases (ID) was involved 

in 47 deep PJI cases (57%). S. aureus or coagulase-negative staphylococcus were 

the infecting organisms in 82% of deep PJI knees and 78% of hips. Preoperative or 

intraoperative deep specimen for culture was obtained in 24/63 (38.1%) patients. 

With inclusion of joint aspirates, cultures were obtained in 58/63 (92.1%) patients. 

Nine patients (14.3%) underwent bone scan. Cefazolin was the first line antibiotic 

in 52% of patients (33/63), followed by ciprofloxacin (17.5%, 13/63) and oral 

cephalexin (12.7%, 8/63). 

95

Fifty-two patients (83%) underwent revision surgery (20 knees, 32 hips). Hereof, 28 

(54%) patients underwent irrigation and debridement (I&D) with/out liner exchange, 

17 (33%) underwent one stage revision, and 7 (14%) two stage revision. Median 

antibiotic duration was 65 das (IQR 44-106) for knees and 65 (IQR 43-155) for hips, 

and 70 (IQR 43-170) for I&D, 65 (IQR 42-139) for one stage and 52 (IQR 44-82) 

days for two stage revision. Despite large variance, we could not demonstrate any 

statistical differences in terms of antibiotic treatment duration, duration by treatment 

route, or total PJI time to clearance by joint or infecting organism. 

Conclusion 

We found significant variability in how PJI were diagnosed and managed, which likely 

reflects the relative lack of a gold standard approach for this type of recommendation 

and the large number of health care providers involved. Furthermore, the highly 

individualized nature of each PJI case presents with a unique set of circumstances. 

While variability could be reduced by treatment guidelines it also limits the uniform 

application of such guidelines for each case. 

Paper 13 

Presenter: C Wilson 

Authors: Shunmugam M, Bowman A, Krishnan J & WILSON CJ 


Abstract title: Long Leg Radiographs vs CT Perth protocol: Mechanical alignment 

analysis 

Introduction 

There are many modalities of alignment assessment, however long-leg radiographs 

(LLRs) have a long track record of use. In the centre conducting this study, the CT 

Perth protocol is standard practice and thus an ideal setting for comparison between 

LLRs and CT Perth for predicting mechanical alignment. The CT Perth protocol has 

a radiation dose of 1mSV, compared to 0.7mSV for LLRs, however provides more 

information on rotation. The aim of this study was to determine comparability of 

alignment using CT Perth and LLRs. 

Method 

120 patients were included who all received a Vanguard TKR in the same centre. 

All patients received LLRs and CT Perth pre- and post-operatively. The LLRs were 

standadised following an established protocol for each patient in order to reduce 

any rotational or human error and mechanical alignment was measured by a single 

Orthopaedic Surgeon. The CT Perth protocol was reported by a single Consultant 

Radiologist. For the purpose of this study only the coronal mechanical alignment was 

utilised. 

Results 

Intra-class correlation coefficient (ICC) was calculated pre- and post-operatively to 

assess comparability between the 2 imaging modalities. A Bland-Altmann plot was 

also created to identify the trends and any specific outliers. 

Pre-operatively, the ICC was 0.8, with the average difference in measurements being 

1.9 degrees. 

Post-operatively, the ICC was 0.7, the average difference being 1.6 degrees. 

FREE PAPERS 

96

Conclusion 

This study found good correlation in alignment between CT Perth and weight-bearing 

LLR pre- and post-operatively. This conclusion validates that current practice, where 

patients are assess by numerous different surgeons of differing levels of experience in 

the outpatient clinic setting, is adequate for review of long-leg alignment in patients. 

Paper 14 

Presenter: DK Jan Philippe 

Authors: Kretzer JP, Reinders J, Mueller U 


Abstract title: Wear performance of two PMMA knee spacers. 

Temporary use of antibiotic-impregnated polymethylmethacrylate (PMMA) bone 

cement spacers in two-stage revisions is considered to be standard of care for patients 

with a chronic infection of a joint replacement. Spacers should be wear resistant 

and load-bearing to avoid prolonged immobilisation of the patient and to reduce 

morbidity. Most cement spacers contain barium sulphate or zirconium dioxide as 

radio-opaque substrate. Both are quite hard materials that may negatively influence the 

wear behaviour of the spacer. Calcium carbonate is another radio-opaque substrate 

with lower hardness potentially increasing the wear resistance of the spacer materials. 

The purpose of the study was to compare a prototype PMMA knee spacer (calcium 

carbonate loaded) with a commercially available spacer (containing barium sulphate) 

regarding the wear performance and particle release in a knee wear simulator. 

Spacer K (TECRES, Italy) was used as barium sulphate (10%) containing spacer 

material. A prototype material (Heraeaus Medical, Germany) with 15% calcium 

carbonate was compared. Both were gentamicin impregnated, ready-made for 

clinical application (preformed) and consist of a tibial and a femoral component. 

Force-controlled simulation was carried out on an AMTI knee simulator. The test 

parameters were in accordance to ISO 14243-1 with a 50% reduced axial force 

(partial weight bearing). Tests were run for 500,000 cycles at a frequency of 1 Hz. 

For wear analysis, gravimetric wear measurements according to ISO 14243-2 and 

wear particle analysis according to ASTM F1877 – 05 were performed. 

For the Spacer K cement a mean articular wear mass of 375.53 ± 161.22 mg was 

determined after 500.000 cycles. The prototype cement showed lower mean total 

wear of 136.32 ± 37.58 mg However, a statistically significant lower wear rate was 

only seen for the femoral components (p=0,027). Isolated PMMA wear particles of 

Spacer K cement had a diameter of 0.429 ± 0.224 µm and were significantly larger 

as compared to the prototype cement (0.380 ± 0.216 µm, p=0.02) 

The prototype material showed better wear performance in terms of gravimetric wear 

and particle release. Thus calcium carbonate seems to be a promising material as 

radio-opaque substrate in PMMA spacers. Nevertheless, the wear amount released 

97

from both spacer materials is much higher as compared to conventional total knee 

replacements with polyethylene inserts. In this context biological reactions against 

PMMA particles and an increased release of cytokines have been reported in vitro 

[Shardlow et al., 2003] and furthermore, the promotion of osteolysis has been shown 

in vivo in the presence of PMMA particles [Wimhurst et al., 2001]. 

As a clinical consequence we suggest excessive debridement during removal of the 

cement spacer components to reduce the risk of third body wear for the final joint 

replacement. 

Beside the wear performance further studies are essential to prove the mechanical 

stability and the antibiotic release kinetics for the prototype cement. 

Paper 17 


Authors: Wilson CJ, Georgiou K & Krishnan J 


Abstract title: OBESITY AND SURGICAL SITE INFECTION IN PRIMARY TOTAL KNEE 

ARTHROPLASTY 

Introduction & aims 

Deep prosthetic infection remains a serious complication in TKA. Obesity has been 

identified as a significant risk factor for infection, thus the aim of this study was to 

evaluate the rate of surgical site infection in patients undergoing TKA, to identify a 

potential association between infection rate and obesity. 

Method 

Data was retrospectively reviewed for 839 primary TKA performed at a National 

Arthroplasty Centre over one year (April 2007–March 2008). BMI data was 

available for 825 patients (333 male, 492 female) and was obtained from patient 

clinical records. Surgical site infection data was collected prospectively by the 

Infection Control team for inpatient stays and up to 30 days post-operatively was 

available for all patients. Patients were grouped based on WHO classifications of 

obesity; normal, overweight (BMI≥25), obese class I (BMI 30-35), obese class II 

(BMI 35-40), obese class III (BMI≥40). Statistical significance was assessed by The 

Fisher’s Exact Test. 

Results 

When grouped by cohort, 31.2% of patients were obese class I, 19.0% obese class 

II and 8.6% obese class III. Of these patients, 22 (2.6%) had superficial surgical site 

infection and 13 (1.5%) had deep infection. The superficial surgical site infection 

rate for the normal weight, overweight, obese class I, II and III, were 1.2%, 2.3%, 

1.5% 3.1% and 8.2% respectively, illustrating a significant increase in infection rates 

between obese class III and all other cohorts (p=0.009). In addition, deep infection 

rates were 1.2%, 1.5%, 0.8%, 0.6%, 6.8% for normal weight, overweight, obese 

class I, II and III respectively, demonstrating a significant increase in obese class III 

deep infection rate when compared to all other cohorts (p=0.003). However when 

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98

comparing the obese cohort with non-obese, there was no significant difference in 

superficial surgical site infection rates (p=0.389), or deep infection (p=1.00). 

While there were no significant changes in infection rate between males and females, 

there tended to be more females constituting the obese class III cohort (11.2%) than 

males (5.0%). Interestingly in this obese cohort, superficial surgical site infection tended 

to be greater in females (8.9%) than males (5.9%), yet deep infection appeared lower 

in females (5.4%) than males (11.8%). 

Conclusions 

This study suggests that obese class III patients are at an increased risk of superficial 

surgical site and deep infection, compared to other TKA cohorts. It is important that 

surgeons are aware of these higher risks and this cohort of patients are informed by 

their surgeon when considering primary TKA. 

Paper 19 


Authors: Cundy WJ, Theodoulou A, Ling M, Krishnan J, WILSON C 


Abstract title: Blood Loss in Total Knee Arthroplasty – Patient Specific vs. Navigated 

vs. Conventional Instrumentation 


Patients undergoing total knee arthroplasty have expected blood loss during and 

after surgery. The current literature remains inconclusive in regards to which surgical 

instrumentation techniques in total knee arthroplasty are effective in minimising 

peri-operative blood loss. The primary objective of this retrospective review of a 

prospective randomized cohort study is to compare surgical and patient factors 

and their influence on blood loss and transfusions rates between one type of Patient 

Specific Instrumentation (PSI) (Signature TM) , Navigated Computer-Assisted Surgery 

(CAS) and Conventional Total Knee Arthroplasty (TKA) surgical techniques. 

Method 

128 matched patients (38 Signature TM , 44 CAS, 46 Conventional surgeries) were 

compared. Pre-operative factors were analysed including; age, gender, Body Mass 

Index (BMI), pre-operative hemoglobin (g/L), International Normalized Ratio (INR), 

use of anticoagulants and co-morbid bleeding diathesis. Maximal hemoglobin drop 

were compared on Day 1 to 3, as well as, transfusion requirement. Peri-operative 

factors were collected including; surgical time, tourniquet time, drain output, insitu 

drain time, order of tibia or femoral cut and intra-operative loss from suction. 

Results 

No significant differences were found between the three groups on the pre-operative 

patient demographics examined. The mean Hb pre-operative was 140 for PSI, 

135 for CAS and 139 for Conventional. The mean post-operative Hb was 111 

for PSI, 104 for CAS and 107 for conventional. Thereby calculating that the mean 

percentage drop was 21%, 23% and 23% respectively. The difference between 

Pre-Op Hb and the lowest of the Post-Op Hb readings does not significantly differ 

between the three groups (p=0.39). A significant difference is seen between the three 

99

groups with respect to Day 1 Hb drop (p=0.05). In the study, 4 patients required 

transfusion due to either hemoglobin

outcomes in patients treated with early range of motion compared to six weeks of 

immobilization. In addition, healing was compared at 24 months postoperatively. 

Methods: 

189 patients with full-thickness rotator cuff tears underwent a MORCR and 

were randomized following preoperative assessment of pain, ROM, abduction 

strength and health related quality of life (HRQL). Subjects randomized to early 

mobilization (n=97) self-weaned from the sling as pain allowed and performed 

painfree active ROM for activities of daily living while the standard immobilization 

group (n=92) wore a sling. Both groups performed passive ROM for the first 6 

weeks and completed identical rehabilitation protocols after 6 weeks. ROM and 

pain were assessed at 6-weeks and 3-months postoperatively. At 6, 12 and 24 

months, ROM, pain, abduction strength and HRQL were assessed. Ultrasound 

was conducted after 24 months on a subset of patients (n=72; 36 early 

mobilization, 36 standard mobilization) to compare healing between groups. 

Results: 

165 (87%) patients completed the 24 month follow-up. The two groups were similar 

preoperatively in all clinical measures (p>0.06). Six week ROM comparisons demonstrated 

increased abduction (p=0.002), flexion (p=0.03) and scaption (p=0.006) in the 

early mobilization group, but these differences disappeared by 3 months (p>0.51). 

There were no differences between groups at 3, 6, 12 and 24 months on all clinical 

measures (p>0.21). At 24 months, 23 of 72 (32%) patients had full-thickness tears on 

postoperative ultrasounds, with no difference in healing seen between groups (p=0.31). 

Conclusions: 

Patients who performed pain-free active ROM for ADLs showed no difference in clinical 

outcomes at 24 months compared to those who were immobilized for 6 weeks. Early 

ROM did not have any significant benefits for minimizing long-term stiffness and 

pain; however, postoperative shoulder power and HRQL were not compromised. In 

addition, there was no difference in healing at 24 months postoperatively between 

groups. Consideration should be given to allow patients to start actively using their 

shoulder within the first 6 weeks following a MORCR. 

Paper 25 


Authors: Sheps DM, Saliken D, Linklater D, Lappi V, Bouliane M 


Abstract title: Rates of Return to Work in Claimants Receiving Shoulder Surgery in 

the Workers’ Compensation Board System in Alberta 

Background: 

Worker’s Compensation Board (WCB) claims have been shown to negatively 

impact outcomes following orthopaedic surgical procedures. Shoulder pathology, 

101

specifically rotator cuff tears, are a frequent cause for musculoskeletal pain in 

WCB patients behind back and neck pain. Many patients suffering from workrelated 

shoulder disability proceed to surgical management prior to returning 

to work. The literature suggests that WCB patients have worse outcomes and 

take longer to return to work than non-WCB patients. We sought to determine 

the work fitness level and actual return to work level of patients undergoing 

shoulder surgery for a WCB-related claim compared to their pre-injury work level. 

Methods: 

We retrospectively evaluated the final work fitness level and actual return to 

work level at two years in consecutive patients undergoing shoulder surgery 

with an active WCB claim. Surgical management included one or more of 

the following: rotator cuff repair (open and arthroscopic), labral repair, bicep 

tenotomy/tenodesis, distal clavicle excision, subacromial decompression, and/ 

or debridement. Work fitness level and actual return to work level at two years 

post-surgery was obtained from the WCB Alberta administrative database. 

Results: 

1277 surgeries were performed with 1188 (93%) patients deemed fit for 

work by two years while 958 (75%) patients actually returned to work. Fitness 

levels for work showed 476 (37.3%) patients at the pre-injury level, 694 

(54.3%) at a lower fitness level, and 18 (1.4%) at a higher fitness level. 450 

(35.2%) patients returned to work at the pre-injury level, 500 (39.2%) at a 

lower level, and 8 (0.6%) at a higher level. At two years 166 (13%) were still 

receiving benefits while 30 (2.3%) had retired and 84 (6.6%) were not working. 

Conclusions: 

Following surgical management of shoulder disorders in workers compensation 

patients, 75% return to work by two years however only 35.2% return to work at their 

pre-injury work level. 

Paper 28 

Presenter: H Wu 

Authors: G.H. Garcia, H.H. Wu, M.J. Park, F.P. Tjoumakaris, B.S. Tucker, J.D. Kelly 

IV, B.J. Sennett 


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Abstract title: Clinical Depression and Anterior Cruciate Ligament Injury: Incidence 

and Impact on Functional Outcome, a Two-Year Prospective Cohort Study 

Introduction: Recent literature has given recognition to depression as a potential risk 

factor for poor functional outcome following orthopaedic procedures. The purpose 

of this investigation was to quantify the incidence of major depressive disorder 

(MDD) and correlate depression symptoms with patient-rated knee function in patients 

undergoing anterior cruiciate ligament reconstruction (ACLR). 

102

Methods: In this IRB approved, multi-center prospective cohort study, consecutive 

adult patients undergoing primary ACLR were given a validated clinical depression 

questionnaire (QIDS-SR16) preoperatively and at 6 weeks, 12 weeks, 24 weeks, 

one year, and two years postoperatively. IKDC and Lysholm scores were obtained 

during the same follow-up period to correlate depression severity with patient-rated 

knee function. A QIDS score of 6 or greater served as a validated threshold for 

diagnosis of MDD. 

Results: Among the 82 patients enrolled in the study, 36 (44%) scored 6 or greater 

on the QIDS preoperatively and were categorized in the MDD cohort. No significant 

differences were found between the MDD and non-MDD cohorts with respect to 

demographics, laxity, concomitant knee pathology and postoperative complications. 

The average QIDS score was significantly higher in the MDD group versus the non- 

MDD group at all six time points. MDD patients reported significantly lower IKDC 

scores at one year (71.8 vs. 89.3, p=0.001) and two years (74.8 vs. 91.3, 

p

stem. All patients were followed with anteroposterior (A~P) and lateral radiographs 

at 3 days, 6 weeks, 3 months, 6 months, 1, 2, 3, 4, 5 and 10 years. PE wear was 

measured with PolyMig, which has a phantom validated accuracy of ± 0.09mm. 

RESULTS: 

At minimum 10 year follow-up, 20 patients had died, 10 had been revised, and two 

patients were unable to attend for x-rays, leaving 90 patients for analysis. No patients 

were lost to follow-up. Average follow-up was 10.97 years (range 10.08 – 12.01). 

A total of 1,674 radiographs were anaysed (approximately 7 pairs of A~P and 

lateral radiographs/patient) There were 42/61 Enduron and 48/61 Marathon hips 

analysed. After the bedding-in period, Marathon liners had a wear rate of 0.0284 

mm/year (sd=0.0266, range 0.0 - 0.0854) and Enduron liners had a wear rate of 

0.2677 mm/year (sd=0.1370, range 0.1157 - 0.6536). 

CONCLUSIONS: 

By 10 years, there was no overlap between the wear rates of patients in the two 

groups. This is the first RCT with 10 year results which supports simulator studies 

showing a 90% reduction in liner wear when XLPE is used. 

Paper 31 

Presenter: P Devane 

Authors: P Devane, G Horne, G Foley, A Thompson 


Abstract title: Type of THJR Should be Matched to Patient Age. Evidence from the 

NZ Joint Registry 

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Introduction: Recent reports, including data from the NZ Joint registry, suggest the 

failure rates of cemented THJR’s (0.61 per 100 component years, CI 0.57-0.65) are 

significantly lower than failure rates for cementless THJR’s (0.87 per 100 component 

years, CI 0.83-0.91). This suggests the results of cementless THJR’s are inferior to 

cemented THJR. This paper refute’s this statement, using hybrid results to show that 

fixation of the cup and femur should be matched to the age of the patient. 

Method: Using data from the 16 year report of the NZ joint registry (01/01/1999 

– 31/12/2014), the results of three types of THJR, cementless (38.02%), hybrid 

(cementless cup, cemented femur, 37.17%) and fully cemented (24.20%), have been 

separated into four groups depending on the patients’ age, less than 55 years, 55-65 

years, 65-75 years, and greater than 75 years. Reverse hybrid THJR’s (cemented cup, 

uncemented femur) have not been analysed due to their limited use in NZ (0.6%). 

Results: In patients under the age of 55 years, failure rate of cementless THJR is 

0.97 per 100 component years (CI 0.90-1.05). This is significantly lower than 

for cemented THJR 1.81, CI 1.48-2.19). For patients over the age of 75 years, 

104

cemented THJR has a significantly lower revision rate (0.37, CI 0.37-0.41) than 

cementless THJR (0.74, CI 0.61-0.9). Results of the hybrid hip more closely resemble 

cementless THJR in patients under 55 (1.14, CI 1.02-1.28) and cemented THJR in 

patients over 75 years of age (0.50, CI 0.44-0.56). 

Conclusion: In patients under 55 years of age, rates of revision for cementless and 

cemented femurs and cementless cups are low. The high rate of revision of cemented 

THJR in this age group may well be due to the cemented acetabulum. We recommend 

cementless fixation of the acetabular component for patients under the age of 55. In 

patients over 75 years, the low rate of revision for cemented and uncemented cups 

and cemented femurs suggests that uncemented femurs are a major factor in the high 

rate of revision of uncemented THJR in this age group. We recommend cemented 

fixation of the femoral component for patients over the age of 75. 

Paper 33 

Presenter: S Isaacs 

Authors: S. J. Isaacs , M W Solomons 


Abstract title: Hyperextension mallet fracture - direction of force is predictive of 

volar subluxation not fragment size 

Hyperextension mallet fracture – mechanism of injury is predictive of volar 

subluxation not fragment size 

Aims 

• Review mechanism of injury in mallet fractures (MF) in 30 adult patients. 

• Identify direction of force (Hyperextension/Hyper-flexion injury) in the above 

group. 

• Determine if direction of force predicts DIPJ volar subluxation. 

• Does fragment size (% joint involvement) predict DIPJ volar subluxation? 

Method 

• Retrospective review - 30 patients treated for mallet fracture had x-rays 

reviewed, interviewed for mechanism of injury, digit affected and direction 

of force. A standardized questionnaire was used. The X-rays were reviewed 

by a Hand surgeon to confirm % of joint surface area involvement. 

Results 

• 9/30 patients: Hyperextension MF with DIPJ volar subluxation. 7/9 had 

joint involvement =25-50% and 2/9 = 0- 25%. 

• 12/30: Hyper-flexion MF with no DIPJ volar subluxation. 4/12 joint 

involvement = 0 – 25%, 4/12 joint involvement = 25-50%; 4/12 = 50- 

75%. 

• 9 /30: unable to recall direction of force. 4/9 had DIPJ volar subluxation 

with joint involvement 25-50%. 5/9 no DIPJ volar subluxation. 2/9 had 

0-25% joint involvement; 1/9 = 50-75%; 0/9 =75%- 100%. 

105

Conclusion 

• Hyperextension mallet fracture: important subgroup - must be identified and 

managed surgically. 

• Hyperextension Direction of force predicts DIPJ volar subluxation. 

• No correlation between fragment size and DIPJ volar displacement. 

Paper 34 

Presenter: SA Khan 

Authors: Khan SA, Rastogi S, Poudel R, Bakhshi S 


Abstract title: Functional Outcome following “No Reconstruction” in Patients 

undergoing Periacetabular (Type-II) Pelvic Resection 

Background: 

Limb salvage in malignant pelvic lesions is poorly reported in world literature. A lack of 

consensus in surgical techniques along with a difficult anatomical location makes them 

the one of the most challenging lesions to be treated surgically at any musculoskeletal 

oncological Centre. Besides, reconstruction options in Type II resections are limited 

and have been reported with significant complications. 

Objectives: The main aim of our study was to evaluate the functional outcome in 

patients undergoing limb salvage for malignant lesions of the Pelvis without any 

reconstruction following Enneking’s Type II pelvic resection. 

Methods: We retrospectively evaluate the results of limb salvage in Malignant lesions 

of the Pelvis. A total of 49 cases of different malignant Pelvic lesions treated at our 

Centre (over a period of eight years) were included in the study. Strict inclusion and 

exclusion criteria were set and patients who had undergone a Type I, Type III or a 

Type IV Pelvic resection were excluded from the study. All patients were classified as 

“no reconstruction” following pelvic resection. Patients were evaluated for age, type 

of tumor, survivorship and functional outcome using the MSTS scoring. Visual Gait 

score was also evaluated. 

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Results: There were 35 males and 14 females in the study. 27 patients 

had Chondrosarcoma, 8 had Ewings Sarcoma, 4 patients had malignant GCT, 

3 patients had MFH, 5 had Osteosarcoma and one patient had Myeloma and 

Clear Cell sarcoma each. Metastatic lesions were excluded from the study. 

Patients underwent neo-adjuvant chemotherapy wherever warranted. Post excision, 

hip was not stabilized by any prosthesis. The mean follow-up in the study was 49.5 

months. The average age was 37.8 years. Oncological survival: after seven years a 

total of 24 patients were alive and they were evaluated for MSTS scoring and gait 

evaluation. The median MSTS score was 70% (17% to 100%). We compared our 

results with a historical cohort of patients who had undergone biological or prosthetic 

106

hip reconstruction post Type II pelvic resection. Mutivariate and univariate analysis 

was done. There was no significant difference in the functional outcome between the 

two groups. 

Conclusions: Our study shows satisfactory results of limb salvage in malignant 

pelviclesions that are considered to be dangerous lesions with poor acceptability of 

surgery both amongst the patients and orthopaedic surgeons. We also concluded 

that patients with prosthetic reconstruction had significantly poorer MSTS Scores as 

compared to reconstruction through biological means 

Paper 35 


Authors: Khan SA, Poudel R, Rastogi S, Bakhshi S 


Abstract title: Functional Outcome in Children undergoing Resection-Arthrodesis 

for Malignant Tumors Around the Knee Joint 

Background: Knee is the commonest site of bone sarcomas in the paediatric 

population. In view of lack of available resources and poor socio-economic status, 

Knee arthrodesis following wide excision of malignant tumors around the knee still 

forms an important means of limb salvage in many developing countries. 

Objectives: The main aim of our study was to evaluate the functional outcome in 

children (less than 18 years) undergoing knee arthrodesis for malignant tumors in and 

around the knee joint. 

Methods: We retrospectively evaluated the results of knee arthrodesis following wide 

excision of bone sarcomas in and around the knee joint in children (that is less than 

18 years of age at the time of presentation). The study included 32 cases of knee 

arthrodesis following excision for either a sarcoma of the distal femur or the proximal 

tibia. Our inclusion criteria was a minimum follow-up of 4 years following the primary 

procedure. Patients were evaluated for age, type of tumor, survivorship and functional 

outcome using the MSTS scoring and the knee function. Knee function was evaluated 

using the Knee Society Score. 

Results: There were 21 males and 11 females in the study. 25 patients had Ostesarcoma 

while 7 had Ewings Sarcoma. All Patients underwent neo-adjuvant chemotherapy. 

Knee arthrodesis following tumor excision was achieved using different methods using 

autograft, morcellised allograft, non-vascularized fibular grafting, turnoplasty (using 

the remaining tibia or femur) and mother’s fibula. Dynamic Compression Plates were 

used in 17 children (prior to advent of LCP) while the Locking Compression Plates 

were used in 15. The mean follow-up in the study was 48.6 months. The average 

age was 14.7 years. Oncological survival: after 4 years a total of 21 patients were 

alive and they were evaluated for MSTS scoring and the Knee Society Scores. The 

median MSTS score was 60% (5% to 80%). The average Knee Society Score was 

107

60. 11 children required multiple procedures at an average of 19.4 months after the 

primary surgery. 

Conclusions: Our study shows satisfactory results of Knee arthrodesis in malignant 

lesions around the knee joint in the paediatric population. Knee arthrodesis is an 

important tool in the armamentarium of the Musculoskeletal oncologist particularly 

when dealing with paediatric sarcomas around the knee more so if an endoprosthesis 

is not doable either due to too young an age or due to lack of resources. 

Paper 36 


Authors: Khan SA, Poudel R, Rastogi S, Bakhshi S 


Abstract title: Do We Need to Remove the Biopsy Tract in Patients Undergoing 

Surgery Following Neo- Adjuvant Chemotherapy for Primary Bone Tumors? 

Aims & Objectives: During limb salvage surgery for malignant bone tumors, it is 

not infrequent to encounter a poorly placed biopsy scar. Whether this biopsy scar 

needs to be removed in patients receiving neo adjuvant chemotherapy is yet to be 

established. Our aim was to study excised specimens of patients who underwent 

surgery 

Methods: Retrospective analysis of excised tumor specimens was done for patients 

operated between 2006 and 2014 at our tertiary care centre. Patients who did 

not receive neoadjuvant chemotherapy and those in whom biopsy was performed 

outside our institute were excluded from study. Demographic data was collected 

from hospital records. Available histopathological slides/blocks of excised tumor 

specimens were carefully examined by a senior Histopathologist (specialist in bone 

tumors) for tumor seeding along/in biopsy tract. 

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Results: Out of 133 patients who underwent wide or radical excision following neoadjuvant 

chemotherapy, 16 were excluded as the biopsy was performed outside our 

hospital. Of the remaining 117 patients, 97 patients (82.9%) were diagnosed with 

Osteosarcoma and 20 (17%) with Ewing’s sarcoma. Limb salvage was done in 86 

patients while 31went for amputation as the primary procedure. The average age 

of patients at the time of performing biopsy was 16.4 years and the male: female 

ratio was 1.3:1. The most frequent site to be biopsied was distal end femur (50%), 

followed by proximal end tibia (16.7%) and humerus (10%). Mean delay between 

biopsy and definitive surgery was 5.2 months. On examination of the histopathology 

blocks/slides, it was seen that tumor seeding was present in only one specimen. 

On retrospective analysis it was seen that this patient was a diagnosed case of 

Osteosarcoma of the distal femur and had undergone upfront amputation following 

failure of response to neoadjuvant chemotherapy. Eleven patients (18.3%) did not 

have any viable tumor tissue in the whole of the biopsy specimen. Nine patients (15%) 

108

who underwent limb salvage surgery had local recurrence but none of them had 

tumor seeding in the biopsy tract of the specimen received after the index procedure. 

Conclusions: Response to neoadjuvant chemotherapy is most important predictive 

factor for skin involvement by Osteosaracoma and Ewings sarcoma. Main drawback 

of study is its retrospective nature and presence of a small number of cases. We 

strongly feel that in patients who respond to neo-adjuvant chemotherapy, need to 

remove biopsy tract in primary procedure is questionable. 

Paper 37 


Authors: Tiwari V, Khan SA 


Abstract title: Hip Arthroscopy in Children with Tuberculosis- Experience from the 

Developing World 

Objectives 

Aim of present study was to retrospectively evaluate changes in tubercular Paediatric 

hips as seen on hip arthroscopy. The study was aimed at grading the disease process 

and evaluating any improvement in hip mobility, which is greatly reduced following 

tuberculosis of the hip. 

Methods 

We retrospectively evaluated records of 22 arthroscopies performed in known cases 

of tuberculosis of hip joint. All patients in our study were less than 12 years age. 

Arthroscopy was performed after a minimum of 6 weeks of anti-tubercular therapy so 

as to avoid further disease activation. Synovial debridement, labral debridement and 

shaving off bony bumps from femoral neck were the commonest procedures done 

during arthroscopy. Pre and post operative Harris Hip Scores were noted in all cases. 

Imaging like plain radiograph and MRI was obtained in all cases. Hip arthroscopy 

was performed under general anaesthesia with the hip distracted. All hips which 

could not be distracted prior to the artrhoscopy were excluded from the study. A note 

of the changes in the peripheral and the central compartments of the hip was made 

and all data was recorded on a pre-fixed proforma. 

Results 

Total of 22 children underwent hip arthroscopy (14 males and 8 females). Tuberculosis 

was classified into four stages using the Kumar classification of TB hip. There were 7 

chidlren in stage II, 11 in Stage III and 4 children in stage IV of disease process at 

time of arthroscopy. Average age in study was 10.5 years. The mean pre-operative 

Harris Hip Score was 56. The post operative Harris Hip Score was 89. All except 

one child had pain relief following hip arthroscopy. There were no complications 

109

in our series. The average follow-up was 1.3 years. We devised an arthroscopic 

classification of tuberculosis hip which consisted of: 

Grade I: only inflammatory changes in the periphery with no central changes. (n=3) 

Grade II: Peripheral inflammatory changes plus pulvinar and inflammation in the 

aceabular fossa. All anatomical hip structures are intact. (n=6) 

Grade III: Changes of Grade I + II with labral tear (n=11) 

Grade IV: Totally destroyed hip with no structural integrity (n=2) 

Conclusions 

Hip Arthroscopy in tuberculosis offers a good alternative for treatment and preventing 

disabilities. Arthroscopy based classification of tuberculosis hip indicates that the 

disease process spreads from the periphery to the centre. Kids with peripheral disease 

do better than children with central disease. 

Paper 39 


Authors: L.Obert , S. Rochet, J. Boudard, J. Uhring, D. Lepage, G. Leclerc, F. Loisel 


Abstract title: Proximal ulnar comminuted fractures : fixation by a double plate 

technique : a prospective multicentric study 

INTRODUCTION: Comminuted fractures of the proximal ulna are severe injuries often 

associated with bone and ligament injuries of the elbow joint (Monteggia lesion, 

radial head fractures, dislocation or the elbow). The treatment of these fractures is very 

demanding and the functionnal results often fair mediocre due to associated injuries. 

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In a monocentric retrospective study we report the results of the treatment of these 

fractures fixed by a double plate technique. The aim was to evaluate the fiability of 

the fixation and to compare it with others series fixed by two plate in term of bone 

union, , function of the elbow joint, and complications due to plates). 

METHOD: 24 patients with an average of age of 45 years (32-67) sustained a 

comminuted proximal ulna fracture between 2002 and 2012The fractures were 

associated in five cases with a Monteggia type lesion ,in two cases with elbow 

dislocation ,and in four cases with a Mason 3 radial head fracture.Four patients 

had an open fracture. These comminuted ulna fractures included nine Mayo Clinic 

IIIB fractures. Bone fixation was performed with two third-cylinder tubular plates, one 

plate on each side of the proximal ulna.This allows more versatile solutions for screw 

insertion. 

110

RESULTS: With a minimum follow up of 2 years (24-56 months), 21/24 patients 

achieved bone union with a delay of 3,5months. No septic complications occured. 

In 72% cases Morrey-score indicated excellent to good results with a mean score 

of 84. Mean flexion reached 128° (90°-140°), lack of extension reached 15° (0°- 

35°). Pronation reached 84° (65°-90°) and supination 70° (10°-90°). 2 non union 

with stiffness have been treated by arthrolysis and new fixation. 

DISCUSSION In the reported series of fixation by plate of proximal ulna fracture 

20% of patients need the removal of the plate. On another hand the anatomy of 

proximal ulna has been rediscovered recently with the definition of the PUDA (posterior 

angulation). A single straight plate on the the dorsal crest remain unlogical due to the 

posterior angulation of the proximal ulna ( 6° on the first 6 cm of the ulna in 96%of 

patient). There is no report in the litterature of technical point of fixation concerning 

complex fracture of ulna. Two plates mean two fold more solution of fixation. This 

fixation remain easy to perform, and allow with a stable anatomic reconstruction of 

the ulna to win time to solve others injuries in the spectrum of complex injuries of the 

elbow. 

Paper 41 


Authors: L. Obert, A. Jacquot, P. Mansat, F. Sirveaux, P. Clavert, J. N. Charissoux, 

L. Pidhorz, T. Fabre and SOFCOT 


Abstract title: Complications of treatment of distal fractures of the humerus in 

patients over 65 Prospective & retrospective multicenter study on 497 cases 

Purpose : Fractures of the distal humerus in patients over the age of 65 are a therapeutic 

challenge. Treatment options include immobilization/conservative treatment, internal 

fixation or total elbow arthroplasty. The complications of these different treatment 

options have been evaluated in a multicenter study. 

Materials and Methods : 497 files were evaluated. A retrospective study was 

performed in 410 cases: 34 received conservative treatment (immobilization), 289 

internal fixation and 87 underwent total elbow arthroplasty. A prospective study was 

performed in 87 cases: 22 received conservative treatment (immobilization), 53 

internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated 

after at least 6 months follow-up. 

Results : The rate of complications was 30% in the retrospective study and 29% in the 

prospective study. The rate of complications in the conservative treatment group was 

60%, and were mainly malunion. The rate of complications was 44% in the internal 

fixation group and included neuropathies, mechanical failure or skin perforation/ 

wound dehiscence. Although complications only developed in 23% of total elbow 

arthroplasties, they were often more severe than those following other treatments. 

111

Conclusion : Complications develop in one out of three patients over 65 with distal 

humerus fractures. Three main types of complications were identified. Neuropathies 

especially of the ulnar nerve must always be identified, isolated and transposed, 

especially during arthroplasty. Bone complications, due especially to mechanical 

failure, were found following internal fixation. Despite technical progress, care must 

be taken not to force the use of this treatment option in complex fractures on fragile 

bone. Although there were fewer complications with total elbow arthroplasty they 

were more difficult to treat. Ossifications were frequent whatever the surgical option 

and can worsen the functional outcome. 

Paper 51 

Presenter: N Ferreira 

Authors: N. Ferreira, L.C. Marais, C. Aldous 


Abstract title: Hexapod external fixator closed distraction in the management of 

stiff hypertrophic tibial nonunions 

Tibial nonunion represents a spectrum of conditions which are challenging to treat, 

and optimal management remains unclear despite its high rate of incidence. We 

present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod 

external fixators and distraction to achieve union and gradual deformity correction. 

There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a 

mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures 

were performed. Bony union was achieved after the initial surgery in 41 (89.1%) 

tibias. Four persistent nonunions united after repeat treatment with closed hexapod 

distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union 

was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral 

side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 

(91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to 

union without further surgery or bone graft. In addition to generating the required 

distraction to achieve union, hexapod circular external fixators can accurately correct 

concurrent deformities and limb-length discrepancies. 

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Paper 54 

Presenter: N Ferreira 

Authors: L. Nieuwoudt, N. Ferreira, L.C. Marais 


Abstract title: Short Term Results of Grade III Open Tibia Fractures Treated With 

Circular Fixators 

Grade III open tibia fractures have high infection and non-union rates and the optimal 

treatment remains controversial. We present the short-term results of 94 consecutive 

Gustilo-Anderson grade III open tibia fractures treated with definitive circular external 

112

fixators. A total of 94 patients (80 males and 14 females), with a mean age of 36,9 

years (range 8 – 73) were followed up for a mean period of 12 months (range 6 - 

52). Deep infection occurred in four patients (4,3%) and non-union in three patients 

(3,2%). The median time to union was 23 weeks (range 11 – 79). The prevalence 

of HIV infection was 34% and it was not associated with an increased risk of deep 

infection (p = 0.601) or non-union (p = 0.577). Pin site infection occurred in 16% 

with the majority being low-grade infections. The management of grade III open tibia 

fractures with definitive circular external fixation delivered promising short-term results 

with low complication rates in terms of infection and non-union. 

Paper 55 


Authors: L. Obert, E. Jardin, C. Pechin, C. Echalier, I. Pluvy, F. Loisel 


Abstract title: Undisplaced metacarpal shaft fracture : is early active motion an 

option ? Prospective continue study 

Introduction: undisplaced metacarpals shaft fractures are classically handled by 

an irremovable gauntlet from four to six weeks. We report an continue prospective 

evaluation of the treatment by immediate active protected motion (syndactylia for 4 

weeks) of metacarpals shaft undisplaced fracture of M2 to M5. 

Material and method: 54 fractures (15 transverses /short obliques and 39 spiroïdes 

/ long obliques) were included during 1 year in 51 patients, middle-aged 31 years. 

The clinical and radiographic evaluation was perfrrmed at 15 days, 1, 2 and 6 

months. 

Results: 31 were able to be revised at 15 days, 27 at 1 month, 22 at 2 months. 

The initial palmar angulation was on average 26 ° for the short obliques/ transverse, 

and of 11,5 ° for the long obliques / spiroïdes. Secondary displacement (but without 

a need of surgery) happened in 6 cases (11 %) (with an average of 16°) in short 

obliques/ transverse fractures. Bone union was achieved in 37 % of the cases at 1 

month, and in all cases at 2 months. The improvement of Quick Dash and EVA showed 

a fast functional recovery. TAM and TPM were comparable to the contralateral side 

in 90 % at 2 months. The loss of grasp and pinch was 33 % relative to the opposite 

side at 2 months. 

Conclusion: functionnal results of this simple technique are good even if secondary 

displacment occured in 11% of cases in trnasverse fracture which probably have to 

be operated. 

Paper 56 


Authors: L. Obert, D. Potage, T Autom, F. Loisel, T. Lascar 

Disclosure: Yes: consultant for FX 

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Abstract title: Osteosuture with double Ring Knot in case of trauma shoulder 

prosthesis: Prospective multicenter evaluation of a simple, and versatile selflocking 

sliding knot 

INTRODUCTION: Long-term fixation of tuberosities around a humeral implant due to 

fracture depends mainly on the height of the stem: this can be positioned in an easily 

reproducible way by using the pectoralis major tendon as a marker. But osteosuture 

remains the essential tool for anchoring tuberosities. A new technique for osteosuture 

(tuberosities) that offers more security is described. 

METHODS: We prospectively evaluated 93 consecutive hemi and reverse 

arthroplasties performed for 3 & 4 part fractures which involved reattaching the 

tuberosities using a polyester suture precisely tied with the double-loop sliding knot. 

The length of the stem was 15 cm with a proximal coating of HA automatic locking 

system (2 screws) and 4 different diameter. The Double Ring or double running or 

Tag knot has a special property in that it can be unfastened and retightened in case 

of premature locking and unintended loop loosening. is easy to tie. Cadaver studies 

(24 shoulders - 12 cadavers) have been carried out with constructed loops to perform 

tuberosity suturing. For each test, the speed of the technique, its reproducibility, the 

reliability of the loop and the strength of the mounting were checked. Three systems 

of 2 looped threads were done in each clinical case and seem valuable to us: The 

first to anchor and draw the tuberosities, the next to press them onto the implant, and 

the final group of two threads to create a vertical tie-down system. 

RESULTS: In the group of hemi Constant score with ponderation reached 72,3 (31,5- 

120) and QDash 30,2 (4,5-68,1) with a mean FU of 26 months. 

In the group of reversed Constant score with ponderation reached 79 (36,4-109,4) 

and QDash 36,5 (2,27-70,4) with a mean FU of 24 months. Specific complications 

due to locking system reached 3 % but without reoperation. Other complications 

were : Capsultis (6%), infection (2%). No complications secondary to the knot have 

been described. 

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DISCUSSION : Recent studies have examined braided suture as a possible alternative 

to stainless steel wire to increase bone fixation and decrease non union tuberosities. 

Moreover, the design of the stem at the metaphyseal level risks reducing the primary 

stability, and the tuberosities may slide “turning over” with the tension of the suture. 

The other advantage of a loop and this knot is to create a simple self-stabilising 

system, allowing mobilisation of the fracture fixed around the implant, which is easy 

to change, undo and and re-tie. This is a well-known knot that has been used for a 

long time just not in surgery. The benefit of the loop is double. With this being “tendon 

surgery”, the quantity of suture is known to be an element of resistance, but a looped 

thread, used in flexor surgery, allows us to make a series of running knots, which are 

simple and effective, for reliable anchoring of the tuberosities. This technique was 

found to be effective, simple, fast, easy to learn, and saves time and material. 

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Paper 57 

Presenter: PFRG De Muelenaere 

Authors: P.F.R.G. de Muelenaere, A. Von Strempel 


Abstract title: Non-Fusion is an Option for Lumbar SPine Problems in the Long 

Term (8 years) 

Purpose of study. 

Lumbar spine fusion was thought to be the only option for instability or deformity. 

However, the long term results after lumbar fusion have shown reoperation rates 

ranging from 5% up to 25% 1 . 

With non-fusion philosophy and good outcomes, we hoped to reduce reoperations 

(especially adjacent segment failure) 2 . 

The purpose was to proove even in the long term, lumbar non-fusion stabilization is: 

good/better than regular fusion outcome, 

shorter operating time 

less invasive with less morbidity 

sustainable 

Description of methods. 

A prospective study of 107 patients who underwent 1 or 2 levels fixation without 

fusion (cosmic system) was undertaken from 2006 to 2008. 

Patients: 

Completely non-fused fixation: 40 pts 

hybrid fusions: 67 pts 

Indication for surgery: Varied degenerative indications, Failed back Syndrome 

(27%) 

Clinical parameters: 

Oswestry Disability Index (ODI), 

Visual Analog Scale (VAS), 

sitting time, walking distance, 

intra-operative blood loss, 

surgical time, 

hospital stay and 

adverse events. 

Radiological parameters: 

adjacent levels disc height, 

range of motion. 

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Follow-up visits: 6 & 12 weeks, 6 & 12 months and annually until 4 years. Final 

evaluation was done at 8 years (72 pts). 

Results 

Average age at surgery: 62 (24-84 years). 

The average follow-up: 89.9 (70-103 months). 

Mean surgical time: 73 min. 

Mean blood loss: 200 ml 

Average hospital stay: 3.6 days. 

Mean ODI score improvement: 53% after 8 years (51.33 to 27.5 points). 

VAS improvement: preoperative 7.96 points to 2.1 after 8 years. 

Sitting time improvement: 90.3% pts. > 30% could sit indefinitely at final follow-up. 

Walking ability improvement: 67.6% pts. 

13 patients had re-operation. Only 4 of these were at the adjacent levels. 

8 patients had (mostly asymptomatic) screw breakages at final follow-up. 

Average preoperative adjacent disc height: 7.07 mm above, 7.27 below mm. At 

final follow-up disc height maintained (6.55 mm above, 7.36 mm below). 

Average range of motion in non-fused segments: 3.44°.This indicates that fixation 

was NOT responsible for accelerated degeneration. 

Conclusion 

The cosmic device was safe and effective in treatment of common low back pain. It 

can be associated with sustainable good clinical outcome over a long period, less 

morbidity, shorter surgical time and hospital stay. It preserves adjacent levels disc 

height in the long term and may prevent adjacent level problems contrary to fusion 

devices. 

Paper 60 

Presenter: S Tennant 

Authors: S Tennant, P Calder, A Hashemi-Nejad, A Catterall, DM Eastwood 


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Abstract title: Bilateral DDH: Double Trouble, or Something Entirely Different? 

Introduction 

DDH occurs bilaterally in 20% of cases, and is widely reported to have a worse 

outcome than unilateral DDH. The aim of this study was to report the outcome of a 

closed reduction (CR) protocol in a cohort of 28 patients with bilateral idiopathic 

DDH and to compare it to our unilateral cases, in order to better define the indications 

for closed reduction in bilateral DDH. 

Methods 

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We reviewed a consecutive series of 28 patients (56 hips) under walking age who 

underwent attempted CR including soft tissue release as necessary, and a short leg 

cast for 18 weeks. A limited cut CT scan 2 weeks after CR was used to assess the 

maintenance of reduction. There were 23 Females and 5 males. Follow up was to 

at least one year, with a median of 58 months (range 19-126 months). 

Results 

3 patients (6 hips) failed a closed reduction at the time of surgery (primary failure 

rate 11%). 5 patients had both hips fail in the first 3 months following CR, 6 hips (3 

patients) being dislocated on the CT scan; 4 hips (2 patients) were subluxated at 

the 6 week cast change. In 5 other patients, 1 hip was found to be dislocated on 

the CT scan. In these cases, casting was maintained to allow the reduced hip to 

stabilize. All dislocated hips then went on to have open reduction at an appropriate 

age. 

This represents a secondary failure rate of 30% for any hip in bilateral DDH, and of 

20% for both hips. 54 % of hips succeeded bilaterally. Of the 35 successful hips, 7 

hips (20%) required surgery for residual dysplasia. The significant osteonecrosis rate 

in the successful group was 8.3%. All of these rates are higher than a comparable 

group of unilateral DDH undergoing the same CR protocol. The highest failure rate 

was found in Tonnis 4 hips (87%), for which we do not recommend this protocol. 

There was no significant osteonecrosis, or later detrimental effect, in the hips that were 

splinted in dislocation to allow the contralateral hip to stabilize. 

Conclusions 

We recommend that a closed reduction protocol for bilateral Tonnis 2 and 3 hips is 

a valid treatment option, allowing reduction of the hip at an early age with minimal 

surgery, without prejudicing the results of open reduction if it fails. Parents need to 

be aware however that even when treated early with CR, bilateral DDH has a worse 

outcome than unilateral DDH under the same protocol. 

Paper 62 

Presenter: LC Marais 

Authors: LC Marais, J Bertie, R Rodseth, B Sartorius, N Ferreira 


Abstract title: Pre-treatment serum lactate dehydrogenase and alkaline 

phosphatase as predictors of metastases in extremity osteosarcoma 

Background: The prognosis of patients with metastatic osteosarcoma remains 

poor. However, the chance of survival can be improved by surgical resection of all 

metastases. In this study we investigate the value of serum alkaline phosphatase (ALP) 

and lactate dehydrogenase (LDH) in predicting the presence of metastatic disease at 

117

time of diagnosis. 

Methods: Sixty-one patients with histologically confirmed conventional osteosarcoma 

of the extremity were included in the study. Only 19.7% of cases presented without 

evidence of systemic spread of the disease. Pre-treatment serum ALP and LDH were 

analyzed in patients with and without skeletal or pulmonary metastases. 

Results: Serum LDH and ALP levels were not significantly different in patients with or 

without pulmonary metastases (p=0.88 and p=0.47, respectively). The serum LDH 

and ALP levels did however differ significantly in patients with or without skeletal 

metastases (p 454 IU/L equated to 100% sensitivity for detected bone 

metastases (positive diagnostic likelihood ratio (DLR)=1.32). With a cut-off of 76 IU/L 

a sensitivity of 100% was reached for serum ALP predicting the presence of skeletal 

metastases (positive DLR=1.1). In a multivariate analysis both LDH ≥ 850 IU/L (odds 

ratio [OR]=9; 95% confidence interval (CI) 1.8-44.3) and ALP ≥ 280 IU/L (OR = 

10.3; 95% CI 2.1-50.5) were predictive of skeletal metastases. LDH however lost 

its significance in a multivariate model which included pre-treatment tumour volume. 

Conclusion: In cases of osteosarcoma with LDH >850 IU/L and/or ALP >280 IU/L 

it may be prudent to consider more sensitive staging investigations for detection of 

skeletal metastases. Further research is required to determine the value and the most 

sensitive cut-off points of serum ALP and LDH in the prediction of skeletal metastases. 

Paper 65 

Presenter: M Held 

Authors: M. Held, M. Laubscher, S. Mears, S. Dix-Peek, L. Workman, H. Zar, R. 

Dunn 


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Abstract title: Diagnostic accuracy of Xpert MTB/RIF for musculoskeletal TB. 

Background 

Xpert MTB/RIF (Xpert) is effective for the diagnosis of pulmonary tuberculosis (TB) in 

adults. However there is limited data on its usefulness for extrapulmonary TB. We 

aimed to investigate the accuracy of Xpert for diagnosis of musculoskeletal TB. 

Methods 

A prospective study of adults and children hospitalised in Cape Town, South Africa, 

with suspected musculoskeletal TB was undertaken from April 2012 to March 2015. 

The diagnostic accuracy of Xpert was compared to culture and histopathology. 

Findings 

315 biopsies from 303 patients (52% male, average age 26) were evaluated, 129 

were HIV negative (42.5%) and 49 HIV positive (16.1%). In 125 (37.8%) the HIV 

status was unknown. Xpert was positive in 103 of 315 samples (32.7%), culture in 

90 (28.6%) and culture or histology in 113 samples (35.9%). Xpert detected 12 

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TB cases more than culture. The sensitivity was 87.9% (102/116) with a specificity 

of 99.5% (198/199). The median (IQR) days to Xpert detection was 1 (1 – 1) 

compared to culture 18 (12 – 26), p 0.01). There was no difference in the 

average force to produce 150 μm of displacement in the 6 cm or 9 cm segments. 

Average loads to produce failure (4 mm subsidence) were also higher for tapered 

stems with a 3 cm segment (1574 N vs. 500 N, p

Discussion and Conclusion: 

Tapered stems required higher loads to produce subsidence than cylindrical stems in 

a revision THA model. Revision tapered stems require a minimum intact segment of 

1.5 to 2.5 cm to obtain adequate initial fixation stability. Revision tapered stems have 

superior initial fixation stability to cylindrical stems in the setting of severe bone loss. 

Paper 67 

Presenter: A Lisowski 

Authors: A.E. Lisowski, L.A. Lisowski 


Abstract title: Mobile Unicompartmental Knee Arthroplasty: A Prospective 

Independent Study. Ten To 15 Years Follow-up. 

Purpose of the study 

The use of unicompartmental knee arthroplasty (UKA) in the treatment of medial 

osteoarthritis of the knee has rapidly increased over the recent years. The outcome 

of the first mobile UKAs with a minimal 10 years follow-up (FU) performed with a 

minimally invasive surgical technique is reported. 

Description of methods 

Between 1999 and 2005, 138 consecutive medial UKAs (129 patients) were 

performed by a single surgeon. Thirty-two patients deceased prior to their 10 year 

assessment. Eighteen patients were not available for clinical evaluation due to 

poor general health condition but reported no revision of the prosthesis or other 

implant related surgical procedure. Eighty-one knees were available for clinical and 

radiological evaluation. A standard pre- and postoperative protocol with clinical 

reviews and radiographs was used. The survival of the arthroplasty was analysed. 

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Summary of results 

The median follow up was 11 years (SD ±1.7, range 10 to 16 years) with 81 knees 

being followed for a minimum of 10 years. The mean age at surgery was 72.0 years 

(SD ± 8.3). The mean Knee Society Knee score at latest FU was 81.0 (SD ± 20.7). 

The mean Oxford Knee score at FU was 41.1 (SD ± 6.4). Eleven (8.0%) knees were 

revised to total knee arthroplasty at a mean of 5.7 years (SD ± 3.3). Of these 11 

there were 3 revisions because of failure of using strict selection criteria. Reasons for 

revision: six progression of arthritis in the lateral compartment, one recurrent bearing 

dislocation and four due to pain. There have been no revisions due to loosening 

of the components, infection or patellofemoral degeneration. Complications: one 

perioperative proximal tibia fracture which was functionally treated with brace. Eight 

knees with persisting pain were successfully treated by an arthroscopic procedure. The 

15-year cumulative survival rate with revision for any reason was 90.6%. Fluoroscopic 

evaluation showed radiolucency beneath the tibial component in 24,7% (N=20: 5 

complete and 15 partial). None of these patients had complaints. 

120

Conclusion 

Current study supports the use of UKA in isolated medial compartment osteoarthritis 

with excellent long term functional outcome and a high 15-year survival rate. The 

presence of radiolucency has no influence on functional outcome, survival and pain 

complaints. When strict indication criteria are followed, an excellent, reliable and 

durable functional and radiological outcome can be expected. 

Paper 68 

Presenter: U SHAHI 

Authors: Shahi U, Al Farhan MF, Shahi N 


Abstract title: EFFECT OF PRE-EXISTING JUXTA - ARTICULAR OSTEOPENIA IN 

OUTCOME OF TOTAL KNEE REPLACEMENT 

Purpose: Juxta articular osteopenia is a troublesome entity for orthopaedic surgeons 

dealing with joint replacements, leading to a poorer outcome. The purpose of present 

study is to understand that whether Juxta-articular osteopenia is a cause or effect of 

osteoarthritis and its effect in outcome of a total knee replacement. 

Methods: This is a randomized control trial including 152 patient undergone for 

unilateral total knee replacement with a follow up of 5 years. These patients were 

selected with taking age (Between 51-60 Years), sex (only males) and physical activity 

(non-athlete, moderate physical activity) in consideration. Out of these 152 patients 

98 were found to have Juxta-articular osteopenia around the effected knee. These 

98 patients were randomly assigned in two groups equally. In first the replacement 

surgery was delayed for six months and anti-osteoporotic therapy was administered 

prior to surgery, whereas in the other group the replacement was done without any 

delay and no therapy of osteoporosis was given. In both the groups same prosthesis 

was used and the cases were operated by same operating unit in a span of one 

year. The post-operative assessment was and results were compared. The assessment 

tools used were WOMAC Score, KL Grading and DEXA scan. The statistical tool was 

SPSS version 16.1. 

Results: In first group 41/49 and in the other group 38/49 completed five year 

follow up. The mean WOMAC score one year after treatment in first group was 78.6 

± 5.2 and in second group was 71.2 ± 4.7. The mean WOMAC score five year 

after treatment in first group was 71.8 ± 6.7 and in second group was 64.1 ± 8.1. 

In first group 2/41 had moderate pain and activity limitation whereas in other group 

it was 7/38. In first group 1/41 had peri prosthetic lysis of bone whereas in second 

group it was 4/38. In first group there were no peri prosthetic fractures, whereas in 

second group there were 2/38 peri prosthetic fractures. 

Conclusion: With present study we can conclude that it is difficult to ascertain that 

whether juxta articular osteopenia is a cause or effect of osteoarthritis, as these 

121

conditions co-exist and either osteopenia lead to osteoporosis or reduced use of limb 

after osteoarthritis accelerates osteopenia. However once the synergistic equilibrium 

is established among these two entities, both of the problems accelerates in an 

exponential way. Also it is beneficial to administer anti – osteoporotic therapy prior 

to TKR. 

Paper 72 

Presenter: T Petheram 

Authors: HA Kazi, SL Whitehouse, AJ Timperley 


Abstract title: Are all cemented stems are the same? A report from the National 

Joint Replacement Registry of England and Wales. 

Introduction: 

We aimed to ascertain differences in outcome between the different cemented design 

philosophies using a large-scale registry analysis. 

Materials and Methods: 

A retrospective cohort study of National Joint Registry of England and Wales 

(NJREW). Population included all primary total hip operations performed in the UK 

from 1 April 2003 to 31 September 2012. Analysis by stem type, revision and 

brand was performed. 

Results: 

304,328 primary cemented hip replacements were recorded during the period. 

159 stem designs were utilised of which 40 brands had >100 implantations. 

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Non-polished stems accounted for 16.2% of all primary cemented hip replacements. 

Mean age for non-polished stems was 73.0 years and 71.8 for the polished group 

(p

(p

Paper 73 

Presenter: M Vosloo 

Authors: M. du Toit, M.A. de Beer, N. Keough 


Abstract title: MACROSCOPIC ANATOMY OF THE ROTATOR CUFF COMPLEX: 

REVISITED 

The rotator cuff (RC) insertions according to anatomical texts are described as being 

separate from one another. However, clear fusion of RC tendon fibres exist with prior 

studies showing this interdigitation forming a common and continuous insertion onto 

and around the lesser- and greater tubercles (LT and GT) of the humerus. Current 

surgical repair methods (especially arthroscopic techniques), rarely mention or 

consider these connections during repair and suture anchor implantation. Current 

desired mechanical repair principles considered during RC repair include; good 

contact between the repaired tendon and bone (maintenance), even load distribution 

over sutures, repair of bone to tendon should include side-to-side, tendon-tendon sutures 

(tear pattern specific) and, a congruent upper surface of the repair cuff-tuberosity 

construct should be maintained. Nowhere is it mentioned that the interdigitation of 

fibers, the extension hood and the internal capsule should be identified and repaired 

separately in order to maintain full joint biomechanical properties post-operatively. 

Therefore, the purpose of this project was to study, visualise and define the RC 

extension insertions/interdigitation. Twenty shoulders (fresh and cadaveric) from the 

National Tissue Bank and the Department of Anatomy (University of Pretoria - ethical 

clearance: 239/2015) were used. The results positively corroborated with previously 

published works demonstrating a critical, interconnecting meshwork of fibers between 

infraspinatus (IP), supraspinatus (SP) and subscapularis (SC). The tubercles may well 

act as a form of sesamoid bone between the RC and SC. Additionally, the deeper 

layers of SP and IP were observed to fuse to the internal capsule of the glenohumeral 

joint (GHJ), respectively forming an integral part of the insertion. These findings clearly 

illustrate that the RC muscles, static stabilisers of the GHJ and, the internal capsule 

are one complete and inseparable unit/complex. This interconnected singularity is 

often not given the importance it warrants during current surgical repair. The fact that 

the RC unit is more complex in its structure and attachment places importance on the 

biomechanical stresses encountered after repair. Functions of one RC muscle are not 

necessarily isolated, but instead can be influenced by surrounding muscles as well. In 

addition to providing greater understanding of the basic anatomy of the RC unit, these 

findings also provide clarity for surgeons with the goal of improving and enhancing 

surgical methods for better post-operative patient outcome. 

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Paper 74 

Presenter: S Tennant 

Authors: S Tennant, C Douglas 


Abstract title: The Size And Growth Of The Clubfoot Compared With The Normal 

Childs’ Foot: The Creation Of A Foot Length Database In Normal Feet. 

Introduction 

Clubfeet are frequently noted to be smaller than normal feet, and parents often have 

concerns regarding the size and growth of their childs’ clubfoot, however there is little 

information regarding the growth of the normal foot or the clubfoot. 

Objectives 

The aim was to create a database of measurements of normal childrens 

foot length, to allow comparison with foot length measurements in 

unilateral and bilateral clubfeet in order to answer some of these questions. 

Methods 

500 normal children between the ages of 3 and 10 years had both feet measured 

using a conventional shoe-shop measuring device, resulting in 1000 measurements. 

Data was analysed according to racial origin and age. 100 unilateral and 50 

bilateral idiopathic clubfeet treated using the Ponseti technique were measured. Data 

was compared with the normal database. 

Results 

Across all ages, 20% of children in the normal data-base had no difference in foot 

length between left and right. 50% had 1-2mm difference. Mean difference was 

2.1mm (Range 0-11mm). A difference in foot length was more likely with increasing 

age, and the magnitude of the difference also increased with age. 

Unilateral clubfeet were significantly smaller than controls of a similar age in the normal 

database, and the foot length differences between right and left were significantly 

larger in unilateral clubfeet. Only 2 feet (5%) had no foot length difference compared 

with 29% in the normal database. The mean foot length difference in the clubfeet was 

5.1mm (range 1-23mm), compared with mean 1.47mm (range 0-7mm) in normals. 

48% of unilateral club-feet had >5mm foot size difference, compared with 3% in the 

normal data base. 

In unilateral feet, there was a greater difference in foot length between those feet 

requiring < 4 casts for correction (mean 3.3mm) compared with those requiring >4 

casts for correction (Mean 4.5mm), and in those requiring a tenotomy. 

Conclusions 

This preliminary study, using one-off measurements, has gives useful information about 

the range of lengths of normal childrens feet across a wide range of ages and racial 

groups, and data about length differences in clubfeet, suggesting that even using 

the Ponseti technique, the treated clubfoot is smaller, and that stiffer feet requiring 

more serial casts and a tenotomy are likely to have a larger difference in foot length. 

Measurements continue, with sequential measurements with increasing age of both 

normal children and clubfeet. 

125

Paper 75 

Presenter: T Petheram 

Authors: T.G. Petheram, S.L. Whitehouse, H. Kazi, M.J.W. Hubble, A.J. Timperley, 

M.J. Wilson, J.R. Howell 


Abstract title: The Exeter Universal cemented femoral stem at 20 to 25 years: a 

report of 388 hips 

1. Purpose of study The Exeter Universal stem was introduced in March 1988. 

Apart from a minor change to the trunion taper to the current V40 taper in 2000, 

the current Exeter V40 stem is identical. The outcomes of the Exeter Universal stem 

at up to 17 years have been published, and the Exeter V40 femoral component 

performs well at medium term in arthroplasty registries from around the world. This 

study aimed to describe the survivorship beyond 20 years, and secondarily to 

present the clinical and radiological outcomes. 2. Description of methods A total 

of 388 hips were identified in 352 patients with mean age 66.4 years (range 17 

to 94) at operation. These patients were prospectively followed up and outcomes 

recorded. 3. Summary of results Over the 25 year study period 223 patients with 

240 (65%) hips died, 42 (11%) hips had been revised and 106 (28%) hips in 93 

patients were available for review, for who mean follow up was 22.4 years (range 

20 to 25.9). Mean age at operation of the survivor group was 54.6 years (range 

24 to 75). This was the exclusive stem used during this period and all indications 

for surgery were included. 39 (10%) hips had undergone previous surgery. Primary 

osteoarthritis was the indication for surgery in 72% of patients. With an endpoint 

for aseptic loosening, stem survivorship at 22.8 years was 99% (95% CI 97.4 to 

100%). The one stem revised was in a patient with Gaucher’s disease and rapid 

onset osteolysis 21 years after implantation. All acetabular components were 

cemented, however the components themselves varied and are now obsolete. With 

an endpoint for aseptic loosening, cup and stem survivorship at 22.8 years was 

85.5% (95% CI 80.2 to 90.8%). Overall survivorship of the hips with revision for 

any reason as an endpoint at 23.5 years was 79.6% (95% CI 73.5 to 85.7%). 

The median Merle D’Aubigne and Postel scores at review were 6 (IQR 1) for pain 

and 4 (IQR 4) for function. The median Oxford score was 39.5 (IQR 16) and the 

median Harris Hip Score pain component 44 (IQR 4) and function component 34 

(IQR 19). Median Euroqol score was 77.5 (IQR 25). Radiological review showed 

excellent preservation of bone stock at 20 to 25 years, and no impending failures 

of the femoral component. 4. Conclusion The Exeter femoral component continues 

to perform well beyond 20 years. 

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Paper 76 

Presenter: PT Thornley 

Authors: P. Thornley, N. Evaniew, M. Riediger, M. Winemaker, M. Bhandari, M. 

Ghert 


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Abstract title: Post-operative antibiotic prophylaxis in total hip and knee 

arthroplasty: A systematic review and meta-analysis of randomized controlled 

trials 

Purpose of Study: 

Post-operative antibiotic prophylaxis is currently the standard of care for patients 

undergoing total hip and knee arthroplasty. We evaluated the evidence for this 

practice in the reduction of surgical site infections. 

Description of methods: 

We systematically searched MEDLINE, Embase, and the Cochrane Library for 

randomized controlled trials published up to October 1, 2015 using MeSH and 

EMTREE headings with free text combinations. We included all randomized controlled 

trials that compared post-operative antibiotic prophylaxis to post-operative placebo 

or no treatment. Surgical site infection outcomes were combined using a random 

effects model and heterogeneity was quantified using the chi-squared test and the 

I 2 statistic. We assessed the overall quality of the evidence according to the Grading 

of Recommendations Assessment, Development, and Evaluation (GRADE) approach. 

Summary of results: 

Across four eligible randomized controlled trials (n=4036), there were 63/2055 

(3.1%) surgical site infections in the prophylaxis group and 45/1981 (2.3%) surgical 

site infections in the placebo/no treatment group. Post-operative prophylaxis did not 

reduce the rate of surgical site infections compared to placebo (risk difference 0.01, 

95% Confidence Intervals [CIs’] -0.00 to 0.02, p = 0.19; I 2 =26%). This result was 

robust to sensitivity testing for losses to follow-up. According to the GRADE approach, 

the overall quality of evidence was ‘very low’. 

Conclusions: 

The available evidence does not demonstrate efficacy for post-operative antibiotic 

prophylaxis for prevention of surgical site infections in patients undergoing total hip 

and knee arthroplasty. Multi-center randomized controlled trials are likely to have an 

important impact on the confidence in the effect estimate and to change the estimate 

itself. 

Paper 79 

Presenter: M Haber 

Authors: M.D. Haber, D.J. Bokor, S. Ahmad, D Biggs, B. Gooding, E. Dolev 

Demshchak 


Abstract title: Clinical Outcome Scores Following Arthroscopic Rotator Cuff Who 

Re-Tear: Patients Prior To Re-Tearing Are Better Than Patients That Don’T Re-Tear 

1. Purpose of study. 

Establishing factors relating to patient who re-tear outcomes is of significant clinical 

importance. Numerous papers have established pre-operative and intra-operative 

factors that predispose to re-tearing. There has been little written about post-operative 

factors which predispose to re-tearing. Understanding characteristics within post- 

127

operative outcomes may provide indicators into re-tear. Developing a greater 

understanding of post-operative outcomes related with re-tear can identify patients “at 

risk” allowing further customization of rehabilitation protocols. 

2. Description of methods. 

769 patients who had undergone rotator cuff repair between February 2006 and 

January 2014 by one surgeon. The minimum patient follow-up period was 26 weeks. 

This group of comprised of 482 males and 287 females with an average age 

at surgery of 59.08 years (SD 10.06). Preoperative, 6 week, 12 week, and 26 

week Constant Shoulder Scores (CSS), Western Ontario Rotator Cuff Index (WORC), 

Oxford Shoulder Score (OSS) and Short Form 12 physical scores (SF-12) were 

assessed. A two-tailed, unequal variance paired samples t-test was used to compare 

preoperative and postoperative outcomes. An outcome p-value of p

postoperatively as a significant independent prognostic factor 


All patients with rotator cuff (supraspinatus ± infraspinatus) tear that required 

arthroscopic repair during the period between 1st June 2010 and 31st May 2012, 

with completed serial ultrasound at 6 weeks, 12 weeks, and 26 weeks postoperatively 

were included. Intraoperative findings were noted. Functional clinical outcomes were 

assessed by Constant scores, Western Ontario Rotator Cuff Index, and Oxford score. 

Compliance of patients with postoperative rehabilitation was established. 

3. Summary of results 

There were 127 cases with a mean age of 60. Overall re-tear rate was 29.1%. 

The percentage of new re-tears was significantly higher in the first than the second 

12 weeks postoperative (25.2% and 3.9 % respectively). Patient’s postoperative 

compliance was a significant prognostic factor for re-tearing. Significant associations 

were also found between re-tear and primary tear size, tendon quality, repair tension, 

cuff retraction and footprint coverage. Poor-compliance of patients was highest 

(17.3%) during the second 6 weeks postoperative. Better functional outcomes were 

noted in patients that have re-torn their cuffs at the 12 weeks period (Oxford mean 

scores, p=0.04). 

4. Conclusion 

The patient’s poor compliance to rehabilitation postoperatively is a significant 

independent prognostic factor that determines cuff re-tearing after surgery. Other 

significant factors that may reduce the repaired cuff integrity include a large primary 

tear size, poor tendon quality, high repair tension, highly retracted cuff, and 

poor footprint coverage by the repaired tendon. The patient’s compliance may be 

reduced throughout different phases of rehabilitation. Continuous monitoring of the 

patient’s compliance is therefore important, and an early significant improvement in 

symptoms should alert the surgeon that the patient’s compliance may be suboptimal, 

leading to cuff re-tearing or loss of repaire 

Paper 83 

Presenter: L Jameson 

Authors: Burger, E.L, Sandoval, Melanie 


Abstract title: Implementation of SSI bundles in spine surgery 

Surgical site infections (SSIs) have been identified as the most prevalent and costly 

health care acquired condition (HAI). The average cost of a surgical site infection 

ranges between $18,500 and $28,000k. This cost does not take into account the 

indirect costs of missed work days or impact on the patient or care taker’s quality of 

life. Bundles of care aimed to minimize the occurrence of post-operative SSIs have 

been found to be effective in reducing infection rates and associated costs. 

The purpose of this quality improvement project was to identify evidence-based 

129

elements for a standardized bundle of care to reduce surgical site infections, followed 

by the implementation and evaluation of elements aimed to decrease infection rates, 

increase patient satisfaction with preoperative treatment, minimize variance and error 

in practice, and decrease the overall healthcare-associated costs among surgical 

patients undergoing spinal fusions or laminectomies. 

A multidisciplinary task force was formed to implement interventions after an extensive 

review of the literature was conducted and best practices were identified. Elements 

of a spine SSI-bundle were specified and a hospital-wide bundle was created. The 

bundle included replacing the standard staph decolonization (mupirocin ointment, 3-5 

days preoperatively) with one nasal application of povidone-iodine. Bundle elements 

included: Preoperative showers x3 consecutive days with antibacterial soap, nasal 

povidone-iodine, chlorhexadine gluconate wipe to surgical site, appropriate hair 

removal, and standardization of intraoperative skin prep. Infection rates and patient 

satisfaction/adverse effects were collected and compared pre and post intervention. 

A gap analysis was performed and areas for improvement were identified, including: 

standardizing order sets, preference cards, and continued improvements in nurse, 

physician, and patient education. 

Overall spine infection rates decreased among laminectomy patients (0.97 to 0) over 

the course of one year post-implementation, and the raw number of infections (n=3) 

has decreased post-intervention compared to 2012 (n=13) and 2013 (n=7). Postoperative 

patient surveys (N=44) found nasal povidone iodine as very acceptable 

(53%, n=23); acceptable (37.2%, n=16); undecided (4.7%, n=2); unacceptable 

(2.3%,n=1); and, very unacceptable (2.3%,n=1). The most common adverse effects 

of povidone-iodine among patients included headache (23.7%); congestion (21.1%); 

cough (18.4%); pain (15.8%); irritation (7.9%). 

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Evidence-based bundles should be identified and implemented to reduce infection 

rates, improve patient satisfaction, and practice cost-avoidance in healthcar 

Paper 85 

Presenter: EL Burger 

Authors: Noshchenko, Andriy; Lindley, Emily M.; Burger, Evalina L. Cain, 

Christopher M.J. Patel, Vikas V 


Abstract title: Long Term Patient-Centered Clinical Outcomes of Lumbar Arthrodeses 

in Degenerative Disc Disease: A Systematic Review with Meta Analysis 

Purpose 

The effective treatment of lumbar spondylosis is a complex clinical and economic 

concern for patients and health care providers. The purpose of this study was to 1) 

evaluate long-term patient-centered clinical outcomes after lumbar arthrodesis, with 

or without decompression for lumbar spondylosis and 2) compare these outcomes 

130

to those of alternative treatments, nonsurgical and surgical, which maintain lumbar 

spine mobility. 

Methods 

This systematic review with meta-analysis included skeletally mature adults with lumbar 

DDD included in prior published studies. Selection criteria: RCT’s comparing treatment 

effects of lumbar arthrodesis with other interventions in skeletally mature adults with 

lumbar DDD. Databases searched included Ovid MEDLINE, Embase, and the 

Cochrane Library. All years through February 2013 were included. Patient-centered 

clinical outcomes before treatment and at 12, 24, or >24 months follow-up, and rate 

of additional surgical treatment were included in the analysis. A meta-analysis was 

performed to evaluate pooled treatment effects. The GRADE approach was applied 

to evaluate the level of evidence. 

Results 

Electronic searches provided a total of 1411 citations; 38 RCT’s of 5738 participants 

were included in the review. The studies investigated clinical outcomes of: 1 or 2 level 

lumbar arthrodesis, 1 or 2 level lumbar arthroplasty, decompression without arthrodesis, 

and nonsurgical treatment. The following patient-centered clinical outcome scales 

were used: Oswestry Disability Index; European Quality of life Questionnaire; SF-36 

physical scale, and SF-36 mental scale; Numeric Rating Scale or Visual Analog Scale 

for back pain, Numeric Rating Scale or Visual Analog Scale for leg pain; Dallas Pain 

Questionnaire; Roland Morris Disability Questionnaire, and Japanese Orthopaedic 

Association Score. In spite of different scales, all studies showed strong or at least 

moderate treatment effects of lumbar arthrodesis at 12, 24, and 48-72 months of 

follow up. The level of evidence was moderate at 12 and 24 months and low at 

48-72 months. The pooled long term treatment effect of lumbar arthrodesis exceeded 

those of nonsurgical treatment (p

Abstract title: Rates of Complications and Required Additional Surgical 

Interventions after Spinal Arthrodesis versus Alternative Treatment in Lumbar 

Spondylosis: A Systematic Review with Meta Analysis 

Purpose 

The purpose of this study was to 1) evaluate the long-term complication rate (CR) 

and rate of additional surgical treatment after lumbar arthrodesis (LA) with or without 

decompression for lumbar spondylosis, and 2) compare these outcomes to those of 

alternative treatments, including nonsurgical (NST) and disc replacement (TDR). 

Methods 

This systematic review with meta-analysis included skeletally mature adults with lumbar 

DDD included in prior published studies. Selection criteria: RCTs comparing treatment 

effects of LA with other interventions for adults with lumbar DDD. Databases searched 

included Ovid MEDLINE, Embase, and the Cochrane Library. All years through 

February 2013 were included. Complication rate and additional surgical treatment 

at 12, 24, or >24 months follow-up was assessed. A meta-analysis was performed. 

The GRADE approach was applied for the level of evidence. 

Results 

Electronic searches provided 1411 citations: 26 RCTs of 4949 participants 

were included in the review. The studies investigated 1 or 2 level LA, 1 or 2 level 

decompression without arthrodesis, and NST at 12-48 months follow up. The pooled 

CR after LA was 25.4% , p

Paper 87 

Presenter: C Kleck 

Authors: Kleck CJ, Perry J, Burger EL, Cain C, Patel VV 


Abstract title: Minimally Invasive Technique for Placement of Sacroiliac Arthrodesis 

Implants using O-Arm and Stealth Navigation 

Purpose 

New techniques have been developed for sacroiliac (SI) joint arthrodesis; however, 

they typically require surgeon and staff exposure to radiation, as well as complicated 

pelvic imaging. The purpose of this study was to describe a new minimally invasive 

technique for SI joint arthrodesis. 

Methods 

We report a minimally invasive SI fusion technique using O-Arm/Stealth Navigation. 

45 patients (50 joints) underwent surgery and were reviewed for complications 

associated with instrumentation placement. Technique: patients are positioned prone 

on a Jackson Frame, the operative side bolstered. A knick is made 10mm proximal 

and anterior to the PSIS. A terminally threaded pin and sleeve for the navigation frame 

is placed on the ilium and advanced into the bone. O-Arm images are obtained and 

transferred to the Stealth Station. The navigated ball-tip probe is placed on the skin. 

The SI joint and appropriate entry points are evaluated utilizing a projection. The skin 

is marked corresponding with these points. An incision is made such that all marked 

points can be accessed with minimal soft tissue interference. A navigated soft tissue 

protector is pre-loaded with a guide pin, held in place with a kocher. A ruler is used 

to measure and mark the previously calculated depth for guide wire. The first implant 

entry site is identified. The fascia is pierced and the guide is advanced to the lateral 

ilium. The guide pin is advanced across the SI joint. A projection of the implant size is 

made and saved on the Stealth Station. The soft tissue guide is removed, leaving the 

wire in place. The implant soft tissue protector is advanced over the wire to the ilium. 

The path is drilled, and the implant is placed. The guide wire is removed and these 

steps are repeated. Once implants are placed, a final O-Arm image is obtained. 

Results 

2 guide wires broke intraoperatively; 1 was left in bone, the other was removed. 

No additional perioperative complications or adverse outcomes were noted. After 

modification of the pin and drill, no breakages have occurred in the last 25 procedures. 

Conclusions 

The use of O-Arm/Stealth Navigation in MIS SI joint fusion is a safe and effective 

method for implant placement. It allows for accurate placement and better visualization 

of underlying joint anatomy with no radiation exposure to the surgeon. 

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Paper 88 


Authors: Kleck CJ, Burger EL, Patel VV 


Abstract title: OneStep Technique for Minimally Invasive Placement of Pedicle 

Screws with O-Arm and Stealth Navigation 

Purpose 

Minimally invasive techniques have been described in the literature for pedicle screws 

placement and are safe and effective methods for pedicle screw instrumentation. 

However, these techniques routinely use C-arm fluoroscopy with increased radiation 

exposure to the surgeon and multiple instrument passes through the pedicle. The 

purpose of this study is to describe a new technique for minimally invasive placement 

of pedicle screws in the lumbar spine using O-Arm and Stealth Navigation in 

combination with current MIS pedicle screw technology. 

Methods 

We report a new technique for MIS pedicle screws; we started with a 2-step technique, 

with a navigated pedicle awl followed by screw placement, but have modified it to 

the 1-step technique described here. Thirty-one adult patients (168 screws) underwent 

lumbar surgery with pedicle screw placement using the 1- (9 patients/56 screws) or 

2-step (22 patients/112 screws) technique. Patients were reviewed for complications 

associated with instrumentation placement. Technique: An small incision is made over 

the L4 or L5 spinous process, through the fascia on either side. A navigation clamp is 

attached and tightened. 3D CT images are captured with O-Arm and transferred to 

the Stealth Navigation system. A blunt navigation probe is used on the skin to identify 

deep bone anatomy, utilizing a generated projection. An entry point for each pedicle 

screw is identified and the skin marked. An incision is made in line with the skin marks 

followed by the fascia.. The blunt probe is placed at the pedicle entry point. Screw 

length and width are measured with a projection. A guide wire is placed through the 

cannulated driver and screw until 5 mm is visible beyond the tip. The wire is held at 

the handle to prevent migration. The screw is placed at the pedicle entry point with 

stealth navigation. The wire is advanced 5 mm in order to dock the screw to the 

pedicle. The screw is then started with 2 taps on the driver. The screw is advanced 

15mm, the wire is removed, and the screw is fully seated. A second 3D CT spin can 

be performed for position confirmation. 

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Results 

Two screws (1.2%) were revised after the second O-Arm spin with the 2-step technique. 

No postoperative complications or adverse outcomes were noted. 

Conclusions 

The use of O-Arm/Stealth Navigation with MIS technology allows for safe placement 

of posterior spinal instrumentation with no radiation exposure to the surgeon. It also 

134

provides intraoperative evaluation of instrumentation and decreases the number of 

instrument passes through the pedicle. 

Paper 89 


Authors: Christopher J. Kleck MD, Damian Illing BS, Emily M Lindley PhD, Vikas V 

Patel MD, Cameron Barton BS, Todd Baldini MS, Christopher MJ Cain MD, Evalina 

L Burger MD 


Abstract title: A Comparative Analysis of Lumbo-sacral Fixation Strengths: What 

is Best in a Long Fusion? 

Purpose 

Pseudoarthrosis, sacral stress fractures, and instrumentation failure are all complications 

observed in long posterior lumbar and thoraco-lumbar fixation constructs. The long 

lever arm of the spine construct creates stress across the lumbosacral region. Various 

techniques have been developed to decrease the rate of pseudoarthrosis, including 

iliac bolts, anterior L5-S1 interbody cages, and anterior column fixation with interbody 

devices. While studies have been performed to support these methods in clinical use, 

there are limited data comparing various fixation methods biomechanically. Thus, the 

purpose of this study was to evaluate the biomechanical properties of anterior and 

posterior spinal fusion constructs using a combination of interbody devices with or 

without screws, anterior fixation, and iliac bolts. 

Methods 

Twelve fresh frozen cadavers were instrumented from L2-S1 for biomechanical 

evaluation. Strain gauges were used to measure strain on the rods between L5- 

S1, on connectors between S1 and iliac bolts, and on S1 screws. Each specimen 

was sequentially tested in flexion, extension, and rotation with different construct 

configurations, including interbody devices and iliac bolts. 

Results 

Extension: Overall, the addition of anterior and posterior instrumentation significantly 

decreased strain on the S1 screw, L5-S1 rod, and S1-iliac bolt connector. 

Flexion: Compared to posterior fusion without iliac bolts, strain at the S1 screw 

increased with iliac bolts, cages placed by a TLIF approach, and cages placed by an 

anterior approach. However, the strain decreased with the placement of an anterior 

cage and iliac bolts or an ATB. 

Rotation: Compared to posterior instrumentation with iliac bolts, strain on the S1 

screw significantly decreased when instrumentation was changed to a SynFix implant 

and iliac bolts were removed. A significant decrease at the S1 screw was seen when 

the ATB was used without bolts in the setting of the SynFix implant. 

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Conclusion 

While the results only present significant findings, several other trends were identified. 

The results indicate that flexion increases strain at the S1 screw and L5-S1 rod. This 

appears to increase with the use of anteriorly placed interbody devices or iliac bolts, 

and can be mitigated with the combination of iliac bolts and interbody cages. It 

appears iliac bolts actually increase the strain in flexion greater than interbody cages 

alone. When evaluating extension-based activities, anteriorly placed devices appear 

to decrease strain when compared to iliac bolts, but a combination of techniques 

provides the greatest decrease. In rotation, anterior interbody constructs appear to 

increase S1 strain compared to iliac bolts, but again, a combination of bolts and 

anterior devices led to decreased strain. 

Paper 90 


Authors: C Barton, A Noshchenko, V Patel, C Cain, C J Kleck, E L Burger 


Abstract title: Risk Factors Associated with Mechanical Complications Including 

Proximal Junctional Failure after Osteotomy for Adult Spinal Deformity 

Purpose 

Osteotomies including pedicle subtraction (PSO and Smith-Peterson (SPO) are widely 

used to facilitate correction in the treatment of adult spinal deformity (ASD), but are 

associated with mechanical complications (MC). The purpose of this study was to 

determine the incidence and risk factors for mechanical complications after osteotomy 

for adult spinal deformity. 

Study Design 

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Retrospective review of adult deformity database (COMIRB #14-1258) 

Methods 

Retrospective review of ASD database yielded 83 consecutive ASD patients (55 

female, avg. age 58) meeting strict inclusion/exclusion criteria and follow up of at 

least 1 year or incidence of MC. Data was extracted for each operation including 

patient variables, surgical variables, instrumentation variables, and postoperative 

variables. Operations were divided into groups based on MC (e.g. proximal 

junctional failure (PJF) vs. non-PJF) and odds ratios were calculated to assess risk 

factors for specific MCs. 

Results 

Incidence of MC occurred in 32/83 (39%) of patients following 37/90 (41%) 

of osteotomy operations and trended higher in PSO 49% (24/49) vs. SPO 32% 

(13/41) (p=.13). Number of operations with specific MCs: 13 with loose screws, 

11 PJFs, 10 pseudarthrosis, 7 subsequent adjacent decompressions, 5 broken rods, 

5 compression fractures, 4 isolated pedicle fractures, 4 uncoupling of instrumentation, 

136

1 sacral fx, 1 screw fx, and 1 osteotomy displacement. Risk factor meeting statistical 

significance for entire MC group was postop lumbar lordosis (LL)

(P=0.078). Significantly more patients with fusion also had ODI and NRS back 

pain scores that exceeded the criteria for minimal clinically important differences 

(MCID) (ODI, OR=2.7, P=0.019; NRS back pain, OR=3.5, P=0.033). However, 

the predictive values of fusion for clinical outcomes were poor, with low specificity 

and low negative predictive values. 

Conclusion 

The presence of radiographic fusion is clinically significant, as patients with fusion 

had better clinical outcomes at 1 and 2 years postoperative than those with nonunion. 

However, patient-centered clinical outcomes should also be taken into consideration 

as independent, complimentary variables when assessing treatment success 

Paper 92 


Authors: Zaghloul K, Lindley EM, Kleck CJ, Cain CMJ, Burger EL, Patel VV 


Abstract title: Pedicle Screw Placement in Spine Surgery: A retrospective review of 

O-arm/Stealth vs Non-Computerized Navigation Techniques 

Introduction 

Pedicle screws are commonly used for posterior stabilization of the thoracolumbar 

spine. Intraoperative CT-based navigation techniques are commonly used to decrease 

the risk of pedicle screw misplacement. The purpose of this study was to compare 

the accuracy of pedicle screw placement using O-arm navigation to that of nonnavigated 

techniques. 

Methods 

597 pedicle screws were measured in 70 patients using intraoperative or postoperative 

CT. Of these, 401 were placed using navigation and 196 were placed without 

computerized navigation. Screw placement was assessed on a grade I-IV scale, 

with Grade I including pedicle screws that were entirely within the pedicle/vertebral 

body. Screws that breached the cortex of the pedicle or vertebral body where graded 

(II-IV) in 2mm increments, noting the direction of the breach. The two groups were 

compared for accuracy in screw placement using chi-square test. 

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Results 

85.5% of navigated screws were Grade I, while 66.8% of non-navigated screws 

were entirely within the pedicle/vertebral body. Overall, 15 screws (3.7%) breached 

the pedicle or vertebral body cortex in the navigated group, and 19 screws (9.7%) 

breached the pedicle or vertebral body cortex in the non-navigated group. The 

number of cortical breaches in the non-navigate group was significantly higher than 

in the navigated group (OR 0.36 [95%CI] P=0.002). There were no neurologic or 

vascular compromises related to misplaced screws. 

138

Conclusion 

This study suggests that CT-based navigated techniques are more accurate than nonnavigated 

techniques for the placement of pedicle screws, and thus decrease the risk 

for pedicle screw breaches 

Paper 93 


Authors: E Burger, A Noshchenko, C Barton, S Molloy, M Chang, V Fiere 


Abstract title: Sagittal Plane Correction is Correlated with Quality of Life at Early 

Follow-up in Adult Deformity Patients 

Purpose 

Adult spinal deformity (ASD) is a debilitating condition defined by alteration of normal 

spinal curvature and is associated with decreased quality of life. Deformity correction 

often requires intensive surgery and has potential for major complications that may be 

outweighed by overall improvement in quality of life (QOL). The purpose of the study 

is to evaluate the correlation between sagittal plane correction and QOL for ASD 

patients treated with instrumented posterior fusion. 

Methods 

Seventy-two consecutive patients who underwent multilevel (4-18) posterior surgical 

correction for degenerative scoliosis and/or kyphosis were enrolled in a multicenter 

prospective study between 2012 and 2014. Sixty-two patients (48 female, and 

14 male), mean age 60.6 years (Standard Deviation=11.7) were eligible for the 

present analysis after exclusion. Patient quality of life questionnaires (SRS22 and ODI) 

and sagittal radiographic parameters (sagittal vertical axis (SVA), pelvic incidence 

minus lumbar lordosis (PILL), T1 pelvic angle (TPA) and pelvic tilt (PT)) were collected 

preoperatively and at 6 months follow-up. Questionnaire scores were compared to 

radiographic parameters to determine correlation and treatment effect (TE). TE was 

defined as mean pre to post difference (MD); standardized mean difference (SMD) was 

defined as the ratio of MD to preoperative standard deviation. 

Results 

Fifty three patients were available at 6 month follow up: compared to preoperative status, 

the ODI MD was -14 (St.D, 8.2), SMD=-0.94, p

Conclusions 

Results of current study suggest that multilevel posterior instrumentation allows successful 

restoration of sagittal alignment in ASD patients. At 6 months follow-up, sagittal plane 

correction corresponded with improvement of QOL. However, the correlation between 

these treatment effects was weak, and other confounding factors should be studied. 

Paper 94 


Authors: Kleck CJ, Jesse MK, Illing D, Williams A, Petersen B, Milligan K, Glueck D, 

Lind K, Patel VV 


Abstract title: 3D MORPHOLOGIC ASSESSMENT OF NORMAL AND ABNORMAL 

SI JOINTS AND THE IMPLICATIONS IN THE DEVELOPMENT OF PAIN SYNDROMES 

Introduction: The purpose of the study was to establish a baseline of normal sacroiliac 

joint morphology through the utilization of 3D surface rendered imaging of the SI joint, 

as well as devise a novel classification system of SI joint articular surface morphology. 

Methods: 3D surface rendered images of the SI joint were acquired in 223 

normal controls. Morphologic 3D assessment of the articular surface morphology, 

and measurements of sacral tilt, inclination and sacral and iliac surface area were 

performed. SI joint morphologies were further classified into three types based on 

shape (Types 1, 2 and 3). Thirty-four pain patients were analyzed in a similar fashion 

as above with emphasis on SI articular surface area and surface morphology. 

Results: Average sacral tilt, inclination and surface areas were established in the 

control group. Visual morphologic assessment revealed a dominance of the Type 2 

morphologic variant. Significant association was found between Type 3 morphology 

and the development of pain (p-value 0.04) and lower mid and caudal inclination 

and the development of pain (p-values 0.01 and 0.049). 

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Conclusion: Our study provides a new look at SI joint morphology with insight 

into visual morphologic differences in articular surface shape and variability in 

articular surface area and determines an association between morphology and the 

development of pain. 

Paper 95 

Presenter: L Biant 

Authors: LC Biant, G Robertson, M Moran 

Disclosure: Yes: Institutional support only (no personal conflict) from JRI Ltd 

Abstract title: Randomized Controlled Clinical Trial of Hip Fracture Hemiarthroplasty 

With vs Without a Flexible Acetabular Buffer 

140

Purpose of study: Patient function after hip hemiarthroplasty is not as good as after 

total hip replacement. Adding a flexible acetabular buffer to the hemiarthroplasty has 

the theoretical advantage of maintaining short operating time and large head of a 

hemiarthroplasty, with the possible improved function and reduced acetabular erosion 

of a total hip replacement 

Method: A randomized controlled trial (RCT) of 98 cognitively intact elderly 

patients with a displaced intracapsular hip fracture. All patients received a standard 

cemented modern femoral component. Patients were randomised to receive either a 

bipolar femoral head or a monopolar femoral head with the addition of a flexible 

polycarbourethane acetabular component. The visual analogue pain scores, Oxford 

Hip Score, Harris Hip Score and The EQ5D quality of life scores were recorded. 

Radiographic analysis by blinded observers measured acetabular penetration by the 

head. 

Results: Both groups did well. At minimum two years (range 2-4 years), there were no 

clinically significant differences between the groups in the patient-reported outcome 

measures. Radiographic acetabular penetration occurs with both techniques but was 

minimal. There were three failures in the tribofit group and one in the standard hip 

hemiarthroplasty group. A retrieved well-fixed buffer after 11 months showed marked 

backside scratching 

Conclusion: There is no clinical benefit at two years to the addition of a 

polycarbourethane acetabular buffer component over standard bipolar hip 

hemiarthroplasty in hip fracture surgery. Acetabular erosion is minimal but occurs 

with both techniques. Retrieval shows of a buffer to bone prosthesis shows extensive 

backside scuffing 

Paper 96 

Presenter: L Biant 

Authors: LC Biant, I Mannelius, MM McQueen 


Abstract title: Clinical Outcome of 622 Consecutive Patients with a Distal Radius 

Fracture at 16-23 Years Follow-up 

Purpose of study: The long-term functional outcome after distal radial fracture is 

unknown. Prospective study of 622 consecutive patients with a distal radius fracture 

at 16-23 year post injury. 

Method: Prospective data and radiographic grading of 622 consecutive distal radius 

fracture patients. Surgical treatment was dependent on the fracture pattern and preinjury 

patient functional demand. At 16-23 years following injury, patients completed 

the Quick Disability of the Arm, Shoulder and Hand (QDASH) scores. Patient mortality 

and time from fracture to death was recorded. Effect of fracture displacement, age, 

socioeconomic status and gender on long term outcome was analysed. 

141

Results: Mean QDASH score at long-term was 10.35. There was no gender difference 

in clinical outcome. Patients sustaining their distal radius fracture in combination 

with another fracture had poorer outcome. Younger, affluent patients and those with 

less dorsal angulation at fracture union had the best outcomes. 303 patients were 

deceased; mean time from distal radius fracture to death was 11 years 5 months. 

Conclusion: The long-term clinical outcome following distal radius fracture is good. 

Mean time from fracture to death is 11 years 5 months. The level of pain and function 

following injury can be predicted based on patient demographics and fracture 

characteristics. 

Paper 97 

Presenter: R Buckley 

Authors: R Buckley, B Meulenkamp, N Desey, R Martin, R Korley, P Duffy, S Puloski 


Abstract title: Incidence, Risk Factors and Location of Articular Malreductions of 

Tibial Plateau Fractures 

Purpose: What is the incidence, risk factors and location of articular malreductions 

following surgical fixation of tibial plateau fractures? 

Description of methods: This prospective cohort study from a Level 1 trauma center took 

tibial plateau fracture patients in a consecutive cohort. De-identified postoperative 

CT scans were reviewed to identify tibial plateau malreductions with a step or gap 

greater than 2mm, or condylar width greater than 5mm. Three independant assessors 

reviewed the scans meeting criteria using Osirix DICOM software. Steps and gaps 

were mapped onto the axial sequence at the level of the joint line. Images were 

then matched to side and overlaid as best fit in Photoshop software to create a map 

of malreductions. A grid was created to divide the medial and lateral plateaus 

into quadrants to identify the density of malreductions by location. A multi-variate 

regression model was used to assess risk factors for malreductions. The p[rimary 

outcome was incidence of articular malreduction. Secondary outcomes included risk 

ractors for malreduction and a descriptive analysis of malreduction location. Ethics 

ID: E-20818 

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Summary of Results: Sixty-five postoperative CT scans were reviewed. Twentyone 

reductions had a step or gap more than 2 mm for a malreduction incidence of 32.3%. 

The incidence in patients undergoing submeniscal arthrotomy or fluoroscopic assisted 

reductions was 16.6% and 41.4% respectively (p

Paper 98 

Presenter: HI Ingoe 

Authors: H Ingoe, A Middleton 


Abstract title: A Functional Angle of 35° at the Distal Interphalangeal Joint Can Be 

Achieved with Headless Compression Screw Fusion 

Purpose of study: 

Arthodesis of the distal interphalangeal joint has been shown to reliably improve 

symptomatic arthritis. Main indications include a painful joint with osteo, inflammatory 

or post traumatic arthritis which has exhausted conservative and joint preservation 

treatment A range of successful surgical techniques including tension band wiring, 

plate fixation and headless compression screws have been described and produce 

a stable painless unions. For best functional outcome the fusion angle should be 

between 20 and 61 degrees. In the past it has been difficult to achieve more than 

10 degrees of flexion with a headless compression screw. Higher fusion angles have 

been reported using tension band wiring technique however metal work prominence 

is a common problem and may require reoperation. It has been reported that headless 

compression screws can cause associated fractures due to the size of the screw 

relative to the small diameter of the phalanx. This case series shows that 35 degrees 

can be achieved with good functional outcome. 

Description of methods: 

Twelve patients have undergone an open fusion of the distal interphalangeal joint 

with a headless 2.2mm cannulated compression screw. A retrograde technique was 

used to create compression over the joint following an open preparation of the bone 

surfaces. Angles of up to 35 degrees were achieved with a single compression screw. 

They received standard follow up to radiographic union. Postoperative functional 

scores were collated using the validated Michigan Hand Questionnaire (MHQ). Postoperative 

radiographs assessed the fusion angle. 

Summary of results: 

Mean age of patients 58 years, M:F ratio 1:3, index:middle:little digits 5:5:2. 

All patients went on to union with no patients requiring revision fusion surgery. 

Radiographic analysis showed fusion angles up to 35 degrees were achieved with 

favourable functional outcome. Complications included superficial infection (n=1) 

and discomfort requiring removal (n=1). There were no associated fractures with 

insertion of the screw. Michigan hand questionnaire scores post operatively showed 

good functional outcome. 

Conclusion: 

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Successful union of up to 35 degrees of flexion can be achieved in the distal 

interphalangeal joint with a 2.2mm headless compression screw. Benefits included 

early mobilisation, better functional angle, low complication risk and no metal work 

prominence. 

Paper 99 

Presenter: S Emery 

Authors: SE Emery, JC France, SD Daffner, GR Hobbs 


Abstract title: The Effects of Perioperative Steroids on Dysphagia Following 

Anterior Cervical Spine Surgery: A Randomized, Prospective, Double-Blind Study 

Introduction: Dysphagia following anterior cervical spine operative procedures 

is expected due to esophageal retraction. Studies have documented persistent 

swallowing difficulty in some patients up to two years after surgery. We performed 

a randomized, prospective, double-blind study to compare the effects of intravenous 

perioperative steroids vs. placebo (saline) on short- and long-term swallowing function. 

Materials and Methods: Sixty-four patients were randomized to receive either 

intravenous decadron before incision (0.3 mg /kg), 8 hours postoperatively (0.15 

mg/kg), and 16 hours postoperatively (0.15 mg/kg) or the same volume of saline 

using the same regimen. All patients underwent an anterior cervical decompression 

and fusion with plating procedure for degenerative conditions, with 49 discectomy 

plus fusion, 9 corpectomy or hybrid constructs, and six disc arthroplasties. Patients 

with a diagnosis of fracture, malignancy, infection, or prior history of cervical surgery 

were excluded. No anterior-posterior (360⁰) patients were included. 

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Patients were surveyed using both the Dysphagia Short Questionnaire and the Bazaz 

Dysphagia Scale. Data were collected one day, two days, one week, two weeks, 

three months, six months, and 12 months postoperatively. Statistical analysis using 

Poisson regression was performed comparing the average scores of the two groups 

at each time point, with statistical significance set at p< 0.05. Clinical outcomes 

were also obtained using the patient-reported QoL-12 and Neck Disability Index to 

compare the two groups. 

Results: Baseline demographics and number of levels fused were similar for the two 

groups. Patients receiving perioperative steroids had statistically better dysphagia 

scores at one day, two days, one week, two weeks, three months and six months using 

the Dysphagia Short Questionnaire. On the Bazaz scale, patients in the steroid group 

had better swallowing function at one day, two days, one week, two weeks, and six 

months postoperatively (all values p

Conclusion: Perioperative intravenous steroids can reduce dysphagia symptoms 

following anterior cervical operative procedures. Benefit was noted immediately 

and up to six months postoperatively. A decrease in length of stay could not be 

demonstrated in this study population. 

Paper 100 

Presenter: O Koch 

Authors: O Koch, A Du Plessis, S Olorunju, H McLoughlin, TLB Le Roux 


Abstract title: Incidence of deep vein thrombosis following shoulder replacement 

surgery 

The objective of the study was to determine the incidence of deep vein thrombosis 

(DVT) in the ipsilateral limb following shoulder replacement surgery and to evaluate 

the incidence of lower limb DVT’s associated with beach chair positioning during 

shoulder replacement surgery in general. 57 patients (28 males and 29 females) with 

30 reverse shoulder replacements, 22 hemiarthroplasties and 5 resurfacing shoulder 

replacements were followed for a period of 6 weeks. This was a cross section 

analytic study. Patients who received shoulder arthroplasty surgery (resurfacing/ hemi 

or reverse) from 1 July 2013 to 30 June 2015 were included in the study. A colour 

flow venous duplex Doppler was done on the affected limb on average 8 to 10 

days following surgery. All duplex Doppler investigations were performed by a single 

board-certified musculoskeletal sonologist specialising in ultrasonography. Patients 

who received preoperative anticoagulation, such as heparin or warfarin, patients 

with active thromboembolic disease and patients who declined to participate in the 

study were excluded. 

A summary of the results showed the mean age, 62 years (Range 35-80 years). The 

mean surgery time was 58.4 minutes. The incidence of DVT was 12.3% (7/57 of 

which 3 were males and 4 were females) with 5 ipsilateral upper limb DVT’s and 2 

lower limb DVT’s. The incidence of nonfatal pulmonary embolism was 1.8% (1/57). 

No fatalities were reported. 

In conclusion, the rate of DVT following shoulder replacement surgery was comparable 

to the study of Willis et al (13%). There was no association between the prevalence 

of DVT and duration of surgery, gender or body mass index. Shoulder arthroplasty 

surgeons should be aware of the potential risk of DVT since there are no guidelines 

regarding thromboprophylaxis in this group of patients. 

Reference 

Willis AA, Warren RF, Craig EV, Adler RS, Cordasco FA, Lyman S, et al. Deep 

vein thrombosis after reconstructive shoulder arthroplasty: A prospective observational 

study. Journal of Shoulder and Elbow Surgery 2009; 18(1):100-106 

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Paper 101 

Presenter: PR King 

Authors: PR King, A Ikram, RP Lamberts 


Abstract title: Effectiveness of a novel intramedullary fixation device compared to 

traditional plating for the treatment of displaced clavicle shaft fractures 

Purpose 

Displaced and shortened clavicle shaft fractures can be treated operatively by intra- or 

extramedullary fixation. The aim of this study was to compare the effectiveness of a 

novel, locked intramedullary device with traditional plating. 

Methods 

Seventy two patients with acute displaced and shortened clavicle shaft fractures were 

randomized to either an intramedullary locked fixation group (Nailing Group, n=35) 

or an anatomically contoured locked plating group (Plating group, n=37). All patients 

were operated by the same surgeon and had identical post-operative treatment 

regimes. The effectiveness of each treatment regimen was assessed based on 

incision length, operative time and union rate. Disabilities of the Arm, Shoulder and 

Hand Score (DASH) and Constant Shoulder (CS) Score were assessed 1 year postoperatively. 

Results 

There were no significant differences in age, gender, fracture comminution, and/or 

displacement between the Nailing and Plating groups. However, mean operating 

time was shorter in the Nailing group than in the Plating Group (45 ± 12 min vs. 

65 ± 21 min, p < 0.001) and scar size was shorter in the Nailing group than in 

the Plating group (37 ± 9 mm vs.116 ± 18 mm, p < 0.001). Although all fractures 

well fully united 12 months post-operatively, both DASH scores and CS scores were 

significantly better in the Nailing group (5 ± 6) than in the Plating group (5 ± 6 vs.15 

± 19, p = 0.03, and 97 ± 5 vs. 91 ± 12, p = 0.002, respectively). 

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Conclusion: 

Both anatomically contoured locked plating and locked intramedullary fixation 

resulted in successful treatment of displaced and shortened clavicle shaft fractures. 

However, intramedullary fixation was associated with shorter operating times and 

smaller incision sizes. Furthermore, patients treated with intramedullary fixation 

had a better functional outcome than patients treated with traditional plating when 

compared 1 year post-operatively. Based on these findings and the absence of 

prominent subcutaneous hardware necessitating removal of the nail, intramedullary 

fixation could be considered a noteworthy alternative to traditional plating for the 

treatment of displaced clavicle shaft fractures. 

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Paper 102 

Presenter: H Johal 

Authors: H.S. Johal, T. Costales, M. Christian, M. Coale, B. Haac, R.V. O’Toole, T. 

Manson 


Abstract title: Complications Associated with the Use of Enoxaparin in Orthopaedic 

Trauma Patients 

Purpose: Orthopaedic trauma patients are susceptible to developing Venous 

Thromboembolic (VTE) complications such as leg deep venous thrombosis (DVT) and 

pulmonary embolism (PE). While VTE prophylaxis using low molecular weight heparin 

(LMWH) has been shown to be effective at preventing limb DVT, it is relatively costly 

compared to other chemoprophylactic agents, and the incidence of related wound 

and bleeding complications in this population is unknown. In arthroplasty literature, 

prolonged wound drainage associated with an increased risk of surgical site infection 

and hematoma have been identified as a reason to seek alternatives to LMWHs. Our 

hypothesis was that LMWH would be highly efficacious at preventing proximal DVT 

and pulmonary embolism in orthopaedic trauma patients and have an acceptable 

rate of bleeding complications. 

Methods: A prospective trauma database was searched for all adult orthopaedic 

trauma patients presenting to a level-I urban trauma center over a 12-month period. 

CPT and ICD codes were used to identify all pelvic, acetabular and hip fractures, as 

well as all operatively treated upper and lower extremity fractures in adult patients (>18 

years) with a minimum of 6 month follow. Only those patients receiving enoxaparin for 

VTE prophylaxis were included for analysis. Patients were excluded if they had a preexisting 

history of coagulopathy, had received confounding anticoagulation, or had 

isolated hand or foot injuries. Outcomes included the 6-month incidence of VTE events 

as well as major bleeding complications. VTE was defined as all confirmed proximal 

deep vein thrombosis (DVT) and central and sub-segmental pulmonary emboli (PE). 

Based on cardiac and anticoagulation literature, major bleeding complications were 

defined as fatal bleeding into a critical organ, clinically overt bleed requiring a 

transfusion of 2 or more units following administration of LMWH. Additional wound 

complications including wound drainage or hematoma requiring reoperation and a 

diagnosis of deep surgical site infection were also recorded. Patient demographic 

and injury characteristics were collected to assess for associations with the outcomes 

of interest. 

Results: 882 orthopaedic trauma patients were identified for inclusion (mean age = 

46.8 years, mean Body Mass Index [BMI] = 28.3, mean Injury Severity Score [ISS] = 

15.5). The incidence of major bleeding and wound complications following LMWH 

prophylaxis was 14.7% (95% confidence interval [CI], 12.4%-17.1%). The incidence 

of VTE events was 3.5% (95% CI, 2.3%-4.7%). Independent risk factors associated 

with VTE events include serum lactate >5 within 6 hours of presentation and lower 

147

extremity fractures at or proximal to the knee. Independent risk factors associated with 

major bleeding complications include increased patient age, elevated BMI, ISS > 

18, open fractures, and multiple extremity fractures. 

Conclusions: We observed a low overall incidence of VTE, however, found a 

significant number of bleeding and wound complications associated with LMWH. 

This leads us to question the safety of its use in this population. 

Paper 103 

Presenter: R Parkinson 

Authors: M Hossain, K Howard, R.W. Parkinson 

Disclosure: Yes: nil 

Abstract title: Early results of fixed bearing medial unicompartmental knee 

replacement using a cemented all polyethylene tibial component 

Objective: Fixed bearing unicompartmental knee replacement (UKR) is traditionally 

performed using a metal-backed tibial component. The objective of this study was to 

evaluate the early results of a fixed bearing medial UKR performed using a cemented 

all polyethylene (UHMWPE) tibial component. To our knowledge this is the largest 

recorded series of a medial UKR using a UHMWPE tibial component. 

Methods: We retrospectively reviewed the medial records and radiographs of 138 

consecutive UKR performed between September 2009 and July 2014. All cases 

were performed by the senior author. 

Results: there were 78 males and 60 females. The mean age was 65 (range 40-87). 

The pre-operative varus deformity ranged from 0-10 degrees. Follow up ranged from 

12-72 months. 2 patients died. 14 (8.70%) were lost to follow up. The pre-operative 

range of movement was 0-130 degrees. The post-operative range of motion was 

0-130 degrees (p>0.05). The mean length of stay was 2.8 days (range 1-9) with 

most of the patients admitted on the day of surgery. The mean body mass index 

(BMI) was 30 (range 21-49). Most patients were mobilised on the day of operation 

and all received both mechanical and chemical thromboprophylaxis. There were 

no clinically significant VTE (venous thromboembolism) events. There were no intraoperative 

complications or deep infections. 1 patient developed a post-operative pain 

syndrome and associated stiffness requiring manipulation under anaesthesia. 127 

patients (92%) were highly satisfied or satisfied with surgery. 17 patients (12.31%) 

were not satisfied followigng surgery, 10 of whom (7.24%) had unexplained pain. 

There were 3 revisions (2.17%), 1 for a progressive radiolucency and 1 was revised 

unsuccessfully by another surgeon for unexplained pain that persisted after revision. 

1 patient awaits revision for progression of patello-femoral arthritis. A radiolucent line 

was observed beneath the tibial base plate in 3 further patients who remain under 

surveillance. The cumulative probability of survival at 5 years was 97.41% (95% 

CI 92.72%-99.23%) which compared favourably to the UK national joint registry 

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148

estimate of 5 year cumulative probability of survival of 95.24% for a fixed bearing 

UKR of similar design. 

Conclusion: Our results demonste excellent early survival and patient satisfaction. The 

complication rate was low. Using an all UHMWPE tibial component resulted in a cost 

saving of 33,810 GBP (245 GBP prer case) compared to the more commonly used 

modular tibial design without adversely affecting the clinical outcome. 

Paper 104 

Presenter: A Bois 

Authors: B. Eubank, N.G. Mohtadi, M. Lafave, J.P. Wiley, A. Bois, D.M. Sheps 


Abstract title: Using the Modified Delphi Method to Establish Clinical Consensus 

for the Diagnosis and Treatment of Patients with Rotator Cuff Pathology. 

Background: 

Clinical pathways are optimal patient care processes that have been developed 

to improve the quality of care for patients. Anecdotal evidence has suggested that 

patients presenting to the Canadian public healthcare system with rotator cuff tears 

experience less than ideal quality care plagued by lengthy wait times, challenges in 

coordinating care, and inefficient use of healthcare resources. Therefore, diagnosis 

and treatment of patients with rotator cuff tears in Canada are in need of quality 

improvement through evidence-informed decision making. The purpose of this study 

is to develop a clinical pathway for patients presenting to the Canadian public 

healthcare system with rotator cuff tears. 

Methods: 

The following steps were taken in developing the clinical pathway: 1) a multidisciplinary 

expert panel was formed; 2) goals of the clinical pathway were identified by the 

panel; 3) the literature and current clinical practices for best practice were reviewed; 

4) recommendations for treatment algorithms were developed using consensus 

methods. 

Results: 

The panel consisted of fourteen experts representing the two largest cities in Alberta, 

Canada (Edmonton and Calgary). The team consisted of at least one member from 

the clinical domains of sport medicine, orthopaedic surgery, athletic therapy, and 

physiotherapy. The first goal of the clinical pathway was to standardize screening, 

diagnosis, and physical examination of the patient. The second goal was to provide 

recommendations for appropriate investigations. The final goal was to map steps 

in the patients’ care pathway including sequencing and timing recommendations for 

treatment and interventions. Best practices were reviewed by the panel and using a 

149

modified Delphi method, clinical pathways for three types of rotator cuff tears (acute, 

chronic, and acute-on-chronic) were developed. 

Conclusion: 

A clinical pathway that reflected best practices was developed from the literature and 

experts. The clinical pathway for diagnosis and treatment of patients with rotator 

cuff pathology will help to standardized patient care, improve patient flow, reduce 

unnecessary interventions, reduce healthcare utilization and costs, and improve the 

quality of patient care in the Canadian public healthcare system. 

Paper 107 

Presenter: DK Jan Philippe 

Authors: Kretzer JP, Mueller U, Braun S, Juszczyk M, Uhlenbrock A, Schroeder M 

Disclosure: Yes: This study has been supported by a research grant from Ceramtec. 

Abstract title: A new method to experimentally determine polyethylene wear in 

anatomic total shoulder joint replacements 

The numbers of anatomic total shoulder joint replacements (ATSR) is increasing during 

the past years with encouraging clinical results. However, the survivorship of ATSR 

is lower as compared to total knee and hip replacements. Although the reasons for 

revision surgery are multifactorial, wear-associated problems like loosening are wellknown 

causes for long-term failure of ATSR. Currently there is no standardized method 

for wear evaluation of ATRS available. Therefore the purpose of this study was to 

define experimental wear testing parameters based on clinical and biomechanical 

data and to perform an experimental wear study. 

Kinetic and kinematic data were adopted from in-vivo loading measurements of the 

shoulder joint (orthoload.com) and from several clinical studies on shoulder joint 

kinematics. As activity an ab/adduction motion of 0 to 90° in combination with 

an ante/retroversion while lifting a load of 2 kg has been chosen. Also a superiorinferior 

translation of the humeral head has been considered. The wear assessment 

was performed using a force controlled AMTI joint simulator for 3x10 6 cycles and 

polyethylene wear has been assed gravimetrically. 

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The studied ATSR (Turon TM , DJO Surgical, USA) resulted in a polyethylene wear rate 

of 60.79 ± 1.85 mg per 1x10 6 cycles and the wear scars dimensions were similar 

to clinical retrievals. Furthermore, it was noticed that the wear rate is effected by the 

extend of combined motions with lower wear if cross shear is reduced. 

This study is the first that experimentally studied the wear behavior of ATSR based 

on clinical and biomechanical data under load controlled conditions. Compared to 

experimental wear studies of total knee and hip replacements the wear rate of the 

studied ATSR was extremely high (approx. 5 to 10 times higher). Therefore further 

research may focus on optimized wear conditions of ATSR and the hereby described 

method may serve as a tool to evaluate a wear optimization process. 

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Paper 108 

Presenter: W Hiddema 

Authors: W Hiddema, J Van der Merwe, W Van der Merwe 


Abstract title: The Transverse Acetabular Ligament as an Intra-Operative Guide to 

Cup Inclination 

Purpose: This study examined a novel method of using the transverse acetabular 

ligament (TAL) to guide cup inclination during primary total hip arthroplasty. 

Methods: A descriptive study using 16 hips from nine cadaveric specimen. A computer 

navigation system was utilized to measure the inclination of the acetabular component 

in three different positions: with the lower edge of cup being either (1) flush with, (2) 

5 mm proximal to, and (3) 5 mm distal to the free border of the TAL. Anteversion was 

recorded with the cup parallel to the TAL and kept consistent in all three positions. 

Results: The median inclination angles were 44° in position (1), 30° in position (2) 

and 64° in position (3). The median anteversion angle was 19°. 

Conclusion: We found the TAL to be an accurate landmark for positioning of the 

acetabular component as far as inclination and version is concerned. We recommend 

positioning the lower edge of the acetabular component flush with, or within 5mm 

proximal to the free border of the TAL as cup inclination was shown to be ideal in all 

cases when adhered to that principle. 

Paper 112 

Presenter: C Wilding 

Authors: E Jenner, R W Jordan, D Westcott, S Cooke 


Abstract title: An audit and comparison of the management of paediatric 

supracondylar fractures across three UK centres 

Introduction 

Supracondylar fractures of the distal humerus are the most common elbow fractures 

in children. The injury can be associated with nerve injury, vascular compromise and 

malunion. The British Orthopaedic Society set clear standards for assessment and 

treatment of these fractures in their 2014 BOAST guidelines. The recent implementation 

of the regional trauma networks in the UK has seen centres categorised as either 

Major Trauma Centres, Trauma Units or local emergency centres. The authors audited 

and compared the performance against the BOAST guidelines at each type of centre. 

151

Methods 

A retrospective audit was performed over a 12 month period at the major trauma 

centre and three years at the trauma unit and local emergency centres. Children 

under 16 years of age were included who required admission for a supracondylar 

fracture. Each set of case notes were audited against the 2014 BOAST guidelines 

which included documentation of a comprehensive neurovascular assessment on 

admission, timing of surgery and surgical technique. Performance at the three centres 

was compared. 

Results 

The number of cases seen at the Major Trauma Centre, the Trauma Unit and local 

emergency unit were 31, 18 and 20 respectively. The majority were boys (77%) 

and the mean age was 6.5 years (range 2-11). The documentation of a complete 

neurovascular assessment ranged from 9% to 39% with the anterior interosseous nerve 

least commonly recorded. There was improved performance at the Major Trauma 

Centre. According to the guidelines appropriate timing of surgery varied from 67% to 

92% and was highest at the major trauma centre. Documentation of safe medial wire 

insertion and achieving bicortical fixation was achieved in the majority of cases but 

the size of wire used was documented in only 50% of cases and often was smaller 

than the suggested 2mm. 

Conclusion 

The assessment of neurovascular injuries in this cohort of patients was poor across all 

centres. Possible reasons include poor documentation, lack of knowledge of anatomy 

and structures at risk. The Major Trauma Centre had better compliance. 

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Paper 113 


Authors: R W Jordan, D Westcott, A Aquilani, E Jenner, S Cooke 


Abstract title: A comparison of ketamine sedation and general anaesthesia in the 

manipulation of paediatric forearm and wrist fractures 

Introduction 

Paediatric forearm and wrist fractures are common injuries. If significantly displaced 

the child traditionally undergoes manipulation under general anaesthetic. However 

this practice has consequences for the patient and hospital in terms hospital resources 

and social impact. The provision of ketamine sedation for reduction of these fractures 

has recently been introduced in the Emergency Department at our centre. Anecdotally 

this has provided an efficient service. This study aims to compare the outcomes of 

those children treated through this pathway when compared to cases reduced under 

general anaesthetic. 

152

Methods 

A retrospective analysis, over a 12 month period, of all children who presented 

with an angulated or displaced distal radius or forearm fracture deemed to warrant 

manipulation. This group were divided into those manipulated under ketamine (group 

A) and under general anaesthetic (group B). Angulation and translation were recorded 

on admission, post-reduction and final follow up. The quality of cast was estimated 

using the Cast and Gap index. Further procedures, radiographic displacement and 

theatre time were also recorded. 

Results 

66 children were manipulated over the study period; 31 in group A and 35 in 

group B. In Group A 77% were boys, the mean age was 8.9 years, 58% were 

wrist fractures and the mean angulation at presentation was 28.5%. In Group B 

51% were boys, the mean age was 8.6 years, 62.9% were wrist fractures and the 

mean angulation was 27.6%. An acceptable reduction was achieved in all but two 

patients (6.4%) in Group A. The mean cast and gap index were higher in Group 

A, 0.77 versus 0.81 and 0.25 versus 0.23 respectively. Significant radiographic 

redisplacement was observed in 9.6% in Group A and 14.3% Group B, although 

only one patient in Group B had a further procedure. The mean time utilised in theatre 

for Group B was 50.8 minutes (range 26-80), 20% had to wait over 48 hours 

for theatre availability and 31% were admitted overnight following the procedure. 

Conclusion 

Manipulation of fractures under sedation can achieve an adequate reduction in 

the majority. If reduced successfully the outcomes in terms of further procedures and 

radiographic redisplacement are comparable to general anaesthetic cases. Over 

the one year period this pathway potentially saved 26 hours of theatre time and 10 

overnight admissions. 

Paper 114 


Authors: RW Jordan, G Shyamalan, P Kimani, P Liverneaux, C Mathoulin 


Abstract title: Assessment of the structures at risk during wrist arthroscopy – a 

cadaveric study and systematic review 

The proximity of neurological structures to arthroscopic portals was assessed in both a 

cadaveric study and systematic review. Following arthroscopy of 10 cadaveric wrists 

the specimens were dissected to isolate SBRN, DBUN, PIN and extensor tendons. 

Respective distances to common portals were measured. For the systematic review 

Pubmed and EMBASE were searched on the 31 st May 2014 for cadaveric studies 

reporting the proximity of neurological structures to any arthroscopic wrist portal. 

The DBUN, SBRN and PIN were placed at greatest risk by the 6U (mean 1.2mm), 

1-2 (mean 1.6mm) and 3-4 (mean 4.4mm) respectively. Partial injuries during portal 

placement were observed to six extensor tendons and one PIN. Seven studies were 

included for systematic review reporting the DBUN to be closest to 6U and 6R and 

153

the SBRN to 1-2 and 3-4 portals. However significant variation exists and although 

anatomical knowledge is important, a safe insertion technique is also required. 

Paper 117 


Authors: RW Jordan, A Saithna 


Abstract title: Physical examination tests and imaging studies based on arthroscopic 

assessment of the long head of biceps tendon are invalid 

Purpose 

The aim of this study was to evaluate whether glenohumeral arthroscopy is an 

appropriate gold standard for the diagnosis of long head of biceps (LHB) tendon 

pathology. The objectives were to evaluate whether the length of tendon that can be 

seen at arthroscopy allows visualisation of areas of predilection of pathology and 

also to determine the rates of missed diagnoses at arthroscopy when compared to 

an open approach. 

Methods 

A systematic review of cadaveric and clinical studies was performed. The search 

strategy was applied to Medline, PubMed and Google Scholar databases. All 

relevant articles were included. Critical appraisal of clinical studies was performed 

using a validated quality assessment scale. 

Results 

Five articles were identified for inclusion in the review. This included both clinical 

and cadaveric studies. The overall population comprised 18 cadaveric specimens 

and 575 patients. Cadaveric studies showed that the use of a hook probe allowed 

arthroscopic visualisation of between 34% and 48% of the overall length of the LHB. 

In the clinical series the rate of missed diagnoses at arthroscopy when compared to 

open exploration ranged between 33% and 49%. 

Conclusions 

Arthroscopy allows visualisation of only a small part of the extra-articular LHB tendon. 

This leads to a high rate of missed pathology in the distal part of the tendon. Published 

figures for sensitivities and specificities of common physical examination and 

imaging tests for LHB pathology that are based on arthroscopy as the gold standard 

are therefore invalid. In clinical practice, it is important to note that a “negative” 

arthroscopic assessment does not exclude a lesion of the LHB tendon as this technique 

does not allow visualisation of common sites of distal pathology. 

Paper 119 


Authors: RW Jordan, A Saithna, C Modi, T Lawrence 


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Abstract title: Total Elbow Arthroplasty in the Management of Acute Distal Humeral 

Fractures. A retrospective case series and systematic review. 

154

Purpose 

The role of total elbow arthroplsty (TEA) in acute distal humeral fractures remains 

controversial. The aim of this article is to report our centres experience and perform a 

systematic review of the functional outcomes achieved after TEA. 

Methods 

A retrospective review of all distal humeral fractures treated at our centre using a TEA 

was performed over a five year period. Patient demographics, co-morbidities, fracture 

pattern and complications were recorded. The systematic review of the Medline 

and EMBASE databases was performed on the 13th August 2015 by two authors 

independently (RJ and AS). Studies of any design were included if any functional 

outcome was reported at over six months follow up. Studies were excluded if patients 

with non-unions or failed internal fixation were included. The quality of study was 

appraised using Rangel’s criteria, the STROBE checklist or the CONSORT checklist 

dependent on study design. 

Results 

During the study period 16 patients underwent IF and 13 TEA. The mean ages were 

74.9 and 76.2 years, the proportion of females was 81.3% and 76.2% and the 

majority were Type C fractures 75% and 92% respectively. The mean follow up was 

35 months (range 14 to 70) for the IF group and 22 months (range 12 to 56) for the 

TRA group. Complications were present in 56.3% of the IF group and 38.4% of the 

TEA group, relative risk 1.46 (CI 0.64 to 3.3). Further surgery was required in 31.3% 

of the IF group and 15.4% of the TEA group, releative risk 2.0 (CI 0.47 to 8.8). 

The systematic review generated 117 results but after the review process 18 studies 

wre included for review; one RCT, three comparative studies and 14 case series. 

The total number of cases included was 387. The MEPS was the most commonly 

included functional measure and the mean ranged from 73 to 99. The reported mean 

complication rate ranged from 10 to 35%, the mean incidence of radiolucent lines 

from 5 to 73% and the mean revision rate 9 to 13%. Data from comparative studies 

suggest that TEA maybe a superior modality to internal fixation in those over 65 years, 

suffering from osteoporosis or rheumatoid arthritis. 

Conclusion 

Data from our centre and the systematic review demonstrate that TEA is a viable 

option for the treatment of acute distal humeral fractures. In groups at risk of failed 

fixation; aged over 65 years, poor bone quality and pre-existing rheumatoid arthritis, 

TEA may be the optimal surgical technique. 

Paper 120 


Authors: G Hooper, N Gilchrist, R Maxwell, C Frampton 


155

Abstract title: Can acetabular Bone Mineral Density be improved by using less stiff 

acetabular components? 

Background. Stress shielding has been a well-recognised problem with uncemented 

femoral components resulting in proximal bone loss and dysfunction, but less attention 

has been paid to the preservation of acetabular bone stock. Uncemented acetabular 

components often demonstrate reduced bone density behind the cup on plain 

radiographs, which may be due to the rigidity of the outer shell. This study reports the 

early results of a long term project measuring the alteration in bone density adjacent 

to a variety of acetabular implants. 

Aim. We wanted to test the hypothesis that less rigid cups retained acetabular bone 

as measured by the bone mineral content (BMC). 

Methods. This prospective randomised controlled trial compared the bone mineral 

content (BMC) adjacent to two different cups with marked differences in stiffness. 

Cup A was a titanium backed all polyethylene implant with a modulus of elasticity 

close to bone, whereas cup B was a stiffer tantalum backed rigid titanium shell. All 

articulations used a 32mm ceramic femoral head. Cup A used polyethylene modified 

by treatment with vitamin E whereas cup B used a liner made of irradiated cross 

linked polyethylene. 

Five regions of interest (ROI) were established adjacent to the cup, regions 2,3 and 4 

that where similar to the DeLee and Charnley regions 1,2 and 3. Bone density was 

measured using IDXA preoperatively, postoperatively, 6 months, 1 and 2 years and 

compared for each ROI and implant. 

Results. Precision measurements showed significant reliability. All areas showed a 

reduction in BMC following insertion of the acetabular implant with Cup A showing 

the least loss of bone compared to Cup B (p

Paper 123 

Presenter: G Pienaar 

Authors: G Pienaar, JH Davis 


Abstract title: 18F-FDG PET/CT as a modality for evaluation of persisting raised 

infective parameters in patients treated for TB spine. A report on results 

18F-FDG PET/CT as a modality for evaluation of persisting raised infective parameters 

in patients treated for TB spine. A report on results 

Background: Current protocol dictates the treatment of spinal TB for a duration 

of 12-18 months, evaluating response to treatment through serial investigation with 

radiographs, ESR and subjective clinical improvement. In the background of an HIV 

pandemic, we are often faced with patients showing a persisting raised ESR at 

completion of treatment, posing the question of persisting TB vs an alternate diagnosis. 

Purpose: To report on results following investigation with 18 F-FDG PET/CT in 

patients with persistently elevated ESR levels following 12 months of appropriate antituberculous 

therapy. 

Methods: We conducted a retrospective case note review of the records of 22 spinal 

TB patients whom underwent a 18 F-FDG PET/CT between January 2012 to December 

2014. These were all indicated for persistent elevated ESR (Westergren Method) 

levels, following at least 12 months of appropriate anti-tuberculous treatment. The 

initial management protocol for our TB spine patients include standard laboratory/ 

radiological workup and MRI prior to biopsy for tissue diagnosis, followed by antituberculous 

treatment according to drug sensitivity testing. Patients are follow-up 3-4 

monthly to document clinical improvement, ESR and radiological changes. Data 

captured included demographics, relevant history, radiological, laboratory and 

histological findings as well as the outcome of the PET/CT investigation. 

Results 15 out of 22 (68%) of the investigated patients was RVD reactive and on 

HAART. 6 out of 22 patients (27%) had active spinal TB on PET/CT scan and all 

these patients undergone a second biopsy. 5 of these patients (83%) had Rif/INH 

susceptible TB and one had MDR- TB from the initial tissue biopsy. 5 out of 6 patients 

(83%) were RVD reactive. 16 out of 22 (72%) patients had no active TB on PET CT 

scan and TB treatment could be stopped. A higher number of infected vertebra on 

MRI at diagnosis was associated with ongoing active TB at 12 months of treatment 

(P

could dictate further appropriate management of the underlying cause through further 

appropriate referral, repeat biopsy or alternate management. We therefore conclude 

that PET CT is a useful diagnostic modality to aid in the follow up and evaluation of 

spinal TB. 

Paper 124 

Presenter: TJ Wood 

Authors: Justin de Beer, Thomas J Wood, Patrick Thornley, Danielle Petruccelli, 

Conrad Kabali, Mitch Winemaker 


Abstract title: Preoperative Predictors of Catastrophizing, Anxiety and Depression 

in Patients Undergoing Total Joint Replacement 

Purpose - The relationship between pain catastrophizing and emotional disorders 

including depression and anxiety in patients with osteoarthritis (OA) undergoing total 

joint replacement (TJR) is an emerging area of study. The purpose of this study was 

to examine the association between pain catastrophizing, anxiety, depression and 

preoperative patient characteristics. 

Methods - A prospective cohort study of preoperative TJR patients at one academic 

arthroplasty centre over a 12-month period was conducted. We examined association 

between catastrophizing, anxiety, depression and preoperative patient characteristics 

including demographics, pain and function. Pain catastrophizing was assessed using 

the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital 

Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/ 

knee pain was measured using a visual analogue (VAS) pain scale. Patient perception 

of physical function was measured using the Oxford Hip/Knee Scores. Preoperative 

radiographic grading of hip and knee OA was determined using the Kellgren and 

Lawrence (K-L) scale. 

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Logistic regression was used to assess pattern of relationship between each of the 

preoperative characteristics and PCS or HADS. Adjusted odds ratio (OR) and 95% 

confidence interval (CI) were reported in the logistic regression model. A secondary 

quantile regression analysis examined whether a model not restricted to pre-defined 

PCS and HADS categories would yield results that are comparable to the logistic 

regression model described in the primary analysis. P-values less than 0.05 were 

considered statistically significant. 

Results - The sample included 463 TJR patients (178 hips, 285 knees). VAS pain (OR 

1.23, 95%CI 1.04-1.45) and Oxford (OR 1.13, 95%C 1.07-1.20) were identified 

as significant predictors for PCS. The same two variables were the strong predictors 

for all sub-domains of PCS excluding rumination. Oxford was the only significant 

predictor for abnormal HADS-A (OR 1.10, 95%CI 1.04-1.17) while VAS pain (OR 

1.27, 95%CI 1.02-1.52) and Oxford (OR 1.09, 95%CI 1.01-1.17) were significant 

158

predictors for abnormal HADS-D. Similar pattern of association for PCS and HADS 

was observed in the quantile regression model, where larger VAS pain and Oxford 

scores significantly increased median PCS across all domains. Female gender, 

younger age or having a higher ASA were associated with higher median HADS-A, 

but unlike in the logistic regression, this association was statistically significant. 

Conclusions - Pain catastrophizing and emotional disorders generally result in poor 

functional outcomes in patients who undergo TJR. The most important predictor of 

catastrophizing, anxiety/depression is preoperative pain and subjective function. 

At risk patients include those with high preoperative pain with generally good 

preoperative function, as well as younger females with significant comorbidities. 

Such patients should be identified, and targeted psychological therapy implemented 

preoperatively to optimize coping strategies and adaptive behaviour to mitigate 

inferior TJR outcomes including pain and patient dissatisfaction. 

Paper 125 

Presenter: J de Beer 

Authors: Justin de Beer, Thomas J Wood, Danielle Petruccelli, Conrad Kabali, Mitch 

Winemaker 


Abstract title: The Burden of Care: A Comparison of Primary Total Hip and Knee 

Arthroplasty 

Purpose - The demand for total joint arthroplasty of the hip and knee is growing. In 

Canada this represents a 118% increase over a ten-year period from 2000-01 to 

2010-11, resulting in a significant stress on limited health care resources as a result 

of the therapeutic and diagnostic burden of care for these patients. As such, there 

is great emphasis to lower the overall burden of care associated with total joint 

replacement (TJR). The literature lacks direct comparison of functional outcomes and 

readmission rates for primary total hip (THA) and primary total knee arthroplasty (TKA) 

which can influence burden of care. Therefore, the purpose of this study was to assess 

such differences in the care of total hip and knee arthroplasty patients. 

Methods - A cross-sectional study of a consecutive series of primary TJR patients from 

one academic arthroplasty centre was conducted to evaluate burden of care. We 

compared the effect of primary TKA and THA patients in regard to demographics, 

number of preoperative comorbidities, acute length of stay, 30-day risk of readmission, 

1 year postoperative Oxford Score, and family social suppport using a quantile 

regression model. The 95% confidence intervals (CI) for the median difference (MD) 

in the regression models were computed using the bootstrap method. The relative risk 

(RR) of various exposure variables on 30-day readmission were estimated using the 

modified Poisson regression. 

Results - The sample included 1459 patients comprising 61.7% TKA and 38.3% 

THA. The median acute length of stay was longer in TKA patients than THA patients 

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(adjusted MD 0.53 days, 95% CI 0.39-0.68). We did not find any discernible effect 

in the length of stay for the variables: number of comorbidities, BMI, and family social 

support. Compared to THA patients, TKAs had a superior median Oxford Score 

(MD 5.17, 95% CI 3.45-6.89) and a higher risk of 30-day readmission (adjusted 

RR 1.93, 95% CI 1.03-3.62). We did not find any evidence of an effect for the 

variables: number of comorbidities, BMI, or family social support on either Oxford 

Score of 30-day risk of readmission. 

Conclusion - There is very little evidence in the literature comparing primary TKA and 

THA in terms of length of stay, readmission rates and functional outcomes, which 

could provide an idea of burden of care in this patient population. Our study shows 

that TKA patients have a half day longer length of stay and are almost twice as 

likely to be readmitted within 30 days post-discharge. Although subjective functional 

outcome scores were superior in primary total knees, it appears that the burden of 

care in general may be marginally greater for primary total knees. In order to optimize 

discharge planning, patient focused care should be implemented preoperatively 

to help identify factors that will prolong length of stay and/or prevent reasons for 

readmission. 

Paper 128 

Presenter: D SOCHART 

Authors: S, Sochart; D.H. Sochart 


Abstract title: The outcome of varus implantation of a polished triple-tapered 

femoral stem, with Palacos-R cement: Minimum 10-year follow-up. 

Purpose of study: Varus alignment of femoral implants has been recognised as a poor 

prognostic feature with regards to loosening of cemented composite beam implants, 

but there have been no published results of the long-term effect on taper-slip designs. 

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Methods: We prospectively analysed the results of 500 consecutive polished tripletapered 

C-Stem implants performed on 455 patients between March 2000 and 

December 2005, using a standard posterior approach and Palacos-R bone cement. 

Patients underwent annual clinical and radiological review. 

Summary of Results: There were 70 femoral components (14%) implanted with more 

than 5 degrees of varus with respect to the long axis of the femur, and 24 (4.8%) in 

more than 5 degrees of valgus. Alignment within 5 degrees of neutral was achieved 

in 81.2% of cases. The average duration of follow-up of surviving implants is 158 

months (120-188) 

The average age in the varus group was 69.7 years (41-92), which was higher than 

in the neutral group (67.7years; 25-89), more patients were male (44% v 35%), but 

the average BMI was similar (29 v 28). 

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There was only one re-operation in the varus group, which was a revision for deep 

infection. There were 2 dislocations, one treated by closed reduction and one 

by open. There have been no revisions for aseptic loosening but one acetabular 

component is currently loose and awaiting revision. 

In the neutral group there have been 8 dislocations; 2 have undergone a PLAD and 2 

a cup revision the others being treated by closed reduction; 6 peri-prosthetic fractures 

treated by internal fixation and 7 acetabular components have been revised for 

loosening associated with wear. Six acetabular components are currently loose and 

in one case there is also aseptic loosening of a femoral component - the only one in 

the whole series. 

Subsidence within the cement mantle occured in 96% of the entire series and there 

was no difference between the groups with respect to the degree of subsidence. In 

the varus group 78% subsided less than 2mm compared to 75% in the neutral group. 

None of the femoral components in either group subsided more than 4mm. 

Conclusion: Varus implantation of a polished triple-tapered implant was more common 

in older male patients, but there was no increased risk of subsidence or loosening at 

a minimum follow-up of ten years. 

Paper 129 

Presenter: DM North 

Authors: D. North, M. Held, S. Dix-Peek, EB. Hoffmann 


Abstract title: French osteotomy for cubitus varus in children: A long-term study 

over 27 years 

Background 

Cubitus varus is a cosmetically unacceptable complication of supracondylar 

fractures of the elbow in children. We have performed the lateral closing 

wedge (French) osteotomy to correct the varus for 27 years. More complex 

osteotomies have been described to correct the associated hyperextension 

and internal rotation deformities and to prevent a prominent lateral condyle. 

Methods 

We retrospectively reviewed 90 consecutive patients (1986-2012). The mean 

age of the patients at surgery was 8.2 years (3 to14 years). The varus angle 

(mean 21.4°, range 8°-40°) was assessed pre-operatively with the humeroelbow-wrist 

(HEW) angle. The postoperative carrying angle (mean 10.4) and 

the pre- and postoperative range of movement were assessed clinically. The 

lateral condylar prominence index (LCPI) was retrospectively measured at union. 

Results 

Eighty-four (93.3%) of the patients had a good or excellent result. Six (6.7%) had a 

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poor result (residual varus, loss of >20°of pre-operative range of flexion or extension or 

a complication necessitating resurgery). There were no neurovascular complications. 

The mean LCPI was +0.14 

Conclusions 

The results of the French osteotomy are comparable to the more technically demanding 

dome, step-cut translation and multiplanar osteotomies, with a lower complication rate. The 

literature reports adequate remodeling of the hyperextension deformity (≤10 years) and 

the LCPI (≤12 years), and that the internal rotation deformity is well tolerated by the patient. 

Paper 130 

Presenter: M Thomas 

Authors: E.F. Ibrahim, A. Rashid, N. Raza, M. Thomas 


Abstract title: Linked and Unlinked Total Elbow Replacement in Juvenile Idiopathic 

Arthritis: A Case Series with 5 to 17 Year Follow-Up 

Background: Use of an unlinked implant for total elbow replacement (TER) in juvenile 

idiopathic arthritis (JIA) has only previously been reported in 12 patients. 10-year 

implant survivorship has been reported for a linked semiconstrained design only (29 

elbows). We report our experience of the benefit of TER using both unlinked and 

linked semiconstrained design. 

Methods: Between 1997 and 2007, 21 elbows in 14 patients (12 women) were 

replaced because of JIA. Mean age at surgery was 39.5 years (range 26-52 

years). Mean age at diagnosis of JIA was 7 years (range 6-13). An unlinked Kudo-5 

prosthesis was used whenever the bone stock and supporting soft tissues allowed (14 

elbows). A linked Coonrad-Morrey prosthesis was used for the remaining 7 elbows. 

Six implants (4 unlinked, 2 linked) had to be customised because of the small size of 

the patient’s bones. Mean clinical follow-up was 10.5 years (range 5.3-17.6). 

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Results: Re-operation was required in 9 elbows (42.9%). There were 8 implant 

revision procedures (38.1%). Using the Kaplan-Meier method, cohort survivorship 

free from revision was 68% at 10 years (95% confidence interval, 45%-86%). Tenyear 

survival for the unlinked group alone was 70% (95% confidence interval, 40%- 

89%). The need for bilateral TER in the same patient was found to be a risk factor for 

revision of either elbow within 10 years of primary surgery (6/11 vs 0/7 elbows, 

p = 0.037). Mean Mayo Elbow Performance Score improved significantly (26.7 

pre-op vs 85.0 at 2 years post-op, p < 0.01) and was not different between linked 

and unlinked groups. The rate of aseptic loosening seen on radiographs was high 

in the unlinked group (12/14, 85.7%) but many of these patients are pain free and 

continue to function well without need for revision. 

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Conclusion: Unlinked and linked semiconstrained TER designs used in JIA patients 

can provide benefit for the mid to long term. The incidence of aseptic loosening with 

unlinked TER is a cause for concern but many patients continue to function well. The 

need for bilateral TER is associated with a higher risk of revision of either elbow at 

10 years. 

Paper 132 

Presenter: A Riddell 

Authors: B.A. Hickey, A. Riddick, M. Mullins 


Abstract title: Can we predict failure of internal fixation of intracapsular hip 

fracture using lateral anterior offset measurement on lateral radiograph? 

Failure of reduction of intracapsular hip fractures is associated with failure of fixation 

of intracapsular hip fractures. Our aim was to evaluate the association between 

fracture reduction and subsequent revision surgery, using a novel measurement of 

anterior offset ratio on lateral radiograph. Radiographs of a consecutive case series 

of 92 patients who underwent internal fixation of intra-capsular hip fracture between 

2005 and 2006 were evaluated. All patients had their post-operative radiograph 

reviewed for the presence of CAM deformity, defined as an anterior offset ratio of less 

than 0.17. 68% were female. CAM deformity was present in 40% of patients (n=37). 

19% of patients with CAM deformity required revision surgery (n=7) compared to only 

1.8% (n=1) of patients without CAM deformity (n=55). Our results demonstrate that 

CAM deformity is common following internal fixation of intra-capsular hip fractures 

and the presence of this deformity is associated with higher rate of revision surgery. 

We recommend the assessment of lateral radiograph for femoral head retroversion 

should be considered when considering internal fixation of intracapsular hip fractures 

with cannulated screws. 

Paper 133 

Presenter: D SOCHART 

Authors: S.Sochart, D.H.Sochart 


Abstract title: Low dislocation rates for total hip replacement with the use of a 

small diameter head (22.225mm) and posterior surgical approach: Minimum 10- 

year follow-up. 

Purpose of Study: Traditionally it was thought that the use of small diameter femoral 

heads in conjunction with a posterior approach would result in a high rate of 

dislocation. We prospectively analysed the results of a consecutive series of 400 hip 

replacements. 

Methods: Between March 2000 and November 2005, 364 patients underwent 400 

total hip replacements with a small diameter 22mm head via a standard posterior 

163

approach under the care of four consultants.The data was collected prospectively and 

patients attended for annual clinical and radiological review. 

All of the femoral implants were cemented polished triple-tapered C-stems and 

cemented UHMW-polyethylene acetabular components were used. Palacos-R bone 

cement containing Gentamicin was used in all cases, with a third generation femoral 

cementing technique. A standard posterior approach was used, with direct repair of 

the short external rotators, but without trans-osseous sutures. 

Summary of Results: There were 252 female and 112 male patients, with 232 

right-sided operations and 168 left, with 36 patients undergoing staged bilateral 

procedures. Average age at surgery was 71.3 years (25-92) and average duration 

of follow-up of surviving patients is 156 months (120-188). The average acetabular 

abduction angle was 43.2 degrees (30-62) and the average femoral offset was 

46mm (35-54). 

Nine hips dislocated (2.25%) at an average of 68 months (17-124), 5 in females 

and 4 in males. Averae age at index surgery was 71.7 years (60-85) and at the time 

of first dislocation was 79 (66-87). Average abduction angle was 43.7 degrees (33- 

54) and average offset was 45.7mm (40-52) Seven occured on a single occasion, 

six treated by closed reduction and one by open reduction. Two were recurrent, with 

one undergoing a PLAD procedure and one a cup revision. Extended skirted femoral 

heads had been used in six of the cases, reducing the head/neck ratio. 

Conclusion: Hip Replacement using small diameter heads and a posterior approach 

provided excellent results and implant longevity, with low complication and reoperation 

rates. Dislocation occured in 9 cases, six of which featured a skirted head 

reducing the head/neck ratio. When using this design of hip, skirted heads should 

be avoided, with high offset stems and standard heads being used in preference to 

achieve the correct length and offset, whilst maintaining the maximum head/neck 

ratio. 

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Paper 134 

Presenter: D Little 

Authors: DG Little, J St George, M Guzman, T Marshall, O Birke 


Abstract title: CHONDROLYSIS FOLLOWING SLIPPED UPPER FEMORAL EPIPHYSIS: 

A PRE-OPERATIVE PHENOMENON? 

Purpose: Chondrolysis is a serious complication following Slipped capital Femoral 

Epiphysis (SCFE) with a reported incidence varying from 1.8% to 55%. It has 

been attributed post-operatively to persistent intra-articular pin penetration, various 

ethnic groups, and avascular necrosis (AVN) but may beunder recognised as a preoperative 

phenomenon. We reviewed severe cases of SCFE pre and post intervention 

specifically for joint space narrowing. 

164

Methods: Sixty-seven patients with unilateral, severe SCFE with Posterior Sloping 

Angle (PSA) > 60 o presenting to our institution from January 2008 to June 2014 were 

recruited. The mean chondral height was measured across the weight-bearing surface 

of the hip joint at presentation and at one year follow up using BIOQUANT NOVA 

Prime (Version 6.90.10 MR) software. This was controlled against the contralateral 

hip. Chondrolysis was defined as a greater than 2mm difference in mean chondral 

height between the affected and unaffected hips, or a mean chondral height less than 

3mm with associated pain and stiffness. 

Results: The cohort contained 38 males and 29 females with a mean age of 13 

(±2.1) years and mean follow up of 1.8 (±1.3) years. Chondrolysis was noted in a 

total of 25.4% (n=17) patients with severe unilateral SCFE. Of these, 13.4% (n = 9) 

of patients had evidence of chondrolysis on their pre-operative radiographs with a 

mean chondral height of 2.5(±0.5) mm in the affected hip compared to 4.5(±0.6) 

mm in the unaffected hip (p

METHODS: 

Following informed consent, patients were placed supine and each nerve was identified 

using surface ultrasonography (18MHz linear array probe B-K400, Denmark). The 

sonographic appearance of each nerve was identified and documented in relation 

to surrounding anatomy. The nerve was then blocked by circumferential injection of 

lignocaine 2% (3-5mL) and the cutaneous innervation mapped using loss of sensation 

to fine touch and thermal modalities. The extent of distal numbness was related to 

the radiocarpal joint. 

RESULTS: 

Under ultrasonography, the LCNF was located deep to the Cephalic Vein in all cases 

(n=17). It was visualised and blocked 9.87mm ± 2.6mm distal to the Interepicondylar 

Line. The distal cutaneous distribution involved the Radiocarpal Joint and surgical field 

in 93% of cases (n=15). The Superficial Radial Nerve (n=8), and Median Nerve 

(n=8), followed typically understood patterns of cutaneous distribution. 

CONCLUSION: 

The LCNF can be easily visualised and blocked using surface ultrasonography. In 

clinical practice, innervation of the cutaneous dorsolateral thumb by the LCNF must 

be considered when performing regional anaesthesia for thumb suspensionplasty and 

other basal thumb joint procedures. 

Paper 142 

Presenter: V Shetty 

Authors: K. Alva, A. Shetty, V. Shetty 


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Abstract title: The tibial tubrosity to trochlear groove measurement in adult Indian 

population 

Abstract 

Background: The tibial tuberosity to trochlear groove (TTTG) distance is an important 

predictor of patellar instability. TTTG distance in western population is extensively 

studied through various modalities such as x-rays, computerized tomography and 

magnetic resonance imaging. However, to our knowledge there is very little or no 

literature support to indicate that TTTG distance has been studied in Indian population. 

Methods: We undertook a study to measure TTTG distance in 100 MRI scans of 

normal Indian knees. Patients with following co-morbidities were excluded from the 

study; ligamentous laxity, patello-femoral instability, mal-alignment and osteoarthritis. 

We measured TTTG distance on the axial MRI slices using free software Osirix. 

166

Results: Our study showed that the mean TTTG distance for the Indian adult population 

was 13.54 mm. The mean value for females was found to be 14.07 mm and that 

for male was found to be 13.34 mm. We found that there is no statistically significant 

difference in the measurements for both sexes. Our study also indicates that the TTTG 

distance, using MRI scans as measurement modality, in the Indian population is 

significantly different when compared to the published western data. 

Conclusion: There is paucity of literature evidence regarding the incidence of patellar 

instability in adult Indian population. It remains to be seen whether these measurements 

have any clinical implications in the management of patellar instability. We believe 

that this study forms a basis for further research into this area. 

Keywords: Tibial tuberosity to trochlear groove (TTTG) distance; Indian knee; patellar 

instability. 

Level of evidence: III 

Paper 144 

Presenter: M Espag 

Authors: K Theivendran, S. Hassan, M Varghese, M Bateman, M Morgan, A 

Tambe, M Espag, T Cresswell, DI Clark 


Abstract title: Reverse total shoulder arthroplasty using a trabecular metal glenoid 

base plate. Functional and radiological outcomes at 2-5 years. 

Background: Most studies of reverse total shoulder arthroplasty (RTSA) involve 

cemented components, however new uncemented designs are now available. To our 

knowledge, this is the largest study to evaluate the clinical and radiological outcome 

of RTSA, using a trabecular metal glenoid baseplate designed for uncemented fixation 

introduced into our unit in 2009. 

Methods: A prospective database of patients undergoing primary RTSA, with a 

diagnosis of cuff tear arthropathy or severe rotator cuff deficiency with a minimum of 

2 year follow up, was retrospectively reviewed. 126 patients had uncemented RTSA. 

Clinical outcome measures included the Oxford Shoulder Score (12-60 version), 

range of motion, and patient satisfaction. Radiographs were taken at 2 weeks, 1 year, 

and 2 years postoperatively and were evaluated for scapular notching, radiolucency 

around the glenoid baseplate, and radiolucent lines by zones around the humeral 

stem. 

Results: Mean follow up was 32 months (range: 2-5 years). Compared with preoperative 

values, significant improvements in all functional scores were demonstrated. The mean 

Oxford Shoulder Score improved from 43 to 24 (P < .001); active forward elevation 

improved from, 58 to 107 degrees (P < .001); and active abduction improved from 

167

54 to 96 degrees (P < .001). On radiographic evaluation, 65 showed no evidence 

of notching, 51 had grade 1 notching, 10 had grade 2 notching and 1 had grade 

4 notching. Radiolucency around the glenoid baseplate was found in 1 and humeral 

stem lucency was found in 5. 8 cases required revision; 4 for mechanical glenoid 

failure, 1 for deep infection, 2 for dislocation and 1 for aseptic glenoid loosening. 

92% of patients recorded they would have the surgery again. 

Conclusion: This study reports on a large single unit series with a low complication 

rate compared with previous RTSA reported in the literature. The most common reason 

for revision surgery was due to glenosphere malseating leading to early glenoid 

mechnical failure experienced very early on in our series. We have had no further 

mechanical glenoid failure after 2011. 

Paper 149 

Presenter: L Geraghty 

Authors: S. P. Talbot, T. Chao, L. Geraghty, P. Dimitriou 

Disclosure: Yes: Own shares in Trochlear Pty Ltd 

Abstract title: Combining the sulcus line and posterior condylar axis reduces 

femoral malrotation in total knee arthroplasty 

Introduction: Femoral component malrotation is a common cause of patient 

dissatisfaction after total knee arthroplasty. The Sulcus Line (SL) is formed from multiple 

points along the floor of the trochlear groove, and has been shown to be more 

accurate than Whiteside Line. A trochlear alignment guide (TAG) is required to 

maintain the accuracy of the SL and allow intraoperative comparison of the SL and the 

posterior condylar axis (PCA). The hypothesis is that averaging these two landmarks 

will lead to decreased femoral malrotation. 

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Methods: Surgery was performed in 90 patients using the TAG. The component was 

inserted at a position between the SL and PCA. An intraoperative photograph was 

taken of the distal cut surface of the femur showing the pin-holes representing the SL, 

the PCA and the final component position. These were compared to the component 

position achieved relative to the surgical epicondylar axis (SEA) on a postoperative 

CT scan. Comparison was made between the final component position and the 

position which would have been achieved using either the SL or PCA individually. 

The theoretical position which could be achieved by averaging the SL and PCA was 

also calculated. 

Results: The SEA was identified on CT scan in 84 cases. The final component 

position was 0.6° (SD1.5°, range -4.2° to +4.0°), calculate SL position was -0.7° 

(SD2.3°, -5.5° to +4.6°), calculated PCA position was 0.9° (SD1.9°, -6.1° to 

+5.0°), the calculated average position between SL and PCA was 0.1° (SD1.4°, 

-3.7° to +2.7°). There was a significant decrease in variance between both the 

component position and the calculated average when each was compared to the SL 

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and PCA individually. The number of outliers greater than 3° from the SEA was also 

significantly less (p

10 days and never returns. This is likely due to reduced clearance between head 

and liner and likely easily correctable. One patient had her hip opened elsewhere, 

with infection concerns but this was negative and she retains her implant. There have 

been no dislocations or restrictions on activity level. Oxford and Harris Hip scores 

along with radiology, blood and clinical examination are collected. There has been 

no difference seen between Ceramic-o-MP-1 and any C-o-C or C-o-Polyethylene hip 

to date in these early results. 

Conclusion: MP-1, a polyimide, as a counter surface for Delta ceramic in Total Hip 

Arthroplasty, looks very promising with advantages of ease of sterilization, insignificant 

wear, very low to no tissue reactivity and ability to have thin section and larger 

femoral heads if desired. 

Paper 152 

Presenter: A Blom 

Authors: K Tucker , M Pickford , C Newell , P Howard , L P Hunt and AW Blom on 

behalf of the National Joint Registry for England, Wales and Northern Ireland. 


Abstract title: Mixing components from different manufacturers in total hip 

arthroplasty: prevalence and comparative outcomes in the National Joint Registry 

for England and Wales: a study of over 90,000 cases of mixed components. 

Introduction: Total hip replacement is an extremely common and successful operation 

used to treat hip pathology including arthritis and femoral neck fractures. However, 

there have recently been highly publicised examples of sub-optimal outcomes with 

some newer implant designs. That has led to calls for tighter regulation. However, 

surgeons do not always adhere to the regulations already in place and often use 

implants from different manufacturers together to replace a hip, which is against the 

Medicines and Healthcare products Regulatory Agency (MHRA) and manufacturer 

guidance. 

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Methods: We used data from the National Joint Registry of England and Wales (NJR) 

to investigate this practice. 

Results: Mixing components is common and we identified over 90,000 cases 

recorded between 2003 and 2013. In the majority (48,156) of these cases stems 

and heads from one manufacturer were mixed with polyethylene cemented cups 

from another manufacturer. When using a cemented stem and a polyethylene cup, 

mixing stems from one manufacturer with cups from another was associated with a 

lower revision rate (p=0.001). Mixing heads from one manufacturer with stems from 

another was associated with a higher revision rate (p0.05). 

170

Conclusion: Mixing components from different manufacturers is a very common 

practice, despite being against regulatory guidance. However, it is not associated 

with increased revision rates unless heads and stems from different manufacturers are 

utilised together. 

Paper 153 


Authors: Linda P Hunt, Yoav Ben-Shlomo, Emma M Clark, Paul Dieppe, Andrew 

Judge, Alex J MacGregor, Jon H Tobias, Kelly Vernon, Ashley W Blom on behalf of 

the National Joint Registry for England and Wales. 


Abstract title: 45-day mortality after knee replacement for osteoarthritis: An 

analysis of 467,779 procedures from the National Joint Registry for England and 

Wales. 

Background: Understanding the risk factors for early death after knee replacement 

may help to reduce the risk of mortality following this procedure. We assessed secular 

trends in death within 45 days of knee replacement for osteoarthritis in England 

and Wales, and investigated whether any change which we observed could be 

explained by alterations in modifiable perioperative factors. 

Methods: We obtained data on knee replacements performed for osteoarthritis in 

England and Wales between April 2003 and December 2011, from the National 

Joint Registry for England and Wales. Patient identifiers were used to link these data to 

the national mortality database and the Hospital Episode Statistics database to obtain 

details of death, sociodemographics, and comorbidity. We assessed mortality within 

45 days by Kaplan-Meier analysis and assessed the role of patient and treatment 

factors by Cox proportional hazards models. 

Findings: 467,779 primary knee replacements were performed to treat osteoarthritis 

over the nine year period. One thousand one hundred and eighty-three patients died 

within 45 days of surgery, with a substantial secular decrease in mortality from 0.37% 

in 2003 to 0.20% in 2011, even after adjustment for age, sex and comorbidity. The 

use of unicompartmental knee replacement was associated with considerably lower 

mortality when compared with total knee replacement (hazard ratio [HR] 0.32, 95% 

CI 0.19-0.54, p

Paper 154 


Authors: : Michele Smith, Paul Dieppe, Adewale O Adabajo, Yoav Ben-Shlomo, 

Andrew Beswick, J.Mark Wilkinson, Ashley.W Blom on behalf of the National Joint 

Registry for England, Wales and Northern Ireland 


Abstract title: The Rates of Hip and Knee Joint Replacement Amongst Different 

Ethnic Groups in England 

INTRODUCTION: Identifying and quantitating ethnic disparities in the rates of hip 

and knee arthroplasty could help focus resources to reduce potential inequalities in 

provision and utilisation. We assessed ethnic trends in the rates of arthroplasty in 

England, with the aim of identifying whether it is the same among different ethnic 

groups, and whether any identified disparities may be explained by patient, surgical, 

socio-economic, and other factors. 

METHODS: We took data on all knee and hip replacements done in English NHS 

hospitals between April 2003 and December 2012 and recorded in the National 

Joint Register. Each record was linked to the patients Hospital Episodes Statistics 

admissions data to collect information on ethnic group, area of residence, and 

area deprivation scores. The observed versus expected number of primary joint 

replacements for different ethnic groups were compared. We tested whether observed 

difference between ethnic groups for osteoarthritis may be explained by factors such 

as age, gender, body mass index, fitness for surgery, area deprivation score, and 

each hospital’s pattern of prosthesis use. 

RESULTS: 426,368 primary knee and 370,550 primary hip replacement operations 

were studied. The standardised ratios for hip replacement in Blacks and Other ethnicities 

was substantially lower than that in Whites (0.34 (95% confidence interval [CI] 0.32- 

0.37) and 0.21 (0.20-0.22), respectively versus 1.05 (1.05-1.06); p

explained by the fact that ethnic minority groups are more likely to have their joint 

replacement in NHS hospitals that are high users of uncemented prostheses. 

Paper 155 

Presenter: E Edwards 

Authors: F Cosic, LA Kimmel, ER Edwards 


Abstract title: Health literacy in orthopaedic trauma patients 

Background Limited patient health literacy is a growing public health issue worldwide 

and has been associated with many adverse health outcomes. Previous work has 

shown that interventions targeted at improving health literacy can be effective. 

Method One hundred and ninety patients with operatively managed lower limb 

fractures were recruited for this pre-post quasi experimental trial. The first ninety-nine 

patients received usual care. The following ninety-one patients received a structured 

intervention presented by junior orthopaedic doctors prior to inpatient discharge 

consisting of patient x-rays, written and verbal information about their injury. Patients 

were then randomised into interview prior to first outpatient review or interview after 

first outpatient review. Patients completed a structured interview at first outpatient 

review to determine their level of health literacy. 

Results Ninety six (97%) of the usual care patients (UC) and 87 (96%) of the 

intervention patients (IG) completed the interview. UC1 (pre-intervention, pre-outpatient 

review, n=46) demonstrated a mean score of 4.67 of a maximum 8. UC2 (preintervention, 

post-outpatient review, n=50) demonstrated a mean score of 5.42. IG1 

(post-intervention, pre-outpatient review, n=47) demonstrated a mean score of 6.70. 

IG2 (post-intervention, post-outpatient review, n=40) demonstrated a mean score of 

7.08. Compared to UC1, IG2 had 4.87 times the odds of demonstrating improved 

health literacy (p=0.001). Patients receiving the intervention were more satisfied with 

information received as an inpatient than patients that did not receive the intervention 

(88.5% vs. 69.7%, p=0.002). 

Discussion Australian orthopaedic trauma patients demonstrate poor health literacy, 

with the outpatient review not acting to improve this. The use of a brief and simple 

structured intervention improved patient health literacy and patient satisfaction 

significantly. 

Paper 157 

Presenter: JC Coetzee 

Authors: J.C. Coetzee, L.J. Nilsson, R.M Stone, J.E. Fritz 

Disclosure: Yes: AAOS: Board or committee member American Orthopaedic Foot 

and Ankle Society: Board or committee member Arthrex, Inc: Paid consultant; 

Paid presenter or speaker Arthrex, Stryker: IP royalties Biomet: IP royalties Elsevier: 

Publishing royalties, financial or material support Foot and Ankle International: 

173

Editorial or governing board Tornier: Paid consultant; Paid presenter or speaker 

Zimmer, Allosource: Paid consultant; Research support 

Abstract title: Takedown of Ankle Fusions and Conversion to Total Ankle 

Replacements:A Prospective Longitudinal Study 

Purpose of the Study: 

With ankle replacements gaining credibility there is a small subset of patients that 

might benefit from a conversion of an ankle fusion to a replacement. Our hypothesis 

was that for the correct indication a conversion of an ankle fusion to a total ankle 

replacement might do as well as a primary total ankle replacement 

Methods: 

Thirteen patients presented to the senior author with either ongoing ankle pain 

after a fusion, or increasing pain after a period of relative comfort after an ankle 

fusion. Exclusion criteria included a history of Diabetes, peripheral neuropathy, 

excision of either malleoli at the time of fusion, pantalar fusion and neurovascular 

compromise 

This study was conducted in compliance and approved with a local IRB. Outcomes were 

evaluated pre-operatively and post-operatively with the Veterans Rand Health Survey 

(VR-12), Ankle Osteoarthris Scale (AOS), Visual Analog Scale (VAS) Pain scale and the 

American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score forms. A 

patient satisfaction survey was distributed to all patients and results were tabulated. 

Average follow up for outcome scores 20.02 months (range 4 – 49.72 months). 

Results: 

All ankle fusion conversions done at our center were included in the study; no patients 

were lost to follow-up. Thirteen patients (four males) with the mean age of 65 months 

(36 – 75) have been followed with a mean follow-up of 20.02 months (4 – 49.72). 

The mean AOFAS improved from pre-operatively of 25.57 (13.0-52.0) to the latest 

follow-up of 83.78 (73-98). VR-12 Mental also improved from 56.01 (37.56 – 72.46) 

to 58.51 (35.22 – 72.31), and Physical 23.06 (14.07-35.79) to 36.45 (19.82- 

47.40) pre-operatively to post-operatively, respectively. The AOS Pain and Disability 

improved as well: Pain decreased from 423 (243-630) to the latest follow-up 245.88 

(20 -852); AOS Disability: 536.75 (320-613) to the latest follow-up 235.63 (2-850). 

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Given patients have minimal to no dorsiflexion (DF) and plantarflexion (PF) with an 

ankle fusion, as expected, the range of motion (ROM) increased with the affected 

side. Patients have a DF of 8.89 degrees (2-15) and PF of 22.00 degrees (11-30). 

Overall patients were extremely satisfied with their results: 84.33 out of 100. 

174

Conclusion: 

This is a small study with reasonable short follow-up, but the evidence show very 

satisfactory functional outcomes after a conversion of an ankle fusion to a total ankle 

replacement. Patient selection is extremely important. Long-term follow-up will show 

whether the longevity of these replacements compare to primary replacements. 

Paper 158 


Authors: B.R. Moser, J.C. Coetzee, R.M. Stone, J.E. Fritz 







Abstract title: Surgical Treatment of Os Trigonum Syndrome in Dancers through 

an open approach 


Management of ankle pain in dancers can be very challenging secondary to the 

complex demands placed on their ankles and feet. There is very little literature 

regarding outcomes after treatment of surgical treatment of os trigonum syndrome in 

dancers. The hypothesis of the study was that it is possible to have dancers return to 

their previous level of activity with an open excision of the Os trigonum. 

Methods: 

We followed 41 ankles (33 patients, 85% female, mean age 18.8 years) with 

patients who had surgery done for posterior ankle impingement. We see a high 

volume of dancers of all levels, including professionals. All patients went through a 

specific well-designed non-surgical rehabilitation protocol prior to surgical discussions 

started. All the Os trigonum excisions were done through an open approach. All 

patients committed to a very specific rehabilitation program and a gradually returned 

to dance. Outcomes were evaluated with the VR-12 Mental and Physical Score, FFI-R, 

VAS scoring and patient satisfaction preoperatively and postoperatively. This study 

was conducted in compliance and approved with a local IRB. 

Results: 

There was a mean 41.1 months follow-up (range 12 – 95.3 months) after the 

surgery. VR-12 Mental Score remained the same pre-operatively to post-operatively 

with mean scores of 57.7 to 52.1, respectively. VR-12 Physical Score improved from 

a mean 37.2, pre-operatively, to 55.7 at most recent follow-up. FFI-R cumulative 

score improved from 70.0 to 36.9. VAS scoring improved from 5.0 to 1.8. 

175

There were three transient Sural nerve injuries that recovered. Two patients did not 

return to dancing due to unrelated issues. The only serious complication was a case 

with Complex Regional Pain Syndrome that took more than a year to fully recover. 

Overall patients were extremely satisfied with their result. 

Conclusion: 

An open Os trigonum excision is fairly simple, has a low complication rate and 

proofed to have a high success rate in returning athletes back to their sport of choice, 

in this study, dancers. It is however imperative to have a dedicated physical therapy 

team working with these patients before and after surgery. The success in returning 

them safely to dancing heavily relies on the PT support structure. 

Paper 159 


Authors: H.H. Wu, K.R. Patel, A.M. Caldwell, R.R. Coughlin, S.L. Hansen, J.N. 

Carey 


Abstract title: Surgical Management and Reconstruction Training (SMART) Course 

for International Orthopedic Surgeons 

Background: The burden of complex orthopaedic trauma in low-income and middleincome 

countries (LMICs) is exacerbated by soft tissue injuries, which can often lead 

to amputation. The purpose of this study was to create and evaluate the Surgical 

Management and Reconstruction Training (SMART) course to help orthopaedic 

surgeons from LMICs manage soft tissue defects and reduce the rate of amputation. 

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Methods: In this prospective observational study, orthopaedic surgeons from LMICs 

were recruited to attend a two-day SMART course in San Francisco. Prior to the course, 

participants were asked to assess the burden of soft tissue injury and amputation 

encountered at their respective sites of practice. A survey was then given immediately 

and one year post-course to evaluate the quality of instructional materials and impact 

of the course in reducing the burden of amputation, respectively. 

Results: 51 practicing orthopaedic surgeons representing 25 LMICs attended the 

course. Prior to the course, participants cumulatively reported 970 amputations 

performed each year as a result of soft tissue defects. Immediately after the course, 

participants rated the quality and effectiveness of training materials to be a mean of 

4.4 or greater on a Likert scale of 5 (Excellent) in 14 of 14 instructional criteria. Of the 

34 (66.7%) orthopaedic surgeons who completed the one-year post-course survey, 

34 (100%) reported performing flaps learned at the course to treat soft tissue defects. 

Flap procedures saved 116 patients from amputation. 554 (93.3%) of the cumulative 

594 flaps performed by participants one-year after the course were reported to be 

successful. 97% of course participants taught flap reconstruction technique to either 

176

colleagues or residents, and a self-reported estimate of 28 other surgeons undertook 

flap reconstruction as a result of information dissemination by one-year post-course. 

Conclusion: The SMART course can give orthopedic surgeons practicing in LMICs 

the skills and knowledge to successfully perform flaps and reduce the self-reported 

incidence of amputation. While this course offers a collaborative, sustainable 

approach to reduce global surgery disparities in amputation, future investigation 

into the other modalities to establish soft tissue management capacity in LMICs is 

warranted. 

Table 1. Total Successful Flaps and Amputations Averted One Year Post-Course 

Flaps 

Total Attempts Total Successful 

Success Total Amputations 

(n=34) (n=34) 

Rate Averted (n=34) 

Cross Finger 69 62 89.9% 15 

Thenar 35 35 100% 5 

Axial 32 32 100% 3 

Kite 11 11 100% 1 

Radial Forearm 9 9 100% 3 

Flexor Carpi Ulnaris 11 11 100% 0 

Brachioradialis 1 1 100% 0 

Anconeus 2 2 100% 1 

V-Y Hand 93 89 95.7% 14 

Flexor Carpi Radialis 1 1 100% 0 

Reverse Radial Forearm 4 4 100% 0 

Gastrocnemius 107 99 92.5% 20 

Soleus 72 67 93.1% 23 

Sural 31 29 93.5% 10 

Reverse Sural 40 32 80% 3 

Gluteus 12 11 91.7% 4 

Tensor Fascia Latae 5 5 100% 2 

Posterior Thigh 2 2 100% 0 

Gracilis 1 1 100% 0 

Latissimus 13 12 92.3% 5 

VY Sacrum 27 26 96.3% 3 

Groin 16 13 81.3% 4 

Totals 594 554 93.3% 116 

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Paper 168 

Presenter: M Uglow 

Authors: J Judd, MG Uglow 

Disclosure: Yes: Mr Uglow has received payments for lecturing from Smith & 

Nephew plc. 

Abstract title: Is neurovascular compromise in complex limb reconstruction a risk 

with epidural analgesia in children? 

Purpose of Study The purpose of this study was to evaluate the incidence of 

neurovascular compromise including compartment syndrome in children whose postoperative 

pain relief was managed with an epidural, following application of an 

external fixator for the purposes of lower limb deformity correction and lengthening. 

Description of Methods Between January 2001 and January 2014, a case series of 

patients undergoing external fixator management of their lower limb condition was 

reviewed. A retrospective note and chart review examined clinical data and included 

treatment condition, surgical procedure, prescription of epidural infusion, validated 

pain scores on day one and two post-operatively using the Faces pain scale or 

Visual Analogue tool depending on age, neurovascular, urinary and specific epidural 

problems. Particular emphasis was to identify neurovascular compromise. 

Eighty six patients with a total of 99 case episodes were included. A further four cases 

were excluded due to incomplete data, leaving 95 individual case episodes in 65 

children. Eighty nine were treated with either a Taylor Spatial (TSF) or Ilizarov frame 

(IF) and 6 with a monolateral rail. The orthopaedic conditions included: relapsed club 

foot (42), leg length discrepancy (33), deformity correction (17), fractures (2) and one 

pelvic support osteotomy. The average age of the child was 11 years (range 4 – 18). 

Ratio of males to females was 34:31. 

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Post-operative analgesia involved an epidural with a prescription of 0.25%/0.5% 

Bupivicaine (+/-Fentanyl, 2 mcg/kg) and a post-operative prescription of 0.15% 

/0.125% Bupivicaine (+/- Fentanyl) was prescribed. The epidural was usually in 

situ for 48 hours post operatively (range, 8-96 hrs) and was supplemented with 

Paracetamol, Ibuprofen and Codeine if necessary. Ibuprofen was only administered 

in the first 48 hours due to its link to poor bone healing and since completion of this 

study the use of Codeine is contraindicated in children under the age of 12 years. 

Results Summary The pain scores documented during the initial 48 hour duration of 

epidural analgesia had a range on day 1 of 0-7, with an average of 2. On day 2 

the range was 0-8, with an average of 2. 

No compartment syndromes occurred in the study period but there was one case of 

foot ischaemia resulting in dry gangrene and subsequent amputation of the little toe. 

The pain scores escalated rapidly during the 2 nd post-operative day despite a fully 

functional epidural. 

178

Conclusion Epidural analgesia is a very effective method of controlling post-operative 

pain and does not appear to mask the pain of ischaemia. 

Paper 169 

Presenter: H Burnand 

Authors: H. Burnand, B. Riemer, S. McMahon, N. Gibson, M. Whitehouse, A. 

Blom, V. Wylde 


Abstract title: Comparison of an SMS-administered health outcome measure and 

clinic-based joint specific outcome score in a new hip arthroplasty service. 

Purpose 

Patient reported outcome measures (PROMs) are now considered a routine part of 

post-operative arthroplasty assessment. This is a challenging requirement in settings 

with scarce resources. 

This paper describes a prospective cohort study assessing the feasibility of administering 

a patient reported health outcome measure by SMS (text-message). In this study we 

compare the completion rate of SMS-administered PROM surveys with clinic-based 

joint specific outcome scoring. 

Methods 

We administered the Euroqol EQ-5D-3L to a consecutive series of 50 patients seen preoperatively 

for hip replacement in a rural South African hospital. Patients completed 

an EQ-5D paper version in clinic and were consented for being contacted by SMS 

survey which were sent 24 hours later and 3 months post-operation. Compensation 

was made remotely by SMS recharges. Patients were offered surveys in IsiXhosa, 

Afrikaans or English using validated Euroqol translations. Harris Hip Scores were 

also completed in clinic and 3 months post-operation. The study had national ethics 

service approval. 

Inclusion criteria: all adult patients with valid consent, ownership of a cellphone, and 

awaiting hip arthroplasty. 

Correlation was assessed using a 2-tailed Pearson test. 

Results 

Of the 50 patients, 41 patients were included in the cohort (9 patients were excluded: 

4 knee arthroplasties, 2 no cellphone, 3 did not wish to participate). Male:female 

ratio was 15:26 and mean age was 59 (range 18-82). 

37/41 patients completed the paper EQ-5D survey and there were 25/41 

completed Harris Hip Scores. The EQ-5D visual analogue (VAS) paper scores and 

24 hour SMS VAS scores showed a good correlation (0.65, p

outcome measures are an important part of patient follow up. There is potential to use 

PROMs either in addition to or in place of joint specific outcome measures. Innovative 

modes of administration can enable the use of PROMs to enhance arthroplasty 

services. 

Paper 170 


Authors: H. Burnand, S.McMahon, R. van der Walt, B. Riemer, M. Kelly, V. Wylde, 

M. Whitehouse 


Abstract title: Comparison of the Orthopaedic Trauma Association Open Fracture 

Classification (OTA/OFC) and Gustilo and Anderson (G&A) Classification in 

predicting the outcome of 123 open tibial fractures in a rural South African setting 

Purpose 

The OTA/OFC has been shown to potentially predict outcome in open fractures. It has 

good reproducibility whilst criticism surrounds the G&A classification. Frere Hospital, 

South Africa is a regional orthopaedic unit where the G&A classification is routinely 

used. This cohort study evaluated the introduction of the OTA/OFC alongside the 

G&A and compared the ability of each to predict outcome. 

Methods 

Classification and treatment data were collected prospectively on 123 open tibial 

fractures in 122 adult patients over 8 months. Outcomes of interest were vacuumassisted-closure, 

3 or more debridements and early (within index admission) 

amputation. Treatment strategies followed local protocol. National ethics approval 

was granted prospectively. 

Both initial classifications were noted by the admitting orthopaedic doctor and then 

confirmed/revised post-debridement by an orthopaedic surgeon. Data on outcome 

measures were recorded on regular trauma rounds by the principal author using 

a data-collection proforma. Bivariate linear regression analyses (SPSSv21) were 

performed comparing initial and final G&A and OTA/OFC classification for each 

outcome. A two-tailed Pearson correlation was performed between initial and final 

scores. 

Results 

Of 123 open fractures in 122 patients the mean age was 36 years (range 18-71) with 

male:female ratio of 96:27. Differences between initial and final G&A classifications 

are shown in the table. There were 14 changes in the G&A classification, all an 

increase in severity and nine by more than two grades. There were eight revisions to 

the final OTA/OFC, four decreases in severity and four increases. 

Gustilo & Anderson classification Initial Frequency Final Frequency 

Grade 1 33 27 

Grade 2 24 21 

Grade 3A 33 37 

Grade 3B 30 32 

Grade 3C 3 6 

Total 123 123 

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180

The initial OTA/OFC had significant predictive potential in all three outcomes, 

outperforming the G&A. The final scores for both systems also favoured the OTA/ 

OFC for significant predictive potential apart from further debridements. Correlation 

was significant for both groups but stronger for OTA/OFC (0.976 p

97.6 months). 20% of patients had previous surgery on their shoulder. Average 

postoperative WOSI scores were 79.5% and average ASES scores were 89.3. 

Six shoulders had dislocation events (11.7%) postoperatively: three were traumatic, 

and three atraumatic. Increasing number of preoperative dislocations increased the 

risk of a postoperative dislocation (p 

2 years of follow up. After inclusion criteria, all HA were statistically matched to a 

TSA patient by preoperative diagnosis, age (+/- 5 yrs), sex, and follow up period 

(+/- 6 months). At final follow up both cohorts completed a questionnaire regarding 

physical fitness, sporting activities, and work status. 

182

Results: 

40 HA and 40 TSA were match. Average age at surgery was 65.7 years or HA 

and 66.2 year for TSA (p=0.06). Average follow up was 62.0 months for HA and 

61.1 months for TSA (p=0.52). 

Average ASES scores improved for HA from 36.3 to 70.2 (p

earing surfaces as an alternative to MoM to reduce wear debris (chromium and 

cobalt ions) and to potentially reduce the incidence of hypersensitivity reactions. 

Hypothesis 

That CoM implants will produce fewer chromium and cobalt ions than MoM surfaces 

with as good clinical outcomes 

Methods 

This double-blinded (patients and assessors) randomized controlled trial compared 

the results of MoM with CoM total hip replacements with a minimum of five years 

follow up. All patients had isolated unilateral hip disease without any other prosthesis 

inserted. There were 83 patients with primary osteoarthritis of the hip who were 

enrolled in this study where all of the components were the same apart from the 

bearing surface. The serum levels of cobalt and chromium, radiological parameters 

and functional outcome scores were compared pre-operatively and at six, 12, 24 

and 60 months post-operatively. Clinical scores using the Oxford hip and the High 

Activity Arthroplasty scores were recorded at each follow up period. 

Results 

At a minimum of five years there were data from 36 COM and 31 MOM patients 

available for analysis. Ten patients were lost to follow-up, 3 patients required revisions 

(2 COM, 1 MOM), 1 patient was excluded due to a subsequent contra-lateral COM 

hip arthroplasty and 3 patients were excluded because of irregularities in the trial 

design. 

All patients had significantly (p

Paper 177 

Presenter: K Strauss 

Authors: K. Strauss, S.H. Pretorius, R.P. Lamberts 


Abstract title: The treatment of complex humerus fractures with a circular external 

fixator; a retrospective case study series. 

The treatment of complex humerus fractures with a circular external fixator; a 

retrospective case study series. 


The treatment of complex humerus fractures which cannot be treated by conventional 

methods such as plating or nailing are a difficult challenge for orthopaedic surgeons. 

Most of these complex cases are caused by high velocity impact trauma, such as 

gunshots and motor vehicle accidents. In attempt to treat these complex fractures, 

circular external fixators such as the Taylor-Spatial Frame (TSF), have been reported as 

a possible treatment modality 1,2 . However the effectiveness of the treatment modality 

has not been well established. Therefore the aim of this study was to establish the 

effectiveness of a TSF to achieve union in complex humerus fractures. 

Methods 

A retrospective analysis of 13 patients with complex humerus fractures and who were 

treated with a TSF was conducted. All patients were treated between January 2010 

and September 2015 at the orthopaedics department of Tygerberg Hospital. The 

mean age of the patients was 51 ± 11 years and ranged from 18 to 70 years. All 

associated imaging and clinical notes were studied in detail, while the disability of 

the arm, shoulder and hand score (DASH) at the point of removing the TSF was also 

captured from the clinical notes 14 t. 

Results 

The main finding of this study is that full union of the humerus was achieved in 11 of 

the 13 patients. The mean TSF treatment period was 170 ± 62 days and ranged 

from 83 to 247 days. Pin tract sepsis was found in 33% of all pins, which could be 

treated successfully with oral antibiotics. At the point of removing the TSF, the mean 

DASH was 60 ± 11 and ranged from 24 to 83. 

Conclusions 

This is the first study to report the effectiveness of a TSF, to treat complex humerus 

fractures until union, in a relatively large group of patients. Although TSF treatment 

was not successful in all patients and was associated with a pin tract sepsis rate of 

33%, full union of the humerus was achieved in 85% of all patients. Future research 

185

should focus on further improving the TSF treatment method, trying to reduce the rate 

of pin tract sepsis complication and, determine the long term functional outcomes of 

this treatment modality. 

References 

1. McFayden I and Atkins R. J Bone Joint Surg Br 2006;88-B:158 

2. Al-Sayyad M. J Pediatr. Orthop 2012;32:169-178 

Paper 178 

Presenter: A Marsh 

Authors: A.G. Marsh, J.W. Kennedy, A. Mohammed, S. Patil, R.M.D. Meek 


Abstract title: Cement In Cement Femoral Component Revision: Mid-Term Results 

Using Two Collarless, Tapered Stems 

Cement in cement revision with preservation of the original cement mantle has 

become an attractive and commonly practised technique in revision hip surgery. 

Since introducing this technique to our unit we have used two types of polished 

tapered stem. We report the clinical and radiological outcomes for cement in cement 

femoral revisions performed using these prostheses. 

All patients who underwent femoral cement in cement revision with a smooth tapered 

stem between 2005 –2013 were assessed. Data collected included indication 

for revision surgery and components used. All patients were followed up annually. 

Outcomes recorded were radiographic analysis, clinical outcome scores (Oxford Hip 

Score, WOMAC and SF-12) and complications, including requirement for further 

revision surgery. Median follow-up was 5 years (range 2 – 8 years). 

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116 revision procedures utilising a cement in cement femoral revision were performed 

in the 8 year study period (68 females, 48 males, mean age of 69 years). The 

femoral component was a C-stem AMT (Depuy) in 59 cases and Exeter stem (Stryker) 

in 57 cases. 

Radiographic analysis demonstrated no progressive radiolucencies around the 

femoral component in any patient and no evidence of stem loosening at most recent 

review. Median Oxford Hip Score increased from 15 to 32, WOMAC from 22 

to 38, and SF-12 from 25 to 32. Two patients had a further revision procedure for 

recurrent dislocation and 1 patient for infection. Two patients had a peri-prosthetic 

fracture at 4 years following initial revision surgery. There were 2 femoral component 

fractures (occurring at 3 and 4 years post revision, both occurring in Exeter stems). 

Our results report cement in cement revision of the femoral component provides 

promising mid-term radiographic and clinical results. No femoral stems required 

186

evision for aseptic loosening. Femoral component fracture however occurred in 2 

cases suggesting surgical technique and femoral component selection are paramount. 

Paper 184 


Authors: K Cutbush, K M Hirpara 


Abstract title: Arthroscopic Posterior Bone Block Augmentation of the Glenoid for 

Posterior Instability 

Purpose of study: Posterior bone block augmentation of the glenoid was first described 

in 1949 by Fried who performed the procedure in 5 cases. Several authors have 

subsequently published on the open procedure with good results, particularly in 

the setting of posterior glenoid bone loss or revision surgery. Recent improvement 

in arthroscopic techniques and equipment has allowed the fixation of iliac crest 

bone graft to the posteroinferior glenoid arthroscopically. We present 8 cases of 

arthroscopic posterior bone block augmentation of the glenoid for posterior instability. 

Description of methods: Surgery is performed in the lateral position using the Arthrex 

glenohumeral distraction tower. Arthroscopy is performed on the shoulder allowing 

assessment of the joint and any associated pathology. The posterior inferior labrum is 

mobilised, and a radial capsular split is formed at the desired level on the glenoid. 

Iliac crest bone graft is harvested and mounted to the Arthroscopic Latarjet holding 

cannula (DePuy Mitek). This graft is introduced though a posterior skin incision and 

passed through infraspinatus and the capsular split. The graft is positioned on the 

glenoid and secured with two guide wires. The graft and glenoid are then drilled 

and fixed with cannulated screws. Finally, the labrum and capsule is repaired over 

the graft using anchors. 

Summary of results: We have performed arthroscopic posterior bone blocks in 9 

shoulders (8 patients). To date there has been one voluntary posterior subluxation (at 

14 weeks post operatively), no significant graft resorption, no dislocation and no 

problems with postoperative stiffness. 

Conclusion: We believe arthroscopic bone block augmentation of the glenoid is a 

useful technique in the management of posterior instability. 

Paper 185 


Authors: k Cutbush, N A Peter, K M Hirpara 


Abstract title: Arthroscopic Subscapularis Repair – Is Preservation of the Rotator 

Interval & Comma Sign Important? 

187

Purpose of study: The all-arthroscopic repair of the subscapularis tendon is a challenging 

procedure that has seen increased interest over the last ten years. The purpose of this 

study was to evaluate the clinical outcomes of arthroscopic subscapularis repairs. 

The technique described utilises an extra-articular approach in which excision of the 

rotator interval, superior and middle glenohumeral ligaments, and biceps tendon is 

integral. Excision of the rotator interval; superior glenohumeral ligament (Comma 

sign) and middle glenohumeral ligament simplifies and streamlines the arthroscopic 

repair. At the same time it provides an extensive release of the subscapularis, which 

is advantageous in complete retracted tears. The study was undertaken to determine 

if this method of subscapularis repair with excision of the rotator interval was a safe 

and successful method of repair. 

Description of methods: Between 2010 and 2015, 29 patients (10 female, 19 male) 

who underwent arthroscopic repair of large full thickness subscapularis tears were 

included in this prospective, cohort study. The mean age at surgery was 58.2 years 

(42-69). Results are reported for 21 patients who have been reviewed at greater than 

6 months post-surgery. Concomitant supraspinatus tear was not an exclusion criterion. 

Summary of results: Pain intensity during normal activities at greater than 6 months 

post-surgery decreased (100 point VAS) from 60 (SD=19) to 14.2 (SD=22.2). 

Overall function and quality of life was measured using the Western Ontario Rotator 

Cuff Index (WORC) showing an improvement from 1524.6 (SD=278.8) to 320.5 

(SD=112.7). The Shoulder Pain and Disability Index (SPADI) scores decreased from 

54.3 (SD=24.2) to 6.6 (SD=8.1). The Constant Score showed an improvement in 

post-surgical measures of pain, function, movement and strength from 36.2 (SD=15.9) 

to 69.59 (SD=24.2). Shoulder active range of motion was: forward flexion 158.4 

(SD=28.2), external rotation 73.9 (SD=12.2) and abduction 156.6 (SD=34.9). 

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Conclusion: An extra-articular approach with routine excision of the rotator interval, 

superior and middle glenohumeral ligaments, and biceps tendon appears to be a 

safe and effective technique. Excision of these structures simplifies and streamlines the 

arthroscopic repair of the subscapularis such that it becomes technically on a par with 

a supraspinatus repair. 

Paper 186 

Presenter: N Jain 

Authors: R Plastow, H Imalingat, N Jain, C Cullen 


Abstract title: Pre-operative Magnetic Resonance Imaging Does Not Predict 

Hamstring Graft Size for ACL reconstruction 

Objective – To identify whether using Magnetic Resonance (MRI) scan pre-operative 

hamstring graft diameter measurement for ACL reconstruction can help predict the 

choice of graft to use. Method – Sixty MR scans in 60 patients that underwent 

ACL reconstruction were assessed. Two surgeons measured gracilis and semi 

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tendinosus graft diameters using axial slices at two different points in the tendon. 

Cross sectional area was also calculated. If the diameter was below a desired 

7.5mm threshold, this case was highlighted as a potential for needing alternative 

graft. This allowed kappa co-efficient scores, for intra and inter observer reliability 

to be calculated. We then correlated these results with the intra-operative graft 

measurement, assessed using 0.5mm incremental sizing cylinders. The grafts were 

measured utilising a four stranded suspensory fixation method. A Pearson correlation 

co-efficient was calculated to determine any relationship between pre and intraoperative 

readings. Results – The surgeons demonstrated perfect agreement for intraobserver 

and inter-observer reliability. All pre-operative measurement calculations 

were agreed to be greater than 7.5mm. The pre op graft diameter measurements 

and Cross Sectional Areas showed poor correlation with the intra-operative graft 

measurements. Of the 60 cases reviewed 5 were highlighted intra-operatively as 

below the desired 7.5mm graft size. None of these cases were highlighted by the 

pre op measurements. Conclusion – MR Images are not reliable enough to estimate 

the size of hamstring grafts prior to ACL reconstruction using the 4 strand technique. 

This is against the current literature but this is the largest series produced to date. 

Paper 188 

Presenter: S Middleton 

Authors: Middleton SD, McNiven N, Anakwe RE, Jenkins PJ, Aitken SA, Keating JF, 

Moran M 


Abstract title: Medium-Term Patient Reported Outcomes after Total Hip Replacement 

for Displaced Hip Fractures 

Purpose of study 

We define the medium-term outcomes following total hip replacement (THR) for hip 

fracture. There is currently very little information regarding longer term clinical and 

patient reported outcomes in this group of patients selected in accordance with 

national guidelines. 

Methods 

We prospectively followed up 92 patients who underwent THR for a displaced hip 

fracture over a three year period between 2007 and 2010. These patients were 

followed up at 5 years using the Oxford hip score, Short-form 12 (SF-12) questionnaire 

and satisfaction questionnaire. These outcomes were compared to the short term 

outcomes previously reported at 2 years to determine any significant differences. 

Results 

Mean follow up was at 5.4 years with a mean age at follow up of 76.5 years. 

74 patients (80%) responded. Patients reported excellent functional outcomes and 

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satisfaction (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 

44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The 

rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to 

those quoted for elective THR. When compared with 2 year follow up, there was no 

statistically significant adverse changes in outcome parameters. 

Conclusion 

Medium term outcomes for THR after hip fracture in fit older patients are excellent and 

these results demonstrate that the early proven benefits of this surgery are sustained 

into the mid-term. 

Paper 189 

Presenter: R Streicher 

Authors: R.M. Streicher, A.A. Porporati, H. Kiefer, J.P. Kretzer 

Disclosure: Yes: General Manager and Principal Dr. Streicher GmbH 

Abstract title: Ion release from metal and ceramic bearings? 

Purpose of the Study 

CoCr metal alloy bearings have a high failure rate because of ion and particle 

release from the bearing and modular interface surfaces. Ceramic components have 

shown to reduce such phenomena dramatically. Nevertheless, the newest ceramic 

generation, alumina matrix composite (AMC), contains among alumina and zirconia 

also traces of chromium and strontium, although in a ceramic bonding. This study 

investigated the ion leaching of AMC clinically as well as experimentally 

Methods 

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Clinically two groups were compared: a control group (n=15) without any 

implant (Controls) and 15 patients with unilateral hip replacement (Patients) using 

AMC (Biolox delta,CeramTec) ceramic-on-ceramic (CoC) bearings. Whole blood 

samples of Controls were measured before the operation and Patients post-operatively 

at 3 and 12 months by means of ultra-trace element analysis using high-resolution-ICP- 

MS. The leaching properties of CoCr metal alloy and Biolox delta 28 mm heads was 

also analysed in-vitro: five each were immersed statically in bovine serum for seven 

days at 37degC. Aluminum, cobalt, chromium and strontium were determined using 

the same HR-ICP-MS equipment. 

Results 

In Patients, most elements remained below the limit of detection (LoD), except for 

aluminium and strontium.The aluminum amount of Controls was below the LoD (27.2 

ug/L). The values of Patients after 3 months showed a median of 34.2 ug/L and after 

12 months of 37.07 ug/L (p=0.510). Stontium ranged from 39.7 ug/L for Controls 

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and 79.6 ug/L and 41.01 ug/L for Patients, after 3 and 12 months,respectively. 

This difference was statistically not significant (p=0.322). The leaching experiment 

revealed high amounts of cobalt (177.3 ug/L) and chromium (4.2 ug/L) released 

by the CoCr metal alloy heads. Ceramic heads didn’t show any significant release 

versus the control. 

Conclusion 

The current study showed no significant increase of any element analysed in patients 

with AMC CoC bearings after 3 and 12 months; the wearing-in period. On the 

contrary metal heads released high amounts of cobalt and chrome in the leaching test. 

As this release occurred without any movement, surface corrosion (general corrosion) 

seems to be a relevant mechanism in the ion release of CoCr metal alloys. As Co-ions 

have been shown to interfere with the immune system, there are concens with CoCr 

metal alloy implants. 

Paper 190 


Authors: S. K. Singh, D. J. Woodnutt, M. M. Mullins, M. B. Dodd 

Disclosure: Yes: Arthroplasty fellow funding support from Implantcast 

Abstract title: Patient specific knee replacement is more cost effective that standard 

knee replacment - Purpose of Study 

Three cohorts for total knee replacement were compared to look at the cost effectiveness 

of patient specific instrumentation (PSI) cutting jigs for total knee replacement. 

Method 

The patient pathway was mapped out, with the guidance of health economists, to 

look at potential financial gains from numerous factors, including reduced sterilisation 

costs, length of stay, post-operative pain requirements and inventory costs. Additional 

increased costs from PSI planning and production were also recognised. Cohorts 

were analysed, retrospectively to prevent bias with regards to treatment received, 

calculating cost savings that were achieved throughout the patient pathway (from 

decision to operate to 1 year follow up) in addition to the theoretical gains that are 

recognised as a result of shorter operative time. Cohort 1 and 2 used PSI jigs with 

a difference between the two being the caseload of the operating list on the day of 

surgery. Cohort three did not use PSI jigs. 

Results 

The cohorts were of similar size (mean 20 patients) and well matched with regards 

to age, functional status and co-morbidities. A significant difference in the total cost 

of the patient pathway was found between all groups. The high efficiency patient 

specific Total Knee replacement cohort was the most cost-effective, followed by the 

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outine efficiency PSI cohort. The standard knee replacement cohort, without the use 

of PSI, was the most expensive group of patients. The difference remained significant 

after the gains that could be achieved for shorter operating time were removed. 

Conclusion 

Total knee replacement performed with the use of patient specific matched 

instrumentation is more cost-effective than standard knee replacement, independent of 

the potential financial gains that can be achieved with shorter case length and high 

efficiency operating lists. The opportunity to create PSI only, high efficiency, operating 

lists offers even greater financial gains but it is accepted that this is not possible in all 

hospital environments. 

Paper 193 

Presenter: H Malchau 

Authors: R. Madanat, O. Rolfson, G.S. Donahue, H.G. Potter, R. Wallace, V. 

Lerner, O.K. Muratoglu, H. Malchau 


Abstract title: Medial Calcar Erosion and Synovial Thickness in Patients with 

Metal-on-Metal Hip Arthroplasty 

Introduction: Medial calcar erosion is considered a late finding in patients with 

severe adverse local tissue reactions (ALTR) following total hip arthroplasty (THA) with 

dual modular neck stems. Although medial calcar erosion has been associated with 

dual modular neck stems, one would expect similar findings in standard stems due 

to analogous mechanically assisted crevice corrosion (MACC) at the taper junction. 

The purpose of this study was to evaluate if medial calcar erosion is also present in 

patients with standard stems in metal-on-metal (MoM) THA. 

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Methods: 96 patients (108 hips) with ASR XL THA had radiographs and hip MRI 

performed using metal artefact reduction at a mean time of 5.7 years after surgery. 

Medial calcar erosion was assessed from radiographs. Atypical medial calcar erosion 

was defined as 1) any radiolucency or endosteal scalloping emerging from the cranial 

edge of the medial femoral stem–calcar interface (“stem-interface erosion”), or 2) any 

“bite type” sign of endo- or periosteal scalloping in the remainder of the medial calcar 

above the lesser trochanter (“cranial-medial erosion”). The diameter, volume, synovial 

thickness and Anderson grade of ALTRs were assessed from MR images. 

Results: The prevalence of ALTRs in this patient cohort was 78% (n=84). There were 

47 hips with Anderson grade C1, 16 hips with C2, and 21 hips with C3 ALTRs. 

There were 24 hips with no ALTR. Calcar erosion was present in 50% (n=54) of hips. 

Stem-interface erosion was present in 16% (n=17) of the hips while 11% (n=12) had 

erosion in the cranial-medial part of the calcar. In 23% (n=25) of the hips, erosion 

was present at both locations simultaneously. Calcar erosion was associated with 

synovial thickness, but not with maximal ALTR diameter, volume, or Anderson grade. 

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The relative risk of having a synovial thickness >3mm increased by a factor of 3.0 

(95% CI 1.3-6.5) if medial calcar erosion was observed. 

Discussion and Conclusion: Subtle erosions of the medial calcar following MoM THA 

may be an early indicator of an adverse reaction to wear particles. Synovial thickness 

may also be more relevant than absolute size in the classification of ALTR severity and 

collateral tissue damage. Future studies should focus on longitudinal radiographic 

changes in the structure of the medial calcar as well as on the prognostic value of 

synovial thickness on ALTR progression and outcomes. 

Paper 194 

Presenter: H Malchau 

Authors: G.S. Donahue, R. Madanat, D.K. Hussey, O. Rolfson, R. McLennan-Smith, 

V. Lerner, M. Nortje, O.K. Muratoglu, H. Malchau 


Abstract title: Simplifying the Current Risk Stratification for Metal-on-Metal Patients 

Introduction: 

In 2014, guidelines for stratifying patients with MoM hip replacement into groups 

of low, medium, and high risk of failure based on multiple criteria were published. 

However, difficulty remains in managing patients with various (high and low) risk 

levels for different criteria within the guidelines. 

The first purpose of this study was to assess if a scoring system can be applied to the 

current MoM guidelines. The second purpose was to test, using this scoring system, 

how the contemporary guidelines would classify a cohort of patients with a recalled 

MoM hip replacement system. 

Methods: 

The study population consisted of 1301 patients (1434 hips) enrolled from September 

2012 to June 2015 in a multicenter follow-up study of a recalled MoM hip replacement 

system at a mean of 6.2 (range 2.4 – 11.2) years from index surgery. Fifteen scoring 

criteria were determined based on existing follow-up algorithm recommendations and 

consisted of patient factors, symptoms, clinical status, implant type, metal ion levels, 

and radiographic imaging results. Criteria considered ‘low’ risk were given 1 point, 

2 points for ‘moderate’ risk, and 3 points for the ‘high’ risk group. Forward stepwise 

logistic regression was conducted to determine the minimum set of predictive variables 

for risk of revision and assign variable weights. The MoM risk score for each hip was 

then created by averaging the weighted values of each predictive variable. 

Results: 

Only two of the proposed eleven criteria were found to be significant predictors of 

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evision in our logistic regression model; clinical status (as measured by the Harris 

Hip Score) and blood metal ion levels.By September 2015, 85 patients had been 

revised. The median MoM risk score for unrevised hips (2.15) was lower compared 

to revised hips (4.49) (p < 0.001). Receiver operating characteristic analysis yielded 

good discrimination between all revised and unrevised hips, with an area under the 

curve of 0.82 (p < 0.001). A high MoM risk score had 5.8-fold increased odds for 

revision relative to the moderate risk group (p < 0.001) and a 21.8-fold increased 

odds for revision compared to the low risk group (p < 0.001). 

Discussion and Conclusion: 

The MoM risk score is an effective tool for applying the current risk stratification 

guidelines to a cohort of patients with a MoM hip replacement. This scoring system is 

one way to simplify the interpretation of current risk stratification guidelines for patients 

with MoM hip replacements. 

Paper 195 

Presenter: J Outerleys 

Authors: J. Outerleys, M. Dunbar, G. Richardson, C. Kozey, J. Wilson 


Abstract title: Gait Function after Total Knee Arthroplasty remains Distinct from 

Asymptomatic 

Purpose: Total knee arthroplasty (TKA) has been shown to improve knee joint function 

during gait postoperatively. However, there is considerable patient to patient 

variability, with most gait mechanics metrics not reaching asymptomatic levels. To 

understand how to target functional improvements with TKA, it is important to identify 

an optimal set of functional metrics that remain deficient post-TKA. The purpose of 

this study was to identify which combination of knee joint kinematics and kinetics 

during gait best discriminate preoperative gait from postoperative gait, as well as 

postoperative from asymptomatic. 

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Methods: Seventy-three patients scheduled to receive a TKA for severe knee 

osteoarthritis underwent 3D gait analysis 1 week before and 1 year after surgery. Sixty 

asymptomatic individuals also underwent analysis. Eleven discrete gait parameters 

were extracted from the gait kinematic and kinetic waveforms, as previously defined 

(Astephen et al., 2008). Stepwise linear discriminant analyses were used to determine 

the sets of parameters that optimally separated preoperative from postoperative gait, 

and postoperative from asymptomatic gait. Cross-validation was used to quantify 

group classification error. 

Results: Knee flexion angle range, knee adduction moment first peak, and gait velocity 

were included in the optimal discriminant function between the pre and postoperative 

groups (P

-0.501, 0.565 respectively), and a total classification rate of 74%. A number of 

metrics were included in the discriminant function to optimally separate postoperative 

and asymptomatic gait function, including knee flexion angle range, peak stance 

knee flexion angle, minimum late stance knee extension moment, minimum midstance 

knee adduction moment, and peak knee internal rotation moment (P

the standard head group, with an average follow-up of 13.7 years (range 13-16) 

there were 25 females (33%). For the large head group with an average follow-up 

of 11.2 years (range 10-15) there were 32 females (50%). Wear analysis was 

performed using the Martell Hip Analysis software. Detailed radiographic grading 

was performed on the longest follow-up AP hip films. The extent of radiolucency in 

each zone greater than 0.5mm in thickness was recorded along with the presence of 

sclerotic lines and/or osteolysis. 

Results: 

Wear analysis: Using the average of the slopes of the individual regression lines, 

there was no significant difference between the wear rates of the two groups: 

standard head group 0.006±0.033mm/yr; large head 0.004±0.094mm/ 

yr group, (p=0.9). There was a significant difference in the wear rates using the 

early to latest film method: standard head group 0.004±0.056mm/yr; large head 

0.035±0.076mm/yr group, (p=0.008). 

Radiographic analysis, combined: Acetabular side: the greatest incidence of 

radiolucency occurred in zone 1 at 20%; sclerotic lines had a 1% incidence in each 

of the 3 zones; there was no osteolysis identified. Femoral side: the highest incidence 

of radiolucencies was in zones 1 and 6, 9% and 5%; sclerotic lines were rare in any 

zone, maximum in zone 3, 4%; there was no osteolysis identified. 

Conclusion: 

The wear rates of this form of irradiated and melted highly crosslinked polyethylene 

remained at levels lower than the detection limit of the soft wear at minimum 10 year 

follow-up for the large head group and minimum 13 year follow-up for the standard 

head group. Radiographic analysis revealed no identified osteolysis. 

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Paper 197 

Presenter: P MOSES 

Authors: P.MOSES,S. LAKSHMINARAYAN 


Abstract title: EFFECTIVENESS OF COMPREHENSIVE ANALGESIC REGIME AFTER 

DAYCASE SHOULDER SURGERY 

PURPOSE OF STUDY: To study the effectiveness of post-operative pain control 

and patient satisfaction after daycase shoulder surgery including complex and 

open shoulder surgery. METHODS: A prospective cohort study of 61 consecutive 

patients undergoing shoulder surgery as daycases using a comprehensive analgesic 

regimen including pre- & post-operative patient education,peri-operative multimodal 

analgesia & antiemetics,Interscalene block and cold compressive shoulder wraps 

with written and verbal instructions.Telephonic follow-up to document numerical pain 

score,complications and patient satisfaction. RESULTS: 1. PAIN CONTROL: The 

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nerve block was effective in 55 patients(92%) and provided good analgesia for 

12-20 hours.Post-operative pain was adequately controlled in 48(79%,NPV < 4 ). 

13 patients(21 %) had moderate pain which was controlled by opioid analgesics 

and cold compresses. Intermittent cold compresses were used by 17/61 patients 

(27%). 16/17 (94%) of patients found it “definitively effective”.These patients found 

it specially useful after the block had worn off. 2. SLEEP: -55(92%) of patients slept 

well on the 1st night 3. UNPLANNED OVERNIGHT HOSPTIAL ADMISSION: 

-58(95%) of patients were discharged home the same day.3 patients required 

unplanned overnight admission for pain & nausea and vomiting. 4 OVERALL 

PATIENT SATISFACTION: Excellent in 50(83%),Good in 6(10%) and fair in 5(8%) 

of patients DISCUSSION: Post-operative pain can be effectively managed by a 

comprehensive analgesic regimen in arthroscopic and open shoulder surgeries 

done as daycases. Our results compare favourably with other similar studies. A 

combination of patient education, multimodal analgesia, interscalene blocks and 

cold compression packs can provide for a high patient satisfaction,short hospital 

stay and early effective rehabilitation for these patients 

Paper 199 

Presenter: M Swiontkowski 

Authors: M. Swiontkowski 


Abstract title: OUTCOMES OF OPEN CARPAL TUNNEL RELEASE IN A LARGE 

OUTPATIENT ORTHOPAEDIC SURGERY CENTER- THE IMPACT OF A PROTOCOL 

DRIVEN APPROACH 

At the TRIA Orthopaedic Center in Bloomington, MN, USA, we began our outcomes 

program focused on the management of Carpal Tunnel Syndrome. We chose this 

diagnosis as the most common presenting complaint to the group of 6 hand surgeons 

at the center. 

These surgeons created a diagnostic and treatment pathway which was posted on 

the TRIA website for patient education and shared decision making. The diagnosis 

was by history and physical exam with no electordiagnostic testing. The treatment 

pathway was specific all the way to type of closure and splinting duration and type 

as well as return to work instructions. 

Ultimately we evaluted the outcomes of CTR surgery in 2144 patients over three years 

with the Boston Carpal Tunnel outcome instrument documented pre-operatively and 

2.6 and 12 years postoperatively. We analyzed the first 1000 patients in detail with 

a focus on the impact of medical comorbidity on outcome. The surgcial procedure 

consisted of an open procedure done under local anesthesia with interrupted nylon 

suture closure and splintng for 5 day post operatively. Complete data was available 

on 950 procedures in 826 patients. 9.5% of the cohort had diabetes,9.7% thyroid 

diease, and 7.5% rheumtoid arthritis. The mean symptom score improved from 3.1 

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at baseline to 2.0, 1.8, and 1.6 at 2, 6 and 12 weeks. The mean functional score 

improved from 2.4 preoperatively to 2.3, 1.7, and 1.5 at 2, 6, and 12 weeks. 

All symptom score timeframe improvements were significant and the functional score 

improvements were significant at 6 and12 weeks. Patients with diabetes improved 

more slowly but were not different from the entire cohot at 6 weeks post-surgery. 

There was no difference in symptom or function improvement at any time point in 

patients wih any comorbidity. Patients with workers compensation coverage were 

worse at baseline, 2 and 6 weeks but not different at 12 weeks. At no time point 

was there any difference in patient improvement between any of the 6 surgeons. 

Because we have optimized patient outcomes with this procedure, had standardized 

the procedure to eliminate any non-essential costs, and had shown no differences 

between surgeons, we have declared achievemet of the triple aim and are currenty 

not collecting outcomes for this procedure. 

Paper 200 

Presenter: A Strydom 

Authors: A. Strydom, N.P. Saragas, P.N.F. Ferrao 


Abstract title: A Radiographic Analysis of the Contribution of Hallux Valgus 

Interphalangeus to the Total Valgus Deformity of the Hallux 

Background: The hallux valgus interphalangeus (HVI) deformity is described as rare, 

but improved outcomes in hallux valgus (HV) surgery is associated with its surgical 

correction via an Akin osteotomy. The hypothesis of this study is that HVI is common 

and makes a significant contribution to the total valgus deformity of the hallux (TVDH). 

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Methods: 285 pre-operative foot x-rays, utilising standardised radiographic and 

measurement techniques, were analysed retrospectively. The hallux valgus angle 

(HVA), intermetatarsal angle (IMA), interphalangeal angle (IPA) and distal metatarsal 

articular angle (DMAA) were measured. The TVDH was calculated as the sum of the 

HVA and IPA. 

Results: 163 (57.2%) of the study population were Caucasian, 119 (41.8%) African 

and 3 Indian (1.0%). 236 (82.8%) of the population was female. There was a 

statistically significant difference in the proportion of abnormal IPA in the Caucasian 

population 112 (68.7%) compared to the proportion of abnormal IPA in the African 

population 64 (53.8%), p = 0.01. 

The average contribution of the IPA to the TVDH across the whole study population 

was a mean (SD) of 37.9% (21.2). The average contribution of IPA to TVDH was 

greater in feet without HV (58.0%) when compared to feet with HV (28.3%). HVI is 

common, particularly in Caucasians (p=0.01) and makes a significant contribution 

198

to the TVDH (p

either group 

Conclusion 

Despite less pain relief in the revision TKA group, these patients reported similar 

patient reported outcomes in both the AKSS and SF12 compared to the matched 

cohort of primary TKA patients 

Paper 203 

Presenter: SD Smith 

Authors: S. Smith, A. Aden 


Abstract title: Assessing litigation risks in patient-doctor interactions 

Introduction: Medical malpractice lawsuits continue to be filed at an alarming 

rate, with billions of Dollars being paid out across the globe. Most of these claims, 

defendable or not, are often settled out of court. These uncontrolled medical claims 

continue to push up the costs of medical liability insurance, which in turn pushes up 

the cost of health care. These pressures are felt most by the “high risk” specialties 

namely, Obstetrics and Gynaecology, Neurosurgery and Orthopaedics. South Africa 

has not escaped the wave of medico-legal lawsuits, and may be headed towards 

greater challenges than its first world counterparts. With the introduction of the new 

consumer protection act, and having one of the world’s most enlightened constitutions, 

makes the South African medical fraternity an easy target. Litigation involving South 

African orthopaedic surgeons suggests that the majority of claims filed are due to poor 

patient-doctor interaction, accounting for 13.35% of all claims. 

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Methodology: A prospective study conducted in 2014. Using a tailored patient 

satisfaction questionnaire, post operative orthopaedic patients were able to give 

insight into their satisfaction regarding their personal patient-doctor interactions. Each 

question was correlated to an area of patient-doctor interaction, that in the past had 

led to litigation. This was used to asses which areas of patient-doctor interactions 

were lacking in a typical resource starved state hospital. 

Results: Nearly 20% of patients are considering legal action at point of discharge, 

with no demographic data playing any significant role in this decision. All areas of 

patient-doctor interactions showed a significantly lower score, in those considering 

litigation versus those who were not. The two highest risk areas were related to doctor 

availability and consent taking. This study emphasizes the importance of proper 

communication between doctors and patients in preventing litigation, and the need 

for doctors to focus on improving their individual doctor-patient relationships. 

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Paper 204 


Authors: S. Smith, S. Van Deventer, R. Paterson 


Abstract title: The Truelok trauma circular fixator, a viable and cost effective 

alternative to Monolateral fixators 

Purpose 

Open fractures of the tibia are common injuries seen in high-energy trauma events. 

Options for external fixation in our circuit include monolateral and Circular fixators. 

The Majority of the Truelok system can be reused in many ways, e.g: In complex 

fractures, deformity corrections, Ilizerov constructs and lengthening, making it a cost 

effective device for state hospitals 

Despite these benefits, Circular fixation is never used as a primary external fixator in 

our circuit. Monolateral fixators still remain the primary choice for the management of 

acute open fractures. 

Methodology 

A prospective trial was conducted to assess why circular fixation is overlooked and to 

introduce the Truelok trauma fixator (A device never used before in the circuit). This was 

done using questionnaires, video demonstrations and a dry bone workshop. Surgeons 

were randomly divided into groups and assigned a fractured bone with which to 

apply their external fixator of choice. Constructs were priced, timed and graded 

for stability. Questionnaires assessed reasoning behind the surgeons preference for 

fixation and thoughts on circular fixation. 

Results 

100% percent of participants elected to use a monolateral device with the majority 

(83%) of participants opting to use the Orthofix Procallus. The 4 most common reasons 

given for not selecting a circular fixator included: Complexity, cost, time, and lack of 

experience. 

Comparative costing of the constructs revealed no significant difference in price or 

time of application. However, Ring fixation resulted in a significantly more stable 

construct. 

After a video demonstration of a Truelok trauma fixator, 90-95% of surgeons indicated 

they would be comfortable and interested in using the device, and agreed that it 

could play a primary role in the management of open fractures. 

Conclusion 

The Truelok trauma system can be a viable and cost effective option for the treatment 

of open tibia fractures. 

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Paper 206 

Presenter: N Saragas 

Authors: N.P. Saragas, P.N.F Ferrao, E. Saragas, B.F. Jacobson, A. Strydom 


Abstract title: The benefit of chemical venous thromboprophylaxis in foot and 

ankle surgery 

Introduction: Ten percent of patients suffering from a deep vein thrombosis (DVT) will 

develop a fatal pulmonary embolus. Often these are asymptomatic until the fatal 

event. The risks and benefits of chemical thromboprophylaxis are well documented 

with respect to total joint arthroplasty and hip fractures, but little is known regarding 

the incidence of venous thromboembolism (VTE) or the potential risks and benefits of 

chemoprophylaxis in foot and ankle surgery. 

Materials and Methods: A prospective cohort study was performed between March 

2014 and April 2015 of 142 patients who underwent foot and ankle surgery 

requiring a combination of below knee cast immobilisation and non-weightbearing 

for more than 4 weeks. All patients completed a Thrombosis Risk Assessment Score 

prior to surgery and were commenced on rivaroxiban 10mg daily post-operatively. 

The primary outcome measure was a clinical VTE confirmed by either compression 

ultrasonography (DVT) or a ventilation:perfusion scan (PE). 

Results: Three patients (2%) developed a clinical DVT, 2 of which were well beyond 

the immobilisation and anticoagulation period and one who was non-compliant 

with therapy; none while on the prescribed regimen of anticoagulant therapy. The 

average risk factor score in this subgroup was 7. Five patients (3.5%) developed 

wound breakdown, 2 of which required surgical debridement with a local skin flap 

closure. One case of menorrhagia occurred which may or may not be linked to 

the anticoagulant therapy. When compared to a previous comparable study (VTE 

incidence of 8.5%) there was a significant reduction in VTE risk by administering 

chemical thromboprophylaxis (p=0.0179) 

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Discussion: Oral chemical thromboprophylaxis significantly reduces the risk of VTE 

in patients requiring a combination of cast immobilisation and non-weightbearing 

following foot and ankle surgery. The risk/benefit ratio favours this treatment as 

opposed to the treatment of major morbidity following non-fatal VTE. 

Paper 207 

Presenter: P Ferrao 

Authors: N.P. Saragas, P.N.F Ferrao, Z. Mayet, H. Eshraghi 


Abstract title: Peroneal tendon dislocation/subluxation - Case series and review 

of the literature 

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Background: Dislocating or subluxing peroneal tendons is a relatively infrequent 

injury. Although infrequent it is very debilitating for the athlete. This retrospective study 

addresses primarily the surgical technique. 

Methods: Twenty-three patients between 2005 and 2014 were operated on for 

symptomatic dislocating or subluxing peroneal tendons. Five patients presented in 

the acute phase and 18 patients were late cases. Twenty patients were available for 

follow-up at a mean of 53.1 months. Three patients were classified as Stage III and 

17 as Stage I/II. The procedures varied from pure repair of the superior peroneal 

retinaculum (SPR), reattachment of the SPR, groove-deepening or a combination of the 

above. No one procedure was favoured over the other. The choice of procedure was 

decided intraoperatively depending on the findings. 

Results: The mean postoperative VAS score was 1.5 with a mean AOFAS score of 

85. Sixteen patients rated their results as excellent, one as good, one uncertain and 

two poor. The results showed no one procedure superior to another with respect to 

chronicity, stage or satisfaction score. 

Conclusions: Several procedures have been described for this condition. Most 

published studies however, comprise of a small cohort of patients with good results 

following surgery. The surgical techniques vary and depend largely on the surgeon’s 

clinical experience and preference. The authors conclude that the surgical technique 

described in this article is largely successful with a low complication rate and a high 

satisfaction rate 

Paper 208 


Authors: S. Smith, S. Van Deventer, R. Paterson 


Abstract title: A Pilot Study, Truelok Trauma Circular Fixator in the Initial 

Management of Open Tibia Fractures 

Introduction 

In an earlier trial we looked at the use of the Truelok trauma ring external fixator for 

the treatment of open Tibial shaft fractures(see abstract submission titled: The Truelok 

trauma circular fixator, a viable and cost effective alternative to Monolateral fixators). 

In a non-clinical setting, this system proved to be no more expensive, time consuming 

or complex than the standard monolateral systems being used in the state sector. 

The Truelok trauma system was shown to be significantly more stable, with better 

wound exposure. Accurate corrections could be done in the ward, without the need 

for re-manipulations in theatre. This, coupled with the system’s ability to be reused for 

multiple applications, makes it an even more cost effective option in our state hospitals. 

203

Purpose 

This pilot trial was used to determine if the results from our non-clinical trial would 

translate accurately into clinical practice, and to see how easily orthopaedic residents 

would adapt to using a circular fixator they had no experience with. 

Methodology 

Five patients who had sustained open tibia fractures were recruited to the study. 

Four registrars and a consultant, were given the oppertunity to apply a Truelok trauma 

frame, and give feedback regarding their impression of the system, its application, 

and ease of reduction. (All reductions were done solely with the external fixator ) 

All procedures were timed and reductions documented. Poorly reduced fractures were 

corrected using the TL-Hex software in the ward. These patients were then monitored 

for complications, and/or loss of reduction and/or failure of the device, until removal 

of the External fixator. 

Results 

All Registrars were comfortable with the application of the device, found it no more 

complicated than a monolateral system, and indicated that reduction was easier with 

this system. 

All fixators were applied in under an hour, with all reductions being within acceptable 

limits. 

Two patients were selected to test the ability of the system to be converted to a TL- 

Hex (allowing for out of theatre manipulations). Both patients reductions were easily 

improved in the ward with minimal discomfort experienced by the patient. 

All patients were full weight bearing within 2 weeks, and achieved union with an 

average time of 6.2 months, and no loss of reduction. One patient developed pintract 

sepsis which was successfully treated with antibiotics. 

Conclusion 

This pilot study has shown that the Truelok Trauma Circular Fixator, is a cost effective 

alternative to monolateral external fixation in Tibial shaft fractures, and can be used 

safely and effectively. 

On this basis, a larger randomized control trial will begin comparing this system to a 

popular monolateral system. 

Paper 209 

Presenter: JN Cakic 

Authors: J.N.Cakic 


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Abstract title: TREATMENT OF DEVELOPMENTAL DYSPLASTIC HIP CONDITION 

ARTHROSCOPY AND AMIS HIP REPLACEMENT 

Abstract 

Patients with Developmental Dysplasia of the Hip (DDH) may present with symptoms 

of pain related to acetabular rim overloading, labral hyperthrophy and a subsequent 

labral tear. The presence of early osteoarthritic changes caused by the suboptimal 

biomechanical properties of the DDH joint, cannot be excluded. Intra articular 

pathologies of these hips resulting in pain and decreased daily functioning, causes 

204

patients to seek help, hoping that minimal intervention will improve their condition. 

Purpose: 

Hip dysplasia is often believed to be related to the poor results of hip arthroscopy 

treatment. The purpose of this study is to report the results of the operative treatment of 

patients with dysplastic disease of the hip. 

Methods: 

All the patients with diagnosis of DDH were prospectively assessed with a Harris Hip 

Score (HHS), preoperatively and postoperatively: at 6 weeks, 3, 6 and 12 months, 

and annually thereafter. From 2010, the iHot 33 scoring system was introduced in 

the assessment system. 

Results: 

We are reporting results of the treatment of 83 patients treated during the period 

of 10 years, between 2004 and 2014. Of the 83 patients, 34 have had hip 

arthroscopies performed, and 49 patients were not candidates for hip arthroscopy, 

for which reason the AMIS THR was performed. Out of 34 patients, conversion from 

the hip arthroscopy to the THR was indicated in 16 patients. 

Average conversion time period was 3 years (8-1 year). 

Conclusions: 

Results of the hip arthroscopy treatment in the presence of hip dysplasia show a 

favorable outcome. However, careful patient selection is extremely important. Not 

all patients with evidence of dysplastic morphology benefit from a hip arthroscopy. In 

fact, the procedure may accelerate the process of arthritis, similar to the deterioration 

seen with arthroscopy of the hip and knee performed in the presence of moderate 

OA. 

Paper 210 

Presenter: R Ray 

Authors: R. Ray, O. D. Stone, C.E. Thomson, J.N.A. Gibson 


Abstract title: Arthrodesis versus Total Joint Arthroplasty (TJA) for Hallux Rigidus: 

15 year follow up of a Randomised Controlled Trial 

Purpose: Between 1999 and 2001, we recruited 63 patients into the only 

randomised controlled trial of arthrodesis vs TJA for hullux rigidus published in the 

English literature. In 2005 we published two year results, which showed that although 

both interventions were successful, arthrodesis gave better outcomes than TJA. The 

aim of this study was to provide long-term outcome data. 

Methods: 77 toes in 63 patients were prospectively randomized. The primary outcome 

was VAS for pain (visual analogue score). We used the Visual-Analogue-Scale Foot 

and Ankle (VAS FA), which is a validated patient reported outcome measure and 

satisfaction score as secondary outcomes. Data regarding revisions was collected to 

formulate comparative survivorship of arthrodesis and TJA. 

205

Results: Data were available from all surviving patients at a mean of 15.2 years (66 

toes 53 patients). There was no difference in pain score between either group 7.4 ± 

15.7 vs 15.7 ± 19.7 (p=0.06). There was also no difference in the VAS FA scores 

88.9 ± 12.9 vs 86.1 ± 17.1 (p = 0.47). There was however a significant difference 

with regards to patient satisfaction with the arthrodesis group outperforming the TJA 

group: 95.5 ± 10.4 vs 83.6 ± 20.9 (p = 0.004). 

Kaplan-Meier survivorship analysis revealed that there was a significantly higher rate 

of revision surgery in the TJA group (log rank p= 0.009). All arthrodeses clinically 

and radiologically united. Nine patients in the TJA group required revision surgery. 

These patients were significantly more dissatisfied with their outcome than patients 

who did not require revision surgery 59.4 ± 22.7 vs 91.9 ± 12.3 (p

males who presented with AVN scores, classified according to the Ficat classification, 

of between 1 and 3. The outcome was determined by changes in the Harris Hip 

Score. Progression to hip replacement was considered as an end point. The mean 

follow up was 1 year. 

Results: 

At the final follow up consultation, the mean increase in the HHS was for 37.2 

points, from a preoperative score of 59.2, to a postoperative mean value of 96.5. 

Two patients required a conversion to a THR. One of these patients was had a 

THR without performing a decompression, following findings at hip arthroscopy. The 

second patient had progression of symptoms seven months after the decompression 

with a deteriorating HHS from 90.1 to 50.4. The other 8 patients are still showing 

a good outcome. 

Conclusions: 

Even in this small cohort, results are encouraging. The arthroscopic view of the 

intra-articular space of the hip joint presents several advantages to the surgeon. 

Firstly, this allows a more accurate assessment of the chondral surface prior to the 

actual core decompression. Secondly, it allows a more accurate approach to the 

subchondral surface, avoiding the perforation of the chondral surface. The results of 

the core decompression itself, show similar results when compared to the literature. 

Core decompression in combination with an injectable bone substance, should be 

considered as a treatment option in the presence of early AVN, especially in younger 

patient populations. 

Paper 212 

Presenter: N Alfahad 

Authors: N. ALFAHAD, A. BHATTACHARYA, K. KUMAR, J. GEOGHEGAN, WA 

WALLACE 

Disclosure: Yes: There are no conflicts of interest to declare in relation to the current 

research. 

Abstract title: Comparison of Different European and North American Shoulder 

Scoring Systems 

Background: Numerous shoulder scoring systems are in use world-wide to assess the 

outcomes from shoulder operations. Selecting the best outcome scoring instrument 

is challenging for the majority of musculoskeletal conditions. Outcome instruments 

can play an important role in the development of new procedures, techniques and 

protocols. The shoulder scoring systems that are currently used in North America 

are rarely applied alongside European shoulder scoring systems and vice versa. 

The lack of a universal shoulder scoring system impedes the evaluation process as 

it prevents valid comparison of outcomes from different research papers. This study 

aims to explore whether a correction factor which would allow comparisons to made 

between particular shoulder scoring systems. 

207

Methods: 93 participants with shoulder injuries have been included in this study. Six 

shoulder scoring systems were used on each patient Constant Score (CS), Oxford 

Shoulder Score (OSS), Simple Shoulder Test (SST), American Shoulder & Elbow 

Society Score (ASES) University of California Los Angeles Score (UCLA) and the 

Disabilities of the Shoulder and Hand Score (DASH). The results were extracted from 

a database and compared using linear regression analyses to explore the level of 

correlation and to derive the correction factors to allow corrections to be made from 

one scoring system to another. 

Results: The correlation coefficients varied between 0.867 (the best) for OSS score 

vs ASES score to – 0.732 (the worst) for CS score vs DASH score (significant at 

0.01 level; 2-tailed). The linear regression analysis allows conversion of one score to 

another and the best 4 correlations are reproduced below. 

For OSS vs ASES the derived formula is:- ASES = 1.9228 x OSS - 5.842 

For OSS vs UCLA the derived formula is:- UCLA = 0.5728 x OSS + 2.4554 

For OSS vs DASH the derived formula is:- DASH = -1.5652 x OSS + 85.262 

For CS vs UCLA the derived formula is:- UCLA= 0.3073 x CS + 5.252 

Conclusion: This study has established a method of transforming particular shoulder 

scoring systems to the equivalent values in their counterparts. It is important to note that 

this is only applicable to grouped scores, not individual scores. This will now allow a 

direct comparison between North American results and European results for shoulder 

surgery outcome studies. 

Paper 213 

Presenter: Z Mayet 

Authors: Z.Mayet, P.N.F.Ferrao,N.P.Saragas 


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Abstract title: Crossed screw technique for the Lapidus procedure using a headless 

compression screw 

Purpose 

The aim was to evaluate union rates using two cross headless compression screws. 

This was compared to conventional solid screws as recorded in the published literature 

Description 

This was a retrospective study of the Lapidus procedure performed in cases with a 

moderate to severe hallux valgus deformity. Union time was retrieved from medical 

records. Patient demographics included age, gender, smoking and other comorbidities. 

The union rate was compared to the literature using the two population 

probability test, with p< 0.05 being significant. 

208

Result 

Sixty nine feet in 56 patients were assessed for union. There were three delayed 

and two non-unions. The union rate of 97% was not statistically significant when 

compared to studies using conventional solid screws 

Conclusion 

The use of headless compression screws and early mobilization in the fixation of the 

first tarso metatarsal joint was found to comparable to be conventional solid screws. 

The cannulated design enhances the ease of insertion 

Paper 214 

Presenter: P Calder 

Authors: P.R. Calder, M Laubscher, A. Timms, W.D. Goodier 

Disclosure: Yes: Have conducted a work shop on behalf of Ellipse 

Abstract title: The Precice Intramedullary Limb Lengthening System: Extending 

Limbs with Extending Indications. 

There are many theoretical benefits to the patient undergoing limb lengthening using 

an intramedullary device compared to an external fixator. The Precice ILLS has added 

advantages including a variation in implant size and length with an ability to lengthen 

or shorten at an accurate rate. We present our experience with this new device 

building from simple long bone lengthenings to more advanced indications. 

Method 

56 Precice nails including 50 femoral and 6 tibial have been inserted in 40 patients. 

Indications include post traumatic and congenital shortening, syndromic deformity, 

shortening below arthroplasty as well as paediatric conditions such as shortening with 

persistent high hip dislocation and growth arrest. 

Outcomes were assessed in relation to implant, bone and soft tissue. 

Results 

The desired length was obtained in all but one patient. 

One nail failed to lengthen following implantation. 3 out of 108 locking bolts backed 

out during lengthening. One connective bushing splintered after lengthening had 

been achieved. One nail became deformed after the patient was involved in a road 

traffic accident. 

No patients have required bone grafting to the regenerate, in the tibial cases delayed 

ossification of the anterior cortex was seen. 

2 patients have required soft tissue release for knee flexion contracture after completion 

of lengthening. 2 patients have required release of tensor fascia lata. There were no 

cases of joint subluxation or dislocation and no cases of deep infection. 

209

Discussion 

With excellent clinical results and patient satisfaction the Precice nail has become 

the implant of choice for femoral lengthening in our practice and we have extended 

the indications to more complex deformity corrections. Following modification, by 

the manufacturer, certain implant failures have been resolved. Prophylactic soft tissue 

release with robust physiotherapy should minimise soft tissue complications. Early 

tibial results are promising but do raise challenges in osteotomy site, lengthening rate 

and regenerate ossification. 

Paper 216 

Presenter: RW Parkinson 

Authors: R W Parkinson,T R Madhusudhan, K Howard 


Abstract title: Midterm results of Cemented all Polyethylene fixed bearing tibial 

components in Total Knee Replacements 

Aim of the study: The aim of this study was to evaluate midterm results of all 

polyethylene (UHMWPE) tibial components in TKR in patients over the age of 70 . 

Methods: We analysed the medical records and radiographs of 323 knees in 

302 patients between 2011 and 2015. . Patients were followed up at 6 weeks, 

4 months and at 14 months and at 5 years. All patients were evaluated clinically 

and radiologically and had an Oxford knee score at 1 year. All operations were 

performed by the senior author. 

Results: There were 168 females and 134 males. Follow up ranged from 12 months 

to 88 months. All patients were admitted on the day of surgery and mobilised either 

on the same day or the post op day 1. 21 patients underwent staged bilateral 

knee replacements. All but 6 patients were available for follow up. 1 patient died 

due to unrelated cause. Complications included 1 wound dehiscence, 1 capsular 

dehiscence, and 1 patellar fracture. 1 patient required arthroscopic adhesionolysis 

for stiffness and one patient underwent revision for aseptic loosening. With revision 

for aseptic loosening as the end point, the cumulative survival probability was 95.38 

% (95% CI, 99.94% - 93.75%) which compares favourably to the mid-term results of 

metal backed tibial components from the English and Welsh National Joint Registry. 

The cost saving made by using an all poly tibial component was 200 GDP per case, 

giving an overall cost saving for the hospital in this series of 65000 GBP. 

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Conclusion: Our results indicate that the survival rates of the all UHMWPE tibial 

component are not significantly different to metal backed designs. There was also a 

very significant cost saving for our institution. 

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Paper 217 

Presenter: A Ilg 

Authors: A. Ilg, J. Holz 


Abstract title: Evaluation of Clinical, Radiographic, and Work Related Results of 

Patellofemoral Inlay Arthroplasty 


Patellofemoral arthroplasty (PFA) has been in clinical use for over 30 years, yet it 

remains a challenging subject due to the complex etiology and outcomes variability 

reported in the literature. Modern PF arthroplasty can be divided into two treatment 

concepts: Onlay procedures replace the entire articulation, whereas inlay arthroplasty 

is modeled after the patient’s individual trochlear anatomy through a selection of 

various sagittal curvatures. Modern versions of both concepts have demonstrated 

clinical benefits, however, there still remains a lack of published data to guide the 

orthopaedic surgeon. The purpose of this study was to validate our patient selection 

process and assess related clinical, radiographic and work related outcomes after 

inlay PFA. 

Description of Methods: 

33 isolated inlay PFA procedures were performed (7 male, 26 female, mean age 

56.7 years). All patients had failed prior conservative management and presented 

with pain and functional limitations that warranted surgical intervention. All patients 

met the following core criteria: Isolated patellofemoral degeneration and corrected or 

correctable instability or trochlear dysplasia if present. Patient expectation management 

included the discussion of the risk vs. benefits of partial arthroplasty and tibiofemoral 

disease progression. The surgical history included proximal tubercle realignment in 6 

patients, 21 arthroscopies, and 6 patients had a prior lateral release. Intraoperative 

records were reviewed and patients were analyzed with physical and radiographic 

examination. Clinical outcomes scores were used to determine subjective and 

objective results. 

Summary of Results: 

At a mean follow-up of 38 months, the mean Pain VAS score was 2.1, the average 

Tegner activity score was 3, the mean KOOS domains for pain was 77.2, symptoms 

76.1, activities of daily living 79.2, and sports 57.2. The quality of life score was 

58.9. Radiographic results showed no evidence of implant subsidence, disassembly, 

or periprosthetic loosening. 90% of all subjects returned to work at the time of last 

follow-up. Patient satisfaction with the outcomes was rated as good to excellent in 

89%. 

211

Conclusion: 

The study results support a joint preservation approach using patellofemoral inlay 

arthroplasty in a select group of patients. Careful patient assessment is necessary in 

order to optimize the clinical benefits of the procedure. 

Paper 218 


Authors: A. Riddell, M. Dodd, D. Woodnutt, M. Mullins 


Abstract title: Total Hip Arthroplasty in Groups at Higher Risk of Dislocation – Our 

Experience of a Dual Mobility Prosthesis 

The range of patients on whom total hip arthroplasty (THA) is undertaken continues to 

expand. Advances in medicine and patient expectation mean that patients at higher 

risk of dislocation are now becoming routine. One important factor is the latest British 

guidance from the National Institute for Health and Care Excellence (NICE), which 

suggests consideration of THA for all patients with a fractured neck of femur, who are 

mobile with one stick or less pre-injury. This guidance alone is leading to increasing 

numbers of THA being performed in this high-risk population. In our unit we have 

attempted to address the higher dislocation risk by utilising a dual mobility (DM) 

prosthesis based on promising French results. A DM prosthesis has the biomechanical 

advantages of both improved stability and improved range of movement and therefore 

seems a sensible choice in those at increased risk of dislocation. 

We present a consecutive series of 128 patients who have undergone DM arthroplasty 

in the presence of a higher than normal dislocation risk – either with a fractured 

neck of femur, neuromuscular disease, cognitive impairment or other risk factor. The 

majority of patients were treated with a hybrid prosthesis of an uncemented acetabular 

component and a cemented femoral component. All had an Evolutis (Briennon, 

France) acetabular component with the majority having the Captiv DM cup. The 

patient population had a mean age of 78 and a mean ASA of 2.3. We currently 

have follow up to 4 years and there have been no revisions and no dislocations in 

this period. Prospectively gathered data showed a mean Harris Hip score of 73 at 

last follow-up. We believe that our results support the use of this prosthesis in this 

challenging patient group. 

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Paper 220 


Authors: H. Burnand, R. McNinch, D. Simpson, S. Griffin, R. Bhatia 


Abstract title: Catches win matches and also stop fractures? An epidemiological 

study of hand injuries in English professional cricket (2008-2014) 

212

Purpose 

Upper limb injuries constitute a high proportion of injuries to professional 

cricketers[1] ,[2] . Previous studies proposed injury prevention measures to buddystrap 

ring and little fingers during fielding[3]. This study aims to illustrate types and 

mechanisms of hand injuries and reinforce potential prevention strategies. 

Methods 

The English Cricket Board database was analysed using anonymised injury reports 

completed by medical teams (physiotherapists and physicians). Injuries were 

coded according to the Orchard Sports Injury Classification System. Inclusion 

criteria were: adults, completed injury reports and acute injuries during matches or 

training. Statistical analysis was performed using SPSS(v21). 

Results 

Hand injuries comprised 323/654 upper limb injuries. 26 incomplete injury 

reports were excluded. All players were male with mean age: 26 (range 18-44). 

Most commonly injured was the thumb (28%) followed by little (20%) and ring (15%) 

fingers. The distal phalanx was involved in 25% of injuries. Fractures (50%) and 

dislocations (15%) were the most frequent hand injuries. 

Match-day injuries accounted for 78% versus 22% in training. Only 7% of hand 

injuries occurred in bowlers and over half were caught-and-bowled attempts. 

Fielding was the most common activity for hand injuries (61%) with wicketkeepers 

(38/197) and slips (12/197) most commonly involved (159 unspecified). 

Surgery was required in only 11% of injuries however 53% were unfit to play or 

train for more than 2 weeks post-injury. The mean return-to-sport was 22 days 

(range 0-192). Fractures accounted for 27/40 injuries resulting in extended 

periods off (more than 6 weeks). Twice as many fractures occurred in dropped 

catches versus catches held. 

Conclusions 

Cricketing hand injuries are common, specifically to fielders and are frequently 

distal phalangeal fractures. There is a trend suggesting that catching a catch is less 

likely to result in fracture and thus avoids a prolonged return-to-sport. These results 

support existing literature 3 promoting prevention strategies including buddy-strapping 

when fielding. 

[1] Walker et al. Injury to recreational and professional cricket players: 

Circumstances, type and potential for intervention. Accident Analysis and 

Prevention. 2010; 42: 2094-2098 

[2] Dhillon et al. Sports Med Arthrosc Rehabil Ther Technol. Nature and incidence 

of upper limb injuries in professional cricket players a prospective observation. Nov 

2012; 42 (4). 

[3] Ahearn, Bhatia, Griffin. Hand And Wrist Injuries In Professional County Cricket. 

Hand Surgery 2015 20:01, 89-92 

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Paper 222 

Presenter: UM Uglow 

Authors: MG Uglow, R Asp, 

Disclosure: Yes: Mr Uglow has received payments for lecturing for Smith & Nephew 

plc 

Abstract title: Evolution of osteotomy techniques reduces soft tissue and wound 

problems in complex foot deformity in children. 

Purpose of the study A retrospective audit of patients treated for complex foot 

deformity using the Taylor Spatial Frame (TSF) between 2004-2014 was performed. 

Techniques, outcomes and complications were recorded with particular attention to 

the method of cutting osteotomies. 

Patients & Methods Thirty patients undergoing 43 episodes were studied. The average 

age was 12.0 years (range 2.5 – 19.0). The majority diagnosis was sequelae of 

congenital talipes equino-varus including syndromic cases and arthrogryposis. Extraarticular 

osteotomies were performed and included U-, V- or a single limb of the V 

cut and midfoot osteotomies either through the navicular-cuboid or cuneiform-cuboid 

corridors. The TSF was applied using a variety of configurations. Functional outcomes 

were obtained and attention to ongoing shoe wear and orthotic prescriptions 

assessed. 

Results summary Plantigrade feet with good function were achieved in 35 feet. Three 

feet had residual equinus but good function. Five feet have on-going problems with 

pain. There were 13 complications, 7 obstacles and 35 difficulties (pin tract infection 

and admission for pain management). Complications contributed to poorer outcomes 

but the majority of treatment goals were met. The frequency of problems relating 

to the soft tissues has reduced since using percutaneous incisions and the use of 

the cooled burr has not produced any skin concerns. Where swelling has been 

significant, no wound problems have been encountered when using the burr. Three 

repeat procedures were performed for failure of distraction due to an incomplete 

osteotomy with a drill & osteotome technique. No repeat procedures were performed 

when using either a Gigli saw or a side cutting burr. 

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There has been a clear evolution of technique for performing osteotomies from an 

open approach, through drill & osteotomes, Gigli saw and recently osteotomies in 

10 cases have used a cooled side cutting burr through

Conclusion The evolution of techniques for cutting osteotomies in the child’s foot has 

progressed to using a cooled side cutting burr through very small incisions with no 

noted wound problems. This is a very useful adjunct in this cohort of difficult to treat 

feet, often with multiple scars from previous surgeries. 

Paper 223 

Presenter: DR van Der Jagt 

Authors: D.R.van der Jagt, J.R.T.Pietrzak and L.Mokete. 


Abstract title: Custom Made Acetabular Implants. A Short Term Follow up and a 

Cost Analysis. 

Revision hip replacement procedures for severe destructive lesions around the 

acetabulum remain challenging. We report on eleven such procedures where a custom 

made acetabular implant was used to manage type III lesions with pelvic dissociation. 

Implants from two different manufacturers were used. The patients ranged in age 

from 38 to 72 years, and on average had had 7 previous revision procedures. The 

average follow up was 27 months. Complications included 2 dislocations and 2 

cases of sepsis. 

One system used a process of machining the implant from a solid block of metal 

whereas in the other the implant was printed using a 3-D printer. We compared 

the practical strengths and weaknesses of the two systems used. This included 

differences in the planning phase, the manufacturing phase, as well as the actual 

clinical application and results of the two systems. The costs of both systems were 

competitive in our setting. There were no significant differences between the two 

systems in the short term. We do though consider the machine printed system to have 

some advantages. 

We did a cost analysis comparing the procedure related costs of a custom made 

acetabular implant to what would have been used hypothetically with alternative 

implants on a case by case basis. We concluded that whereas the implant costs 

are similar, custom made acetabular implants offer certain benefits such as a shorter 

surgical time and the consequent possible clinical benefits to the patient. 

We conclude that custom made acetabular implants used to manage type III acetabular 

deficiencies offer certain advantages over alternative implant options. These are both 

clinical and cost related. Their short term results are probably little different. 

Paper 225 


Authors: D.R.van der Jagt, J.R.T.Pietrzak, L. Mokete and R.J.L.Stein 


215

Abstract title: PMMA Particulate Debris Generation from Antibiotic Loaded Hip 

Spacers used to manage Septic Hip Replacements. A Histological and Explant 

Retrieval Analysis. 

Antibiotic loaded polymethyle methacrylate spacers are commonly used in the 

management of septic hip replacements. The aim of this study was to determine the 

extent of PMMA particulate debris generation. 

Tissue specimens from fixed points around the acetabulae in 12 cases at the time 

of the second stage procedure for septic total hip revisions were obtained. These 

were subjected to histological analysis to determine the extent of PMMA particulate 

debris contamination. We also performed a basic explant retrieval analysis of the 

articulating surfaces of the PMMA spacers to determine any specific wear patterns. 

We found numerous PMMA particles in the peri-acetabular soft tissues biopsied. 

The particle concentration was highest in the area of the acetabular fovea. We 

could also demonstrate specific wear patterns on the spacers that could be correlated 

with the generally mismatched articulating couple between the spacer and the bony 

acetabulum. We could also demonstrate some boney destruction present in the 

acetabulum with long-term spacer use. 

We concluded that significant amounts of PMMA particulate debris are generated 

by these articulating antibiotic spacers. The total volume of this debris may be 

determined by both the cement characteristics as well as the geometry of the cementbone 

articulation. We recommend a thorough debridement at the time of the second 

stage procedure to decrease the residual PMMA particle load. Consideration in 

respect of the bearing surface implanted after the explantation of the PMMA spacer 

should take into account the effect of the debris on the bearing surfaces. We also 

make recommendations in respect of the design of these PMMA spacers as well as 

how long they should remain in-situ. 

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Paper 230 

Presenter: A Horn 

Authors: A.Horn, J. Wright, D.E. Easwood 


Abstract title: X-Linked Hypophosphataemic Rickets: Orthopaedic Management of 

the Lower Limb Deformity. 

Introduction 

A significant proportion of patients with X-linked hypophosphataemic rickets (X-LHPR) 

demonstrate severe lower limb deformity despite optimal medical management. 

Orthopaedic management aims to restore limb alignment . This study evaluates, the 

deformity in these patients, and the evolution of orthopaedic management. 

216

Methods 

Since 1995, 59 patients with X-LHPR have been treated at our Institution. Standardised 

long leg radiographs were only available for 39 patients (18 male). Twenty patients 

were considered clinically straight and had not been x-rayed. Traumacad Software 

was employed to measure peri-articular deformity in both operated and non-operated 

patients. Statistical analysis was performed using SPSS 23 (SPSS Inc., Chicago, 

Illinois, USA) for categorical and continuous data. 

Results 

Of the 39 patients, 16 (41%) had radiographically straight legs. 20 have undergone 

bilateral lower limb surgery for persistent deformity (Mechanical Axis ≥ Zone 2) in the 

coronal plane. A further 3 patients (6 limbs) are awaiting surgery. Six patients (12 

limbs, 14 segments) had osteotomies and internal fixation as primary intervention, 

one of whom develope recurrent deformity. There were no major complications. 

Fourteen patients (28 limbs, 34 segments) underwent 15 episodes of 8-plate 

insertion (Orthofix, Verona). Sixteen limbs were in varus, and twleve in valgus. In 5 

limbs correction is on-going. Neutral limb alignment (central Zone 1) was achieved 

in 16/23 (70%) patients. A further 5 imporved, but not fully, and 2 patients required 

osteotomy in 3 limb segments for residual deformity. The mean rate of angular 

correction following 8-plate application was 0.3 and 0.7 degrees/month for the 

tibia and femur respectively. The mean age at 8-plate insertion was 10.3y (4.8- 

14.75y). Patients with more than 3 years of growth remaining responded significantly 

better than older patients (Fisher Exact Test, p=0.024). Guided growth was more 

successful in correcting valgus deformity than varus deformity (Fisher Exact Test, 

p=0.04), noting that the unsuccessful cases with varus deformity all developed 

their deformity during adolescence. In the younger patients, diaphyseal deformity 

corrected as the mechanical axis improved at the rate of 0.2 and 0.7 degrees/ 

month for the tibia and femur respectively. There was one case of overcorrection 

which has not recovered, and there have been no recurrences. Patients with corrected 

coronal plane alignment did not complain of significant residual torsional or sigittal 

plane malalignment. Serum phosphate and alkaline phosphatase levels did not affect 

response to surgery or complication rate. 

Conclusion 

Guided growth by means of 8-plates is a successful and minimally invasive method 

of addressing deformity in hypophosphataemic rickets. Surgery is best performed in 

patients with more than 3 years of growth remaining and will obviate the need for 

osteotomy in the majority of cases. 

217

Paper 231 

Presenter: A Fowler 

Authors: A. Fowler, D. Thyagarajan, K. Kumar, B.W.T. Gooding, G. Johnson, G. 

Kocsis, A. Kontaxis, M. Scott, J. Blacknell, K. Edwards, W.A. Wallace 


Abstract title: Outcomes from 3 to 5½ Years for the VAIOS Dual Platform Total 

Shoulder Replacement – Anatomic & Inverse or Reverse 

Purpose The VAIOS (Versatile Anatomic Inverse Optimised Stable) Total Shoulder 

Replacement is a fourth generation design introduced initially onto the UK market 

in April 2010. This design was the first to incorporate the same humeral stem 

and glenoid baseplate for use in both anatomic and inverse (or reverse} shoulder 

replacements. This study reports the short-term outcome from the use of this new 

shoulder design in a cohort of patients from one centre. Methods A consecutive 

series of the first single centre cohort of patients receiving a primary VAIOS shoulder 

replacement between April 2010 and August 2012 has been studied. A detailed 

follow-up of patients over a minimum of 3 and maximum of 5.5 years’ follow-up is 

reported. All patients were scheduled for review pre-operatively and post-operatively 

at 6, 12, 24 and 36 months. At each visit patients were clinically assessed and 

an annual x-ray was performed. The outcome measures used in this study included: 

Constant scores; Oxford Shoulder scores; Satisfaction with surgery; “Would you 

have the same operation again if required?”; Radiological outcome; Re-operations 

on the same shoulder and Serious post-operative complications. Results 115 primary 

VAIOS replacements were inserted – 49 Anatomic (mean age at operation =66) 

and 66 Inverse (mean age =71). Six patients could not be followed-up satisfactorily, 

leaving 109 patients for analysis. Both the Anatomic and Inverse shoulder 

replacements had statistically significant improvements (p

Paper 232 

Presenter: MC Wells 

Authors: M.Wells, C. Anley, Y. Elghawail, A. Ikram 

Disclosure: Yes: Arthrex 

Abstract title: Using a mini-TightRope (Arthrex) alone to suspend the thumb 

metacarpal after a trapeziectomy: Is this a viable option? 2-year results. 

Purpose: The most common procedure for painful carpometacarpal joint of the thumb 

(CMC- I) osteoarthritis remains trapeziectomy with or without tendon suspension 

interposition. Recently the use of a mini-TightRope(Arthrex) has been suggested to suspend 

the thumb metacarpal, replacing the need for tendon suspension and interposition. 

The aim of this prospective study is to report the 2-year results using the mini-TightRope 

alone following trapeziectomy in patients with advanced CMC-I osteoarthritis. 

Methods: 85 Patients (F:81 M:4) with mean age of 59.5 (44-75) years, suffering 

from painful CMC-I osteoarthritis previously treated conservatively for longer than 1 

year, were included in the study. The surgical technique included open trapeziectomy 

with suspension of the thumb metacarpal to the second metacarpal using a mini- 

TightRope. Patients were immobilised for 10 days after which range of motion 

exercises were encouraged. Pain was recorded on a visual analogue scale (VAS) 

before surgery and after 3, 6 and 12 and 24 months. Thumb function was recorded 

at same intervals, measuring quick DASH, key pinch grip strength, first webspace 

angulation and range of motion(Kapandji method).Radiographic measurements 

included the trapezial space ratio. Any complications were documented. 

Results: All patients were reviewed at 2 years. The surgical technique proved 

successful in all 85 patients with no intraoperative complications. No devices needed 

removal or caused complications. The average VAS pain improved from 7.64 

preoperatively to 0.37 postoperatively. The average quickDASH improved from 

57.2 to 9.8. The first webspace angulation improved from 33.7° preoperatively to 

37.9° postoperatively and the range of motion improved from average 7.8 (Kapandji 

score) preoperatively to 9 postoperatively. The average postoperative key pinch 

grip was 3.69 kg, unchanged compared to 3.49 kg preoperatively. The trapezial 

space ratio averaged 0.21. We found no deterioration between 1 and 2 years. 

Conclusion: Use of the mini-TightRope to suspend the thumb metacarpal following 

trapeziectomy is a simple procedure allowing for early mobilisation of the thumb 

postoperatively. It provides significant improvement in pain (VAS) and function 

(quickDASH score), improves range of motion and webspace, and maintains key 

pinch strength. There have been no complications related to the mini-TightRope. We 

therefore conclude, based on 2-year results, that using a mini-TightRope is a safe and 

effective method to suspend the thumb metacarpal after trapeziectomy, without need 

for immobilisation nor tendon harvest. 

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Paper 233 

Presenter: G Abbas 

Authors: G Abbas, DJ Woodnutt 


Abstract title: Use of innovative functional implant positioning system in total hip 

replacement Surgery 

Historical target values for acetabular cup orientation, originated by Lewinnek, 

may be useful in a proportion of patients but should not be considered a safe 

zone given that majority of dislocated total hip replacements components are 

within those target values. Some apparently well positioned cups when judged 

radiographically can be functionally malorientated due to difference in patient’s 

sagittal plane pelvic kinematics. We have used the Optimised Positioning System 

(OPS, Corin) pre-operatively to objectively define the patient’s functional pelvic 

kinematics. Three functional radiographs (standing, flexed seated and contralateral 

leg raise) were used to determine, through software analysis, the most appropriate 

cup positioning to minimise the risk of edge loading in flexion and standing. Patient 

specific geometry was acquired with a low dose CT scan. A sterile, patient specific 

jig was then fashioned by 3D printing. Blind assessment of the intended acetabular 

positioning was made prior to using the jig or reaming. The jig was then used intraoperatively 

with the OPS delivery system comprising laser guides to orientate the 

acetabular component to that suggested from the functional kinematc analysis. We 

used the OPS in 37 primary total hip replacements (20 males, 17 females) in our 

unit for cup positioning. All cases were operated by a single surgeon after functional 

imaging. ANOVA analysis between the means of distribution of the blinded 

cup positioning to the actual cup positioning was used. There was a significant 

difference between the methods (F-ratio 6.390, p=0.002). More than 95% cases 

(36 patients) image guided target was achieved within 5º of component positioning 

with stable THR at the operating table. In 10% of patients, there was a significant 

difference in blinded cup position intention and that suggested by the jig. In one 

case (3%) hip was unstable despite correct acetabular component alignment. This 

was due to excessive femoral anteversion and was corrected intra-operatively. There 

were no reported hip dislocations or other significant complications in this cohort. 

Our preliminary results show that use of OPS can be reliably used to achieve 

optimal cup orientation for individual patients. This system can be a valuable tool 

for surgeons to minimise risk of hip instability, one of the common causes for THR 

revision. 

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Paper 234 


Authors: G Abbas, M Mullins, M Dodd, S Singh, DJ Woodnutt 


Abstract title: Survival Analysis of 1703 Consecutive Cementless Elastic Acetabular 

Cups with non-Highly Cross-linked Polyethylene in Total Hip Replacement Surgery 

Press-fit fixation of uncemented acetabular components is increasingly being used 

for total hip replacement (THR) surgery. This study was aimed to analyse the survival 

of an established, un-cemented flexible metal backed cup with non-highly crosslinked 

polyethylene in primary and simple revision THR. We assessed the outcome 

of 1703 consecutive cementless elastic acetabular cups (Atlas, FH France) with 

non-highly cross-linked polyethylene (GUR1030) in total hip replacement surgery. 

There were 1582 patients (513 males and 1079 females) with mean age of 74 

years (36-97 years). Seventeen senior operating surgeons accounted for 88.5% 

of cases from a single arthroplasty unit. Survival analysis was calculated using the 

Kaplan Meier Estimator. At 184 months post surgery the survivorship was 92.4% 

(95% CI 88.3-94.7) with cup revision for any cause as an endpoint. Three patients 

died within first month of surgery and 268 patients (17.13%) died due to unrelated 

causes. Overall, 59 patients had revisions (3.5%), Thirty eight patients (2.3%) were 

due to acetabular causes such as: aseptic loosening in 6 patients (0.35%); hip 

instability in 13 patients (0.76%); and deep infection in 11 patients (0.64%). We 

believe the cementless elastic acetabular cup on in total hip replacement is tolerant 

of technique and patient variation and continues to give excellent long-term results 

and its continued widespread use can be recommended. 

Paper 235 

Presenter: MA Muderis 

Authors: K. Tetsworth, A. Khemka, V.Glatt, S.J. Lord, H. Van de Meent, J.P. M. 

Frölke, M. A. Muderis 

Disclosure: Yes: Munjed Al Muderis is one of the designer’s of the implants and 

receives royalties. 

Abstract title: Safety of osseointegrated implants for transfemoral amputees: A 

multicentre prospective cohort study 

Osseointegrated implants are attractive alternatives for prosthetic limb attachment for 

those individuals with amputations unable to wear a socket. However, the concept of 

a metal implant anchored to the bone, communicating with the external environment, 

raises substantial concern about the risk of ascending infection and related local 

and systemic consequences. Infections associated with bone-anchored prostheses are 

thoroughly described in dentistry; however, little data on safety has been published for 

its application in transfemoral amputees. We report on the safety of the press-fit type 

osseointegrated implants currently used in Australia and Holland. 

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Prospective case series of adverse events in 86 transfemoral amputees managed 

with osseointegration at two centres between 2009-2013. The procedure was 

performed in 2-stages, involving placement of a customized porous coated implant 

and subsequent creation of a stoma. Adverse events were categorized by type 

(infection/other) and severity. Infections were classified into four severity grades 

based on clinical and radiological findings: Low-grade superficial infection; Highgrade 

superficial infection; deep infection; septic implant failure. 

Patients were aged 25-81 (mean 47) years, and followed-up for a median of 34 

(24-71) months; 31 patients (36%) had an uneventful course without complications. 

Of the remaining 55 patients, 25 had minor complications but no infections. Only 

24 patients developed infections (28%); these were all grade 1 or 2 and did 

not require surgery; no patients developed grade 3 or 4 infections. There was a 

significant association between gender and risk of severe infection, with women 

having over a 6-fold increase in risk (OR 6.5, 95% CI 1.1-38.15). A BMI > 25, 

was associated with a significant 3-fold higher risk of mild infection (OR 3.47, 95% 

CI 1.16-10.39). Smokers had a 7-fold higher risk of recurrent infection (OR 7.5, 

95% CI 1.32-42.35). Other adverse events requiring intervention were observed 

in 26 patients (30%), including: inadequate osseointegration with replacement 

of implant (1); stoma hyper-granulation (17); implant breakage (2); breakage 

of the dual cone component safety pins (3); and proximal femur fractures (3). 

Mild infection and irritation of the soft tissue are common, but successfully managed 

with simple measures. Severe infections resulting in septic implant loosening were 

not observed. Careful soft tissue handling and appropriate intervention as indicated 

appears to effectively limit the risk of deep infection that’s potentially associated with 

osseointegrated implants. 

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Paper 246 


Authors: C.Barton, C.J.Kleck,E.L.Burger 


Abstract title: Preoperative Planning for Patient Specific Spine Rods 

Purpose 

Adult spinal deformity (ASD) is a complex condition that results in alteration of normal 

physiological spinopelvic parameters. Correction of these parameters via osteotomy 

requires intensive surgical planning and long operative times. Preoperative surgical 

planning software is helpful in approximating if proposed procedure (e.g. osteotomy 

type, degree of wedge, and level) will result in adequate correction. After surgical 

planning, a recent innovative approach has allowed for ordering of patient specific 

rods matching contour of surgical plan. The purpose of this case series is to determine 

how effective this approach is at approximating immediate post-operative spinopelvic 

parameters. 

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Methods 

A retrospective case-series was performed on 17 consecutive ASD patients (12F, 

average age 64) meeting strict inclusion/exclusion criteria, treated with posterior 

spine fusion and osteotomy using patient specific rods. Data was extracted including 

patient variables, surgical variables; and preop, predicted (via surgical plan), and 

postop spinopelvic parameters. As this is a novel approach assessing immediate 

postop outcomes, patients were included with any length of follow-up as long as 

postoperative images were available. Variance between surgical plan and postop 

values were determined via plan-postop values and absolute values of parameter 

variance (absolute value of plan-postop). 

Results 

The group’s average preop parameters: sagittal vertical axis (SVA)=86.3mm, lumbar 

lordosis (LL)=34.1 degrees, pelvic tilt (PT)=29.5 degrees, thoracic kyphosis (TK)=40.4 

degrees. The group’s average postop parameters: SVA=15.1mm, LL=61.8 degrees, 

PT=18.4 degrees, TK=43.8 degrees. The average variance in preoperative plan 

vs. postop: SVA=3.9mm, LL=-4.75 degrees, PT=0.6 degrees, TK=-8.9 degrees. 

The absolute value variance in preoperative plan vs. postop: SVA=36.3mm, LL=9 

degrees, PT=4.2 degrees, TK=11.5 degrees. 

Conclusions 

The approach of surgical planning for patient specific spine rods is an effective 

method for ASD correction, yielding an average postop SVA of 15.1mm and PT of 

18.4 degrees. On average, the surgical plan slightly underestimated amount of SVA 

correction, PT relaxation, and LL improvement obtainable by posterior fusion and 

osteotomy. The surgical plan also underestimated the increase in TK as a result of the 

operation. The main limitations of the study are limited follow-up and small patient 

population. Further follow-up will determine if this approach will result in excellent 

long-term results. 

Paper 247 


Authors: C.Barton, C.J.Kleck A Noshchenko, VPatel,C.Cain,E.L.Burger 


Abstract title: Risk Factors for Rod Fracture After Posterior Correction with 

Osteotomy of Adult Spinal Deformity 

Purpose 

Osteotomies including pedicle subtraction (PSO) and/or Smith-Peterson (SPO) are 

used to facilitate surgical correction of adult spinal deformity (ASD), but are associated 

with complications including instrumentation failure and rod fracture (RF). The purpose 

223

of this study was to determine incidence and risk factors for RF, including a clinically 

significant subset (CSRF), after osteotomy for ASD. 

Methods 

A retrospective review of clinical records was conducted on consecutive ASD patients 

treated with posterior instrumented fusion and osteotomy. Seventy-five patients (50 

female; average age, 59) met strict inclusion/exclusion criteria and follow-up of ≥1 

year. Data was extracted pertaining to the following variables: patient demographics; 

details of surgical intervention; instrumentation; and postoperative outcomes. Patients 

were divided into two subgroups: 1) rod fracture (RF) and 2) non-RF. The RF subgroup 

was further divided into CSRF and non-CSRF. Odds ratios (OR) were calculated to 

evaluate the association between risk factors and RF. The χ²-test was used to define 

P-values for categorical variables, and T-test was applied for continuous variables, 

P-values ≤0.05 were considered significant. 

Results 

Incidence rates of RF were: for entire population, 9.3% (95%Cl: 2.7%; 15.9%); 

for PSO, 16.2% (95%Cl:4.3;28.1 ); and for SPO, 2.6% (95%Cl:0%; 7.7%); the 

OR of PSO versus SPO was 7.2(95%Cl:0.8;62.7, P=0.1). CSRF incidence was 

5.3% (95%CI:0.2%;10.4%). Significant risk of RF was revealed for following factors: 

fusion construct crossing both thoracolumbar and lumbosacral junctions (OR=9.1, 

P=0.05), sagittal rod contour >60 degrees (OR=10.0, P=0.04); the presence of 

dominos and/or parallel connectors at date of rod fracture (OR=10.0, P=0.01); and 

pseudarthrosis at >1 year follow-up (OR=28.9, P1 year 

follow-up (OR=50.3, CI: 4.2; 598.8, P60 degrees; presence of dominos and/or parallel 

connectors at date of fracture; and fusion construct crossing both thoracolumbar and 

lumbosacral junctions. Statistically significant risk for the CSRF subset was fusion to the 

pelvis and pseudarthrosis at >1 year follow-up. 

Paper 249 

Presenter: J O’Donnell 

Authors: B.M. Devitt, B. Smith, R. Stapf, J. O’Donnell 


Abstract title: A prospective study exploring the relationship between hip capsular 

thickness and joint hypermobility: Forewarned is forearmed 

224


Hip microinstability is increasingly being recognized as a potential cause of pain 

and disability. The pathomechanism is not clearly defined but is thought to involve 

anatomical abnormalities, repetitive forces across the hip and, importantly, ligamentous 

laxity. The aim of this study was to explore the relationship between joint hypermobility 

and hip capsular thickness measured intraoperatively. 

Methods 

A prospective study was performed on 100 consecutive patients undergoing a 

primary hip arthroscopy for the treatment of hip pain. A Beighton test score (BTS) 

was performed prior to each procedure - The maximum score was 9, and a score of 

4 or greater was defined as hypermobility. At surgery, the capsular thickness at the 

level of the anterior portal, corresponding to the location of the iliofemoral ligament, 

was measured using a calibrated arthroscopic probe. The surgical findings and 

intervention carried out was recorded. The centre edge angle (CEA) was recorded 

on AP radiographs in all cases. 

Results 

55 females and 45 males were included in the study. The average age was 26 years 

(range: 18 – 40 years). There were 49 right and 51 left hips. Measurement of the 

hip capsule ranged from 2.5 mm to 17.5 mm. The average hip capsule thickness 

was greater in men than women, 12.5mm and 7.5 mm respectively (P4 (P=0.002). 

Conclusions 

The main finding of this study was that the measurement of joint hypermobility 

correlated closely with hip capsule thickness. A BTS of ≥ 4 was associated with a 

capsular thickness of < 10 mm. The clinical implications of this relate to the capsular 

management options one may choose based on a simple preoperative examination. 

Paper 250 

Presenter: J O’Donnell 

Authors: B.M. Devitt, B. Smith, R. Stapf, J. O’Donnell 


Abstract title: The reliability of Arthroscopic Classification of Ligamentum Teres 

Pathology 

225

Introduction: 

The Ligamentum Teres (LT) is increasingly being recognised as a pain generator within 

the hip, while also potentially having a role in hip stability. One of the major issues 

with recent studies exploring the incidence of LT tears is that the interpretation of what 

constitutes a tear is so variable. Although classification systems have been proposed 

the reliability of arthroscopic LT pathology has not been well defined. 

Purpose: 

To determine the inter-observer reliability of two existing classifications systems for the 

diagnosis of LT pathology encountered in hip arthroscopy. Secondly, to identify the 

sources of poor reliability and highlight key pathological findings that are not currently 

included. 

Methods: 

Four experienced hip-arthroscopists reviewed standardized arthroscopic videos of 

40-cases. Arthroscopic findings of the LT were classified using the G&V and DC. 

Reviewers were asked to rate the adequacy of the classification system in appraising 

the LT pathology, and offer any other relevant pathology encountered. The reliability 

of arthroscopic classification was defined using the average weighted Cohen kappavalues 

and agreement rates. 

Results: 

Arthroscopic classification of LT pathology using the G&V and DC systems 

demonstrated slight-to-fair inter-observer reliability (average ĸ=0.19; range, 0.04- 

0.29 [G&V])(average ĸ=0.19; range, 0.03–0.37 [DC]). An absolute agreement 

rate of only 27.5% (G&V) and 17.5% (DC) was found. Differentiation between 

partial and degenerative tears and the grade of partial tear were common sources of 

disagreement. The classification system did not adequately describe the pathology in 

on average 44% (G&V) and 48% (DC) of cases. Impingement of the LT against the 

acetabular fossa was a commonly mentioned relevant pathological finding. 

Conclusion: Arthroscopic classification of LT pathology with the current classification 

systems demonstrated only slight-to-fair inter-observer reliability. This coupled with 

the inadequacy of each classification to detail salient pathology would suggest that 

an improved classification is required, particularly considering that arthroscopy is 

regarded as the gold standard for diagnosis. Further detail should be included to 

eliminate common sources of disagreement and improve reliability. 

Paper 251 

Presenter: P Ferrao 

Authors: N.P. Saragas, P.N.F. Ferrao, A. Strydom 


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Abstract title: Adult acquired flat foot deformity: The joint preserving procedures 

in Stage II tibialis posterior tendon dysfunction 

Introduction: The adult acquired flat foot (AAFF) deformity is a chronic debilitating 

condition commonly associated with dysfunction of the posterior tibial tendon (PTT). It 

is often missed unless it is associated with a generalized medical condiction such as 

226

heumatoid arthritis. Surgical management is indicated when conservative treatment 

fails. The joint preserving procedures have evolved over the years and are preferred 

for the flexible, non-arthritic deformity. 

Materials and Methods: Twenty two patients were included in this prospective study. 

The mean age was 59.8 years with the majority being female. The average BMI 

was 28.7. The inclusion criteria was symptomatic AAFF deformity due to Stage II PTT 

dysfunction 

Results: Twenty patients were available for follow-up at one year. The mean AOFAS 

postoperative score of 89 was significantly improved from the preoperative score of 

42 (p-value =

in non-trendlenburg gait pattern. One patient developed deep vein thrombosis in 

early post-operative period. This study emphasises beneficial use the dual mobility 

implant combined with the posterior approach in THR for fracture NOF patients and 

highlights the areas of improvements in hip fracture management. 

Paper 253 


Authors: G Hooper, C Allen, P Armour, J Burn 


Abstract title: The mid term outcomes using custom implants in acetabular revision 

Introduction 

The rate of hip replacement is predicted to markedly increase over the next 15 years 

with a predicted increase of 157% for primary procedures and 137% for revision 

procedures in the USA. These predictions are similar to those shown by analysis of 

the New Zealand Joint Registry. This increasing burden of revision surgery is likely to 

be accompanied by more difficult procedures with multiple areas of bone loss. One 

strategy to deal with marked acetabular bone loss has been to use custom made 

implants to fill the defect. We have used custom acetabulum (CA) augments utilising 

additive manufacturing technology processes to reconstruct severely damaged 

acetabula with substantial bone loss since the mid-2000s. 

Hypothesis 

Is a custom triflange implant clinically effective in acetabular reconstruction for 

Paprosky type 3a/3b defects? 

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Methods and Results 

We studied 20 revision hip replacements in 20 patients that required an Ossis 

custom acetabulum augment between November 2007 and November 2012. The 

mean age of the patients at the time of surgery was 66.19 years (53 - 79) and the 

mean follow up was 57.2 months (35 to 95). All patients had their pre-operative 

X-Rays independent assessed to classify each defect using the Paprosky classification. 

There were 14 with type 3b defects or greater (pelvic discontinuity). Independent 

assessment of the Oxford hip score, the Womac Score and the Harris Hip Score was 

significantly improved at minimum 2 year follow up. There was one revision of the 

custom acetabulum augment due to septic loosening in a patient who had previously 

had an infected hip replacement and one patient died secondary to metastatic cancer 

with a fully functioning implant. 

Conclusions 

Custom made acetabular augments using additive manufacturing technology can be 

228

used to fill massive bony defects in revision surgery with good functional and clinical 

outcomes in the short to medium term. They offer the surgeon a reliable option in 

difficult cases with a low re-revision rate 

Paper 254 

Presenter: R Ray 

Authors: R Ray, ND Clement, SA Aitken, MM McQueen, C Court-Brown, S Ralston 


Abstract title: Middle aged patients sustaining a fracture have an increased 

mortality rate: identification of independent predictors of mortality 

Purpose: The primary aim of this study was to present the mortality rate after a fracture 

in a cohort of middle aged (40 to 55 years old) patients and compare this to the 

general population at risk. The secondary aim was to identify independent risk factors 

of mortality after a fracture in middle aged patients. 

Methods: All patients presenting to the study centre with a non vertebral fracture during 

a one-year period were prospectively documented. We gathered data regarding 

patient demographics, fracture pattern and mechanism of injury. We also collected 

data regarding the Scottish Index of Multiple Deprivation which was used to assess 

the patients’ socioeconomic status. We gathered data on smoking, alcohol excess 

and mortality at five years from injury. Mortality data was cross referenced with data 

held by the General Registrar Office of Scotland. The study cohort consisted of 1006 

patients, of which the majority were male. The commonest mechanism of injury was 

a simple fall. 

Results: We obtained complete data regarding mortality for all patients recorded in the 

fracture database, at a median of 5.4 years (inter quartile range 5.1 to 5.6). During 

this period 46 patients were identified as being deceased. The overall Standardized 

Mortality Ratio for the cohort was significantly increased relative to the population at 

risk with a ratio of 3.89 (95% confidence intervals (CI) 1.59 to 6.19). 

Cox regression analysis was used to identify independent predictors of mortality 

after adjusting for confounding factors. Consuming alcohol to excess and sustaining 

fractures involving the humerus and the hip were independent predictors of mortality. 

Discussion: This study has demonstrated that middle aged adults sustaining a 

fracture have a significantly increased mortality risk after their injury relative to the 

population at risk. A quarter of all middle aged patients sustaining a fracture have a 

significantly increased mortality risk after their injury after adjusting for confounding 

variables. The results of our study suggest that this may be in part, due to a high 

prevalence of underlying lifestyle risk factors. This is a working age population and 

the socioeconomic burden of disease in this age group is substantial. 

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Paper 255 


Authors: R. M. Streicher 


Abstract title: Advanced ceramic bearings can address revision issues 


Aseptic and septic loosening as well as dislocation has been identified in all THA 

implant registers as major factors leading to revision. Several investigations have 

been performed to analyse bearings and materials in vitro and in vivo to estimate their 

role in the incidence of these causes for revisions. 

Methods 

1) Wear of various bearings and especially CoC was determined using a hip joint 

simulator and protocol according to ISO standards. 

2) Friction moment of several bearing combinations from 28 to 40 mm was determined 

by using a previously published set-up. 

3) Fretting and corrosion of modular tapers were investigated in various test set-ups 

and qualitatively and quantitatively of matched retrievals, excluding MoM bearings. 

4) Biofilm adhesion was investigated in-vitro for various materials and the risk for PJI 

was determined by analyzing nine local, regional and national joint replacement 

registers for uncemented implants (>750´000 THA); adjusted for several confounders. 

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5) Revisions for dislocations were determined using in depth analysis of registry data 

and supported by laboratory pull-out/adhesion tests. 

Results 

Wear of CoC in the laboratory was independent on the head diameter, supported by 

registry data. Friction moment was reduced by ceramic components. Consequently, 

interfaces of modular implants with ceramic components exhibit less micromotion and 

contrary to metal heads without release of Co and Cr ions into the host body. As Co 

is known to suppress the immune system and together with the enhanced resistance 

against biofilm formation of ceramics, the data on over 750’000 implants shows a 

10-60% reduction of PJI related revisions. The revision rate for dislocation was also 

reduced by using CoC bearings in most registries. 

Conclusions 

This is the first report combining laboratory wear, friction, adhesion, corrosion, and 

infection data with clinical outcomes. Ceramic components seem to mitigate the 

major reasons for revisions in THA. 

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Paper 258 

Presenter: R Ashford 

Authors: JR Hanson, N Eastley, C J Richards, TA McCulloch, PE Allen, RU Ashford 


Abstract title: Amputation rates, clinical & oncologic outcomes of foot and ankle 

soft tissue sarcomas 

Purpose: 

Poorly defined, narrow tissue margins make Soft Tissue Sarcomas (STSs) in the foot 

and ankle a challenging condition. Historically these issues have been compounded 

by the difficulties associated with the use of radiotherapy in this region, although this 

attitude is shifting. We aim to review our management and the oncologic outcomes 

of foot and ankle STSs, looking specifically at patient demographics, tumour 

characteristics, management, local and distant recurrence rates and amputation rates. 

Methods: 

We performed a retrospective review of cases between 2000-2014. Patients were 

identified from a pathological database and cross referenced with clinical notes and 

radiological investigations. 

Results: 

30 cases were identified (M:F 12:18 mean age 55). Synovial sarcomas were the 

commonest STS subtype seen (n=10), followed by Leiomyosarcomas (n=6). Our 

primary amputation rate was 17% and overall amputation rate 27%. 7 (23%) patients 

underwent attempted surgical resection without a histological diagnosis (biopsy) or 

any discussion with a sarcoma Multi-Disciplinary Team (MDT). 4 (57%) of these 

patients subsequently required further surgery for an incomplete resection or local 

recurrence, with 3 (43%) ultimately requiring an amputation of some kind. 6 patients 

underwent planned limb sparing surgery in conjunction with our regional sarcoma 

MDT. Only 2 (33%) of there patients required additional surgeries, none of which 

were an amputation. 

Conclusion: 

Timely involvement of a sarcoma MDT may reduce amputation rates in those patients 

who undergo an incomplete resection or suffer local disease recurrence. This 

highligths the high index of suspicion needed when dealing with soft tissue lesions in 

the foot and ankle. 

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Paper 259 


Authors: R. M. Streicher, M. M. Morlock, S. Kurtz 


Abstract title: Friction, wear and corrosion of metal and ceramic bearings 


Aseptic and septic loosening, dislocation, wear induced osteolysis and adverse 

reaction to metals are major factors leading to revision in total hip arthroplasty (THA). 

The choice of the bearing couple may exert a significant influence on the incidence 

of revision surgery. 

Methods 

1. Wear rates were evaluated both in vitro and in vivo for ceramic-on-ceramic 

(CoC) articulations by metrology of components from simulator tests and 

retrievals. 

2. Friction measurements were conducted in vitro with CoC and ceramicon-polyethylene 

(CoP), metal-on-polyethylene (MoP), and both materials 

articulating against highly cross-linked polyethylene (CoXP / MoXP) 

bearings with diameters from 28 to 40 mm in bovine serum. 

3. Fretting corrosion estimation was carried out by qualitative (Higgs Score) 

and quantitative (Talyrond) surface analysis of retrievals on i) a matched 

cohort (time in situ, stiffness) of 50/50 THAs made from three different 

alloys, each with either metal or ceramic head; and ii) 54 retrievals with 

various bearings using the same type of hip prosthesis. 

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Results 

1. CoC wear was negligible and independent on the bearing diameter. An 

8-fold decrease for CoC using composite ceramic clinically was found. 

2. CoC demonstrated the lowest friction moment of all combinations; 40% 

less then MoP. CoC bearings with 40 mm had the same friction moment 

compared to bearings with PE/XP with 28 mm. Highly cross-linked PE 

exhibited a higher friction moment than standard PE, while using ceramic 

heads reduced the friction marginally. 

3. Both tribo-corrosion investigations revealed a significant reduction of stem 

taper damage, and subsequently particle and metal ion release, when 

coupled with a ceramic bearing component. On the head taper ceramic 

ball heads showed some metal transfer and no material loss, while metal 

232

Conclusions 

loss of the metal head was evident; being about 10 times higher than 

on the stem taper. As metal heads are made from CoCr alloy this raises 

concerns about local and systemic adverse reactions, especially to Co. 

Reducing the dislocation risk by using larger components for enhanced stability of 

THA can be achieved using CoC bearings, which do not increase wear and friction 

of the bearing. In general ceramic components reduce the issue of wear and friction 

of hip joint prosthesis and also diminish corrosion/fretting effects of modular implants, 

addressing therefore several potential risk factors for THA failure. 

Paper 260 

Presenter: V GONI 

Authors: V GONI, AAKASH P, K.VENKATARAMANA, 


Abstract title: OUTCOME COMPARISION OF FROZEN SHOULDER WITH INVASIVE 

AND NONINVASIVE MODALITIES: A DOUBLE BLIND RANDOMISED CONTROL 

STUDY 

ABSTRACT: 

Purpose: To compare the effects of three modalities of pain management i.e. 

SSNB (suprascapular nerve block) with NIR (non invasive rehabilitation), IAI (intra 

articular injection) with NIR and, NIR alone in idiopathic frozen shoulder patients. 

Methods: A double blinded randomized clinical trial was conducted. 60 cases 

of idiopathic frozen shoulder were selected and randomly divided into three treatment 

groups; group 1: NIR+ placebo injection group 2: NIR+SSNB, group 3: NIR +IAI. 

Range of motion, pain score and disability (SPADI: shoulder pain and disability index) 

score were evaluated pre-treatment and at 12 weeks follow up. 

Results: All three groups were homogenous and comparable regarding their 

age, sex ratio, pretreatment pain score, disability score and range of motion. There 

was significant improvement (p

Paper 263 

Presenter: RP Lamberts 

Authors: R.P. Lamberts (1,2), N. Tam (2), J Cockcroft (3), J Du Toit (1), A.G. Fieggen 

(4), N.G. Langerak (4) 


Abstract title: Long term effects of orthopaedics interventions on gait in adults 

with bilateral spastic cerebral palsy 

1 

Division of Orthopaedic Surgery, Stellenbosch University, South Africa 

2 

Division of Exercise Science and Sport Medicine, University of Cape Town, South 

Africa 

3 

Department of Mechanical and Mechatronic Engineering, Stellenbosch University, 

South Africa 

4 

Division of Neurosurgery, University of Cape Town, South Africa 


The amount of papers that have focussed on the effect of orthopaedic interventions in 

children with cerebral palsy (CP) has grown exponentially over the last 20 years [1]. 

However most of these papers have reported on the short-term effect, while there is 

a lack of knowledge about the long-term effect of orthopaedic interventions. The aim 

of current study is to describe the gait status of adults with bilateral spastic CP who 

received soft-tissue and/or bony orthopaedic surgeries more than 15 years ago. 

Methods 

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Thirty participants with bilateral spastic CP were invited to participate in the study. 

Participants had to have received at least one orthopaedic intervention more than 

15 years ago, not undergone any neurological intervention (e.g. selective dorsal 

rhizotomy) and pre-operatively classified at a Gross Motor Function Classification 

System (GMFCS) level of I, II or III. Three dimensional kinematic data of all participants 

was collected with an 8-camera Vicon system. 

Results: 

The mean age of the participants was a 33±8 years with a mean follow-up time of 

28±7 years after the first orthopaedic intervention. On average participants received 

5±3 interventions during 3±2 surgical operations. The most frequently performed 

intervention was achilles tendon (93%) and hamstrings (57%) lengthening. Bony 

interventions, such as femoral (17%) and tibial (13%) derotation osteotomies, were 

performed less frequently. Gait analyses showed a flexed gait pattern with no hip 

extension (62%), limited knee extension (>10°; 65%) and no plantarflexion (57%). In 

234

addition, a lever arm rotational malalignment with an increased internal hip rotation 

(>15°) was found in 60% of the participants. 

Conclusions: 

Although our participants received a wide range of different orthopaedic 

interventions, most of our participants had an increased flexed gait pattern and 

rotational malalignment. This gait pattern can likely be explained by the general 

treatment protocols that were used 15 years ago; multiple surgical interventions with 

high frequency of soft tissue interventions and low frequency of lever arm derotation 

osteotomies. This is in contrast with the current treatment approach of Single Event 

Multilevel Surgery (SEMLS) [2]. A long-term follow-up study should aim to determine 

if this change in treatment protocol (SEMLS) has resulted in improved gait patterns in 

the long-term. 

References 

[1] McGinley JL, et al. DMCN. 2012;54:117–28 

[2] Rodda JM, et al. J Bone Joint Surg Br. 2004;86:251-8 

Paper 265 


Authors: JC Coetzee, LJ Nilsson, RM Stone, JE Fritz 







Abstract title: Functional Outcome of Bilateral Sesamoid Excision Patients 


Sesamoid issues can have a significantly negative impact on the ability of all levels 

to return to play (RTP). Even with adequate conservative care there are a number of 

patients who continue to have chronic pain and inability to perform. The hypothesis 

of the study was that with proper surgical technique of sesamoid excisions and 

adequate rehabilitation, there is a reasonably probability to return to the previous 

level of sporting activity. 

Methods: 

Patients presented to the clinic with the diagnosis of sesamoid pain in both feet; after 

Institutional Review Board approval, we reviewed only the patients whose symptoms 

235

didn’t resolve. Between January 2006 and September 2015, excision of the medial, 

lateral or both sesamoids was performed for 29 feet in 14 patients (11 females and 

3 males). The mean age was 42 years old (range 14.1-69.2). Serial x-rays were 

done and an MRI to confirm the diagnosis of osteochondrosis/chronic injury to the 

sesamoid. Medial sesamoids were excised through a medial approach, while lateral 

sesamoids through a plantar approach. Care was taken to adequately repair the 

plantar structures after excision. A post-operative protocol was followed to ensure 

stability of the plantar plate/sesamoid complex and a gradual RTP over 6 months. 

A graphite plate was used to limit dorsiflexion for the first 6 months. Outcomes were 

evaluated pre and postoperatively with the VR-12 Mental and Physical Scores, 

Revised Foot Function Index (FFI-R), VAS scoring and patient satisfaction. 

Results: 

Sixteen (16) feet were medial excisions, 6 were lateral excisions and 7 were both 

medial and lateral sesamoid excisions. At a mean follow up of 29.14 months for 

25 patients [11 months to 9 years (108.4 months)], the mean outcome for VR-12 

Mental and VR-12 Physical score were insignificant. The FFI-R improved from preoperative 

to post-operative, 126.78 to 67.82, respectively. The VAS also improved 

dropping from 5.09 to 2.73, pre-operatively to post-operatively. Overall, the patient 

satisfaction was 73.21%. 

Two of the patients did not return to the previous level of activity. 25% of patients still 

report some pain, but not enough to limit their activity level. 

Conclusion: 

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Chronic sesamoid pain is difficult to treat, but this study confirms prior reports that with 

meticulous surgical technique and a dedicated post-operative rehabilitation program, 

the likelihood of returning to the previous level of sporting activity is high. The outcome 

scores also confirm a significant improvement in functional parameters. 

Paper 268 


Authors: JC Coetzee, LJ Nilsson, RM Stone, JE Fritz 







Abstract title: Functional Outcome of Sesamoid Excision in Athletes 

236

Introduction: 

Sesamoid issues can have a significantly negative impact on the ability of athletes of 

all levels to return to play. Conventional treatments include rest, PT, shoe modifications 

and orthotics. Even with adequate conservative care there is a number of patients 

that continue to have chronic pain and inability to perform. 

The literature shows mixed results with sesamoid excisions and ability to return to play. 

The hypothesis of the study was that with proper surgical technique and adequate 

rehabilitation, there is a reasonably probability to return to the previous level of 

sporting activity. 

Methods: 

All athletes presented to the clinic with the diagnosis of sesamoid pain were 

prospectively followed. Only the patients whose symptoms did not resolve were then 

included in the study. IRB approval was obtained from the University of Minnesota. 

Exclusion criteria include any neurologic deficit or Diabetes. All patients had serial 

x-rays done during the conservative part of their treatment and at least one MRI to 

confirm the diagnosis of osteochondrosis or chronic injury to the sesamoid. Medial 

sesamoids were excised through a medial approach, while lateral sesamoids through 

a plantar approach. Care was taken to adequately repair the plantar structures 

after excision. A structured post-operative protocol was followed to ensure stability of 

the plantar plate/sesamoid complex and a gradual return to play over 6 months. A 

graphite plate was used to limit dorsiflexion for the first 6 months. 

Outcomes were evaluated pre and postoperatively with the VR-12 Mental and 

Physical Scores, FFI-R, VAS scoring and a patient satisfaction scale. 

Results: 

Excision of the sesamoids was performed for 106 feet in 96 patients (76 females and 

20 males) between January 2006 and December 2013. Ten patients had sesamoid 

excisions in both feet. Eighty-four were medial and 22 lateral sesamoids. 6 patients 

(7 feet) were lost to follow-up. 

90 Patients, 99 feet were followed and are reported on. 

The mean age was 44.56 years old (range 13-71) 

At a mean follow up of 37 months (19months to 8,7 years), the mean outcomes 

were: 

237

VR-12 Mental Pre-op: 54.55 Post-op: 56.46 

VR-12 Physical Pre-op: 40.79 Post-op: 42.49 

FFI-R Pre-op: 126.45 Post-op: 37 

VAS Pre-op: 5.00 Post-op: 1.4 

Patient satisfaction Pre-op: 17 Post-op: 77 

Complications 

One patient had chronic pain and instability and required a fusion. Two patients 

developed symptomatic hallux valgus deformities that required a surgical repair. There 

were no cock-up deformities. 

Of the 90 patients 78 (86%) could return to their previous sporting activity. Two of the 

4 bilateral sesamoid excision patients did not return to the previous level of activity. 

25% of patients still report some pain, but not enough to limit their activity level. 

Conclusion: 

Chronic sesamoid pain is difficult to treat, but this study confirms prior reports that with 

meticulous surgical technique, and a dedicated post-operative rehabilitation program, 

the likelihood of returning to the previous level of sporting activity is high. The outcomes 

score also confirm a significant improvement in functional parameters. 

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Paper 270 

Presenter: H Pandit 

Authors: T.W. Hamilton, L. Strickland & H.G. Pandit 


Abstract title: Gabapentinoids for acute post-operative pain following total knee 

arthroplasty: A meta-analysis. 

Background: Total knee arthroplasty (TKA) is a painful procedure with half of patients 

reporting severe pain during the early post-operative period. Gabapentinoids, which 

have an established role in chronic pain, have been proposed as a useful adjunct 

for the management of acute post-operative pain and are used in around half of 

Enhanced Recovery Pathways (ERP). We performed a meta-analysis to assess the 

effectiveness and safety of gabapentinoids for the treatment of acute-post operative 

pain following TKA. 

238

Methods: Randomized controlled trials (RCT) of patients aged 18 years or older 

undergoing elective primary TKA that compared the use of Gabapentin or Pregabalin 

against placebo were retrieved with 12 studies meeting inclusion criteria. The primaryoutcome 

was pain intensity with activity at 48-hours following surgery. Secondaryoutcomes 

included pain intensity at other time points, cumulative opioid consumption, 

knee function, incidence of chronic pain and incidence of adverse events. 

Results: No difference in pain-score at 12, 24, 48 or 72-hours following surgery 

was seen between Gabapentinoids and placebo. Whilst subgroup analysis revealed 

that Pregabalin was associated with a reduced pain-scores at 24 and 48-hours this 

corresponded to 0.5 (95% CI 0 to 1.0) and 0.3-points (95% CI 0 to 0.6) reduction 

on an 11-point numeric rating scale (NRS), which is not of clinical significance. 

Likewise, Gabapentinoids were associated with a small, but not clinically significant, 

reduction in cumulative opioid consumption at 48-hours (mean difference (MD) 

-23.2mg; 95% CI -40.9 to -5.4). There was no difference in knee flexion at 48-hours 

(MD 0.1; 95% CI -0.2 to 0.4) or the incidence of chronic pain at 3 (risk ratio (RR) 

0.4; 95% CI 0.1 to 2.2) or 6-months (RR 0.4; 95% CI 0.03 to 6.7) associated with 

the use of gabapentinoids. Whilst gabapentinoids were associated with a significant 

reduction in the incidence of nausea (RR 0.7; 95% CI 0.6 to 0.9) Pregabalin was 

also associated with a significant, clinically relevant, increase in the risk of sedation 

(RR 1.4; 95% CI 1.1 to 1.9). 

Discussion: There was no evidence to support the use of gabapentinoids in the 

management of acute pain following TKA. This study does not support the routine use 

of gabapentinoids as part of an ERP. 

Paper 271 


Authors: T.W. Hamilton, H.G. Pandit, A.V. Lombardi, J.B. Adams, C.A.F. Dodd, 

K.R. Berend & D.W. Murray 

Disclosure: Yes: The author or one or more of the authors have received or will 

receive benefits for personal or professional use from a commercial party related 

directly or indirectly to the subject of this article. In addition, benefits have been 

or will be directed to a research fund, foundation, educational institution, or other 

nonprofit organisation with which one or more of the authors are associated. 

Abstract title: Validation of a Radiological Decision Aid to Determine Suitability for 

Medial Unicompartmental Knee Arthroplasty 

Introduction: UKA is associated with a decreased risk of major complication, faster 

rehabilitation, reduced inpatient stay and improved function compared to TKA. 

Despite being appropriate in half of patients, UKA is used in 8% with large variation 

between centres. A key reason for variation is the recognition of indications for UKA. 

The primary indication for mobile bearing UKA is anteromedial OA (AMOA). Patient 

factors including: age, weight and activity level; radiographic factors including 

chondrocalcinosis and lateral osteophytes; and operative factors including the 

239

presence of a chondral ulcer on the medial side of the lateral femoral condyle have not 

been demonstrated to compromise outcomes. Therefore radiographic identification of 

AMOA is critical in determining suitability for UKA. 

In cases of AMOA the patient should have: 

- medial bone-on-bone arthritis 

- retained full thickness lateral cartilage 

- functionally normal MCL 

- functionally normal ACL 

- absence of bone loss at the lateral patella facet 

Based on these indications a visual radiographic decision aid has been developed 

and this study investigates its utility in an independent population. 

Methods: Pre-operative radiographs including: AP weight bearing, lateral, skyline, 

valgus and varus stress views from a consecutive cohort of 550 knees undergoing 

replacement (UKR or TKR) under the care of single experienced UKR surgeon at an 

independent centre between January 2008 and December 2008 were assessed. 

Suitability for UKR was determined using the radiographic decision aid with the 

assessor blinded to the treatment received. Functional outcome and implant survival 

was assessed at five years. 

Results: Radiographs were available from 457 knees with UKA performed in 210 

knees (46%). Using radiographic assessment alone the sensitivity and specificity 

in predicting suitability for UKR was 92% and 88% respectively. Excluding those 

knees where TKR was determined pre-operatively due to surgeon preference, patient 

preference or clinical contra-indication the sensitivity and specificity was 92% and 

95% respectively. In those patients who met decision aid criteria for UKR and in whom 

UKR was performed the 5 year implant survival was 99% (95%CI 97 to 100%) with 

a mean AKSS – Objective of 88 and AKSS-Functional of 73 at last follow up. 

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Discussion: This study provides evidence that UKR can be used to treat a high 

proportion of knees and supports the use of the radiological decision aid in identifying 

those knees suitable for this procedure. 

Paper 272 


Authors: T.W. Hamilton, R. Choudhary, C. Jenkins, S.J. Mellon, C.A.F. Dodd, D.W. 

Murray & H.G. Pandit 

Disclosure: Yes: The author or one or more of the authors have received or will 

receive benefits for personal or professional use from a commercial party related 

directly or indirectly to the subject of this article. In addition, benefits have been 

or will be directed to a research fund, foundation, educational institution, or other 

nonprofit organisation with which one or more of the authors are associated. 

Abstract title: Are Lateral Osteophytes a Contra-indication To Medial UKA? A 

Fifteen Year Follow Up 

240

Introduction: Lateral osteophytes have been reported to be associated with lateral 

compartment disease and as such it is unclear whether medial UKA should be performed 

in these cases. For mobile bearing medial UKA it is advised that in the presence of full 

thickness lateral cartilage lateral osteophytes are not a contraindication, as in these 

cases they represent a systemic manifestation of disease, as opposed to an indicator 

of local compartment damage. However the long term results of UKA in this patient 

group have not been reported. This study investigates whether lateral osteophytes 

affect the 15 year survival and 10 year functional outcomes in a consecutive cohort. 

Methods: Using the OARSI classification (Grade 0 (no osteophyte) to 3) radiographs 

from the first consecutive 1000 cemented mobile bearing UKAs implanted for the 

recommended indications were assessed. Radiographs were available from 509 

knees, mean follow-up of 10.5 years (5.3-16.6), and were assessed in duplicate 

with assessors blinded to outcome. 

Results: Of the 509 knees, 349 knees underwent unilateral medial UKA and 80 

bilateral UKA. Lateral osteophytes were present in 87% of knees with 20% scored 

as grade 3. Lateral tibial osteophytes were seen in 55%, lateral femoral osteophytes 

in 25% and both lateral tibial and femoral osteophytes in 20%. The inter-observer 

reliability was good (kappa = 0.70). No association was seen between gender, 

age or pre-operative function, as assessed using the American Knee Society (AKSS) 

Objective or Functional Score, Oxford Knee Score (OKS) or Tegner activity score. At 

ten years there was no significant difference in absolute or improvement from baseline 

function between groups. Overall there were 24 implant related reoperations with no 

significant difference in survival rate or mechanism seen between groups (p=0.75). 

Subgroup analysis, performed by grade of osteophyte, found no significant difference 

in functional outcome at 10 years or survival at 15 years. 

Discussion: The presence of lateral osteophytes is not associated with adverse long 

term functional outcomes or lower implant survival. This study supports the hypothesis 

that lateral osteophytes represent a systemic manifestation of disease, likely mediated 

by cytokines and growth factors within the synovial fluid, as opposed to an indicator 

of lateral compartment disease. 

This study supports the current guidance that where a patient meets the indications for 

medial mobile bearing UKA the presence of lateral osteophytes does not compromise 

long term functional outcome or survival. 

Paper 273 

Presenter: M Bhandari 

Authors: The FLOW Investigators 

Disclosure: Yes: Funding for this project was provided by: Canadian Institutes 

of Health Research; Office of the Assistant Secretary of Defense for Health 

Affairs, through the Orthopaedic Trauma Research Program under Award No. 

241

W81XWH-08-1-0473 and the Peer Reviewed Orthopaedic Research Program 

under Award No. W81XWH-12-1-0530; Association Internationale pour 

l’Osteosynthese Dynamique. Study supplies were donated by: Zimmer, Stryker, 

and Triad Medical. Dr. Mohit Bhandari has personally consulted for the following 

companies (not related to the study): Stryker, Smith and Nephew, Amgen, DePuy, Eli 

Lily, DJO Global Inc, Zimmer, Ferring 

Abstract title: A Trial of Wound Irrigation in Initial Management of Open Fracture 

Wounds: Results of the FLOW Trial 

Purpose: The initial management of open fractures requires thorough wound irrigation 

and debridement to remove contaminants. However, uncertainty exists regarding the 

optimal pressures and solutions for irrigation. The Fluid Lavage of Open Wounds 

(FLOW) study investigated the effects of castile soap versus normal saline irrigation 

delivered by high, low or very low irrigating pressures in patients undergoing operative 

treatment of an open fracture. 

Methods: Our 2-by-3 factorial design randomized eligible patients with an open 

extremity fracture to alternative irrigating solutions and irrigating pressures. Patients 

received one of three irrigating pressues - high (>20 psi), low (5-10 psi), or very-low 

pressure (1-2 psi) and one of two irrigating solutions - 0.45% castile soap solution or 

normal saline. The primary outcome was re-operation within 12 months to promote 

wound or bone healing, or treat an infection. Secondary clinical outcomes included 

non-operatively managed infections, wound healing or bone healing problems. The 

primary analysis was a Cox regression stratified by open severity and center with time 

to re-operation as the outcome. Adjusted analyses employing Cox regression were 

completed to adjust for age, upper or lower extremity injury, fracture gap, type of 

internal fixation, and severity of wound contamination. 

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Results: We randomized 2,447 eligible patients across 41 clinical centers in Canada, 

United States, Australia, Norway, and India between June 2009 and September 

2013. Typical patients were male (69.2%), had a lower extremity fracture (68.8%), 

underwent plate fixation (50.3%), and received their first irrigation within 10 hours of 

injury (9.8, IQR 6.4-15.9). Re-operation occurred in 109 of 826 patients (13.2%) in 

the high pressure group, 103 of 809 (12.7%) in the low pressure group, and 111 

of 812 (13.7%) in the very-low pressure group. Hazard ratios for three pairwise 

comparisons were - low versus high (0.92; 95% confidence interval [CI], 0.70- 

1.20; p=0.53), high versus very-low (1.02; 95% CI, 0.78-1.33; p=0.89), and low 

versus very-low (0.93; 95% CI, 0.71-1.23; p=0.62). Re-operations occurred in182 

of 1229 patients (14.8%) in the soap group and 141 of 1218 patients (11.6%) 

in the saline group (Hazard Ratio 1.32, 95% CI, 1.06-1.66, p=0.01). Adjusted 

analyses yielded similar results as the primary analyses for both irrigating pressures 

and solutions. 

242

Conclusions: Results suggest similar re-operation rates irrespective of irrigating 

pressure, and indicate very-low pressure as an acceptable, low-cost alternative 

for irrigation of open fractures. Soap solution increased re-operations compared to 

normal saline solution, indicating that saline remains the solution of choice for initial 

irrigation of open fractures. 

Paper 275 

Presenter: GD Rocca 

Authors: The TRUST Investigators 

Disclosure: Yes: Funding/Support: The Trial to Re-evaluate Ultrasound in the 

Treatment of Tibial Fractures (TRUST) was financially supported by grants from 

the Canadian Institutes of Health Research, and an industry grant from Smith & 

Nephew. 

Abstract title: Low Intensity Pulsed Ultrasound in Acute Tibial Shaft Fractures 

Treated with IM Nails: The Results of the TRUST Trial 

Introduction: Tibial fractures are the most common long bone fracture, and functional 

recovery typically requires six months to one year for patients that heal without 

secondary intervention. Decreasing the time to radiographic union may hasten 

functional recovery. Small randomized controlled trials suggest that low intensity 

pulsed ultrasound (LIPUS) may accelerate radiographic healing; however, due to 

limitations of prior studies, the effect of LIPUS on promoting functional recovery for 

acute tibial fractures treated with IM nailing remains uncertain. The purpose of this 

study was to evaluate the use of LIPUS on functional recovery and radiographic 

healing of patients with acute tibial fractures treated with IM nails. 

Methods: This trial was designed as a multicenter (43 centers) randomized, blinded, 

sham treatment controlled evaluation of the effects of LIPUS on validated functional 

outcomes (SF-36 Physical Component Summary [PCS] score and the HUI-III) and 

radiographic healing (RUST score). All patients ≥ 18 yrs old with an acute closed 

or open fracture of the tibial diaphysis who were treated with intramedullary nailing 

were eligible. Exclusion criteria included: soft tissue damage precluding the use of 

the device, bilateral fractures, segmental fractures, and defects after open fracture of 

>75% of the circumference and longer than one cm. Patients were allocated to an 

active or sham LIPUS device in a 1:1 ratio, stratified by fracture severity (i.e. open 

vs. closed), and used the device once daily for 20 minutes. The devices recorded 

compliance. Outcomes were obtained at six, 12, 18, 26, and 52 weeks. The study 

was powered for the minimum clinically significant difference in SF-36 PCS scores 

using a repeated measures analysis at three levels (patient, center and visit) at 500 

patients assuming a 10% loss to follow-up. Time to adjudicated union was evaluated 

using a Cox Proportional Hazards regression model. 

Results: Five hundred and one patients (156 women, 345 men, mean age 38) 

with 114 open and 387 closed fractures were enrolled. The fracture patterns were: 

comminuted (132), transverse (114), spiral (177) and oblique (154). The study 

243

sponsor conducted an unplanned interim analysis of blinded data and terminated 

the study early due to futility. We acquired SF-36 PCS data from 481 of 501 (96%) 

patients and radiographic healing data from 482 of 501 (96%). There were no 

differences in either SF-36 PCS (p=0.346) or HUI-III (p=0.345) between active and 

sham LIPUS. Similarly, there was no difference in time to radiographic union (Hazard 

Ratio = 1.06; 95% CI: 0.85, 1.33; p=0.594). 

Conclusion: LIPUS does not result in improved functional outcomes or time to union in 

patients with tibial diaphyseal fractures treated with IM nails. 

Paper 277 

Presenter: J Brousil 

Authors: Brousil J, Oakley B, Hahn D and Forward F 


Abstract title: Thromboprophylaxis and Infection after pelvic trauma 

Thromboprophylaxis and infection after Pelvic Trauma. 

Purpose of Study: The incidence of venous thromboembolism (VTE) after pelvic trauma 

has been variably quoted in the literature from 2 to 61%. There is no UK consensus 

on thromboprophylaxis for this patient group in the immediate post-operative period 

after discharge. In the largest available reported series a coumarin was used for 3 

months post operatively. An infection rate of 11% was reported. From a cohort of 336 

patients, we aimed to determine if an extended 4 week course of prophylactic low 

molecular weight heparin (LMWH) provided adequate VTE prophylaxis in operatively 

managed patients without increasing wound infection rates. 

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Methods: The records from a cohort of 336 patients treated between 2006 and 2009 

were examined. These patients all sustained pelvic or acetabular fractures requiring 

operative intervention. Patients fell into two groups dependant upon which pelvic 

and acetabular surgeon lead their care. This determined whether or not they routinely 

received four weeks of prophylactic enoxaparin from date of operation. Electronic 

records and case notes were reviewed for all patients recording the incidence and 

date of VTE, wound infection, demographic data along with admission data. Clinical 

episodes occurring up until 6 months post injury were examined. 

Results: 336 patients were included, 157 patients did not receive any enoxaparin 

after discharge. 175 patients received four weeks of enoxaparin and 4 patients 

were warfarinised during their admission. Overall VTE rate was 4.4% (15) and 

wound infection rate was 4.7% (16). 75% (n=10) of thromboembolic events 

occurred within 28 days of operation, 53% (n=8) occurred after discharge. Extended 

thromboprophylaxis was not associated with a reduced VTE rate (p=0.229) but it 

was also not associated with an increased wound infection rate (p=0.631). 

244

Conclusions: Extended prophylaxis with LMWH produces a VTE rate that is 

comparable to other prophylaxis regimes and is not associated with an increased 

wound infection rate. 

Paper 280 

Presenter: P Mansouri 

Authors: Aslani H,Zaferani Z, Najafi A, Mansouri P 


Abstract title: Intra-articular along with subacromial corticosteroid injection in 

diabetic patients with adhesive capsulitis 

Purpose of study: This study compares the clinical efficacy of intra-articular and 

subacromial corticosteroid injection with single intra-articular injection in diabetic 

patients with adhesive capsulitis. 

Description of methods: Forty-five diabetic patients were randomized into a 

corticosteroid injection group or non-injection control group and received the same 

instruction for a home stretching exercise. The corticosteroid group patients were 

administered intra-articular corticosteroid injection composed of 40 mg triamcinolone 

acetonide. Pain by a visual analogue scale, shoulder range of motion, and functional 

state by the American Shoulder and Elbow score were assessed at the baseline, 4-, 

12-, and 24-week follow-up. 

Summary of results: Diabetic patients treated with corticosteroid injections showed 

significant improvement in the pain score at 4 weeks and in the functional score at 

12 weeks (P = 0.020 and P = 0.042, respectively). The range of motion in forward 

elevation and internal rotation was significantly higher in the corticosteroid group 

than in the noncorticosteroid group at the 12-week follow-up (P = 0.030 and 0.045, 

respectively), but there were no significant differences at the final follow-up between 

the corticosteroid and non-corticosteroid groups. 

Conclusion: A corticosteroid injection in diabetic patients decreases the pain 

perception and accelerates the functional recovery in the early post-injection period. 

An intra-articular corticosteroid injection is considered a viable option for the treatment 

for adhesive capsulitis with diabetes. 

Paper 286 


Authors: Bagheri N, Mansouri P, Najafi A 


Abstract title: outcome of ponseti method in management of idiopathic congenital 

club foot and its correlation with radiological parameters 

Purpose of study: The aim of this study was to evaluate idiopathic congenital clubfoot 

deformity treated by ponseti method, in order to determine different factors such as 

245

adiological investigations that may have relation with the risk of failure and recurrence 

in long term follow-up of the patients. 

Description of methods: In our study 229 feet were treated with ponseti method. 

Dimeglio severity score were used to classified the severity of the clubfoot in our 

patients. Our treatment protocol included Weekly casting and then tenotomy 

and consequent three weeks casting if indicated. The first casting procedure was 

performed in order to correct the cavus through dorsiflexion and abduction of first 

metatarsal in the full foot supination Next times gradually the forefoot abduction has 

been corrected. In this stage if the dorsiflexion of the ankle was less than 10 degree, 

tenotomy had been performed under light sedation and another casting was applied 

for 3 weeks. At the final follow-up visit we have taken radiographies of the standing 

anteroposterior view and Lateral view with dorsiflexion of the foot at the ankle in all 

of our patients. 

Summary of results: In our study from 2006 to 2013, 149 patients (70% male, 30% 

female) with the mean age of 8.3± 5.4 weeks were treated by the ponseti method. 

Among these patients 72(48.3%) cases had unilateral clubfoot (58.3% right foot) and 

77 cases (51.7%) had bilateral clubfoot. Consequently 226 feet were treated with 

this method and 191(84.9) feet required percutaneous tenotomy. In our patient group 

the successful correction rate was 92% which means that they didn’t need surgical 

correction.We found that passive dorsiflexion and the lateral tibiocalcaneal angle has 

significant opposite association (r=-0.466, P 0.05). Our study analyzes showed that the beginning age 

of treatment and remained deformity rate had inverse association (P = 0.049).Also 

there was no significant correlation between percutaneous tetonomy and the passive 

dorsiflexion range.(P >0.05) 

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Conclusion:The authors believe that abnormality in radiologic parameters does not 

mean there is clinical abnormality in physical examination. In another word, diagnosis 

of club foot is a clinical judgment; therefore we may evaluate the treatment process by 

clinical presentations. Ponseti method can just turn the foot in normal shape but cannot 

treat bone deformities, and it may cause some problems in long times. So we suggest 

a modification in the ponsti method to fix bone deformities. 

Paper 287 


Authors: Mirzashahi B, Najafi A, Mansouri P 


Abstract title: A new modified open posterior approach for the fixation of posterior 

cruciate ligament tibial avulsion fractures 

246

Purpose of study:The aim of this study is to assess outcomes of fixation of tibial posterior 

cruciate ligament (PCL) avulsion fractures via a modified technique. Description of 

methods: From January, 2009 to March, 2012, there were 45 cases of PCL tibial 

avulsion fractures that were referred to our hospital and were managed through a 

modified open posterior approach. Fixation of Tibial PCL avulsion fractures were fixed 

by means of a lag screw and washer placed through our modified open posterior 

approach. Range of motion was begun on the first postoperative day. Clinical 

stability, range of motion, gastrocnemius muscle strength, radiographic investigation, 

and patient’s overall quality of life was analyzed at final follow up visit. Summary 

of results:The average of overall musculoskeletal functional evaluation scores was 

15 (range 3–35). All patients achieved union of their fracture and had clinically 

stable knees at the latest follow-up. The mean preoperative Lysholm score for 15 

knees was 62 ± 8 (range, 50-75); the mean postoperative Lysholm score was 92± 

7 (range, 75-101). A significant difference in Lysholm scores between preoperative 

and final follow-up evaluations was found (P < .05). At first-year follow-up, 42 (93%) 

patients revealed a difference of less than 10 mm in thigh circumference between 

their injured and healthy knees. ConclusionThe management of displaced large PCL 

avulsion fractures with placement of a cancellous lag screw with washer by means 

of the modified open posterior approach leads to satisfactory clinical, radiographic, 

and functional results and reduces the operation time and less blood loss. 

Paper 288 

Presenter: HM Malchau 

Authors: M. Greene, A. Nebergall, O. Rolfson, J. Huddleston, R. Emerson, A. 

Troelsen, H. Malchau 

Disclosure: Yes: Authors receive research support from Zimmer Biomet for this study 

Abstract title: 5 Year Multicenter Outcomes with Vitamin E Polyethylene Liners and 

Porous-Titanium Coated Shells 

INTRODUCTION: 

In vitro studies show that vitamin E diffused highly cross-linked polyethylene (VEPE) 

improves wear performance. A porous titanium construct (PTC) was developed for 

improved fixation. Monitoring early clinical outcomes through registries is important to 

document material performance in vivo. 

OBJECTIVES: 

The purpose of this multicenter study is to monitor VEPE liners and PTC shells compared 

to medium cross-linked polyethylene (XLPE) liners and plasma sprayed (PS) shells. Two 

centers implanted RSA beads to measure polyethylene wear. 

METHODS: 

This prospective 10 year study enrolled 977 patients from 17 centers. Patients received 

either a PTC or PS shell with either a VEPE or XLPE liner. Femoral heads were mostly 

32mm (28mm n=4; 36mm n=24). Patients were examined preoperatively and at 

6-10 weeks, 1, 3, 5, 7, and 10 years postop. At each interval, plain radiographs 

247

and surveys were obtained. All complications and revisions were collected. 

RESULTS: There were 977 surgeries with an average age at surgery of 62±9 years. 

There have been 15 dislocations in 11 patients and 13 revisions. There are 949 

patients with 3 year follow-up and 643 with 5 year follow-up. 

The postop cup positioning showed 60% have abduction within the 30° to 45° 

range, 73% have anteversion within the 5° to 25° range, and 44% fall within both 

positioning windows. At postop, 3 years, and 5 years the PTC shells had lucencies 

around 24%, 28%, and 37% of the shells measured, respectively. At the same 

intervals the PS shells had 30%, 9%, and 19% of the shells with radiolucencies, 

respectively. The penetration rate from postop to 5 years was 0.02 mm/yr for XLPE 

and -0.04 mm/yr for VEPE with no significant difference between them (p=0.23). 

The RSA analysis showed that median± standard error penetration into the VEPE 

liners was -0.02±0.03mm, and 0.07±0.05mm for the XLPE liners at 5 years. Both 

cup types appear stable at 5 years. Improvement was seen in all surveys from pre- to 

postop at all centers (p

was 87.7% (CI: 82%-91.8%). Thirty-eight knees (8.1%) were revised (or are pending 

revision) to a TKA, most commonly performed for lateral compartment OA (47%). The 

mean time to revision to TKA was 48.8 months (range, 7-101 months). At revision to 

TKA, 9 stems were used in 9 knees (25.7%). Nine augments were used in 8 revisions 

to TKA (21%). The degree of constraint used included: CR in 12 knees (34.2%), CS 

in 4 knees (11.4%), PS in 18 knees (51.4%), and CCK in 1 knee (2.8%). The bearing 

dislocation rate was 0.64% (3 knees) occurring at a mean of 9 months (range, 3-18 

months). We performed a univariate analysis of independent predictors of failure and 

found that when the coronal alignment was changed ≥3-5° corrected in a valgus 

direction from the preoperative mechanical axis, the odds of subsequent revision 

were statistically significant (p

entry * for implants entering the market through “Beyond Compliance”. It is essential 

for manufacturers to keep their product moving through the benchmarks otherwise they 

are de-listed. 

For hips, the stem and cup are assessed separately and for knees, whilst they are 

considered by brands to be one unit, there may be different ratings for each of the 

components. 

Results 

ODEP has encouraged manufacturers collect and evaluate data about their implants 

with diligence that was rarely seen before ODEP started 

ODEP ratings are used in many parts of the world by hospitals, surgeons and 

manufacturers in procurement agreements 

To date, we have analyzed >700 hip submissions from over 28 companies including 

>320 devices 

There is no evidence that ODEP has frustrated the introduction of new devices. At 

present there are >51 pre-entry products under review and 23 Pre-entry* products 

going through “Beyond Compliance” 

During the lifetime of ODEP >40 implants have been removed from the market and 

ODEP has deemed 22 unacceptable. 

The majority of UK surgeons now use ODEP rated products, usually those with high 

ratings 

Industry, the profession and the public have encouraged ODEP to evolve and the 

standard we require has been raised. 

More recently >50 Knee submissions have been assessed from 16 companies and 

the numbers are growing 

Conclusion 

In the UK, ODEP has become a system against which most Hip and Knee replacement 

implants are now judged. It is important to realize that ODEP does not imply superiority 

of one implant over another; its purpose is to assess the submitted data. 

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Paper 291 

Presenter: G Wood 

Authors: S. Lalonde MDCM, J. Chan MD, K. Harper, G. Wood MD FRCS(C), 


Abstract title: Outcomes of hip and knee total joint arthroplasty in the Kingston 

inmate population over a 10-year period 

Purpose of Study 

The inmate population is a unique cohort with several healthcare-related challenges. 

International studies have demonstrated higher rates of infectious diseases, chronic 

diseases and psychiatric disorders in inmates when compared to general population. 

However, little is known about the outcomes following total joint arthroplasty in this 

population. This retrospective chart review outlines the differences in clinical outcomes 

after hip and knee total joint arthroplasty in the Kingston inmate population compared 

to the national population standard. 

250

Description of Methods 

A list of all inmate inpatient hospital visits with diagnostic/procedure codes pertaining 

to total joint arthroplasty within the last ten years was obtained through a computerbased 

search of the Kingston General Hospital Discharge Abstract Database(DAD). 

The patient charts were reviewed and demographic and outcome data pertinent to 

our study was collected. Data was compiled using Excel and imported into IBM SPSS 

for descriptive analysis. 

Summary of Results 

Twenty male inmate patients underwent 24 primary Total Hip Arthroplasties (THA) or 

Total Knee Arthroplasties(TKA) and one medial unicompartmental knee arthroplasty 

from May 2003 to January 2013. The average age was 58 with mean Body Mass 

Index (BMI) of 34. Median American Society of Anesthesiologist (ASA) score was 3 

and mean Charlston Comorbidity Index was 3.92. The rates of HCV and HIV were 

35% (n=5) and 0%, respectively. 

Average length of stay from time of initial procedure was 4.2 days. The overall revision 

rate was 24% (n=6). Reasons for revision included deep prosthetic infection (50%, 

n=3), aseptic loosening (17%, n=1), arthrofibrosis (17%, n=1) and late periprosthetic 

fracture (17%, n=1). 

Infection rates were 16% (n=4); 75% of which were deep prosthetic infections 

requiring revision surgery. Other complications included ST-elevation myocardial 

infarction (STEMI) (n=1), and postoperative knee stiffness requiring manipulation 

under anesthesia(MUA) (n=1). 

Conclusion 

Compared to Correctional Services Canada (CSC) data on male inmate health in 

2012, our study population demonstrated a higher rate of HCV (35% vs. 9.4%), 

diabetes (30% vs. 4.2%) and overall cardiovascular and respiratory comorbidities. 

Total joint revision rates in our study population was 24%, which is higher than the 

2014 Canadian Joint Replacement Registry’s yearly revision rate of 8.7% in THA and 

5.2% in TKA. Our study population also demonstrated infection as the leading cause 

for revision at 50%, compared to 14.5% for THA and 19.6% for TKA in the general 

Canadian population. 

Further study of the complex biopsychosocial risk factors in the inmate population is 

warranted to better define pre-surgical risk assessment criteria. 

251

Paper 293 

Presenter: JK Tucker 

Authors: K.Tucker, R.Armstrong, P.Kay, P.Lewis, M.Pickford, R.Parkinson, T.Wilton 

Disclosure: Yes: I ahve no conflict with this paper 

Abstract title: The early monitoring of new total hips and knees.... 3 years of 

“Beyond Compliance” 

In this paper we will set out to evaluate our results and experience with the “Beyond 

Compliance” (BC) initiative in relation to Total Hip Replacement (THR) and Total Knee 

replacement (TKR). 

Introduction 

Since 1993, in the countries of the European Union, the CE mark has been held as a 

mark of quality for purchasers of a product, including joint replacement. 

Unfortunately, in spite of the CE mark and National Joint Registries, some joint 

replacements and modifications to joint replacements have unexpectedly performed 

badly, leading to patients being damaged; sometimes in significant numbers. 

This system, which is voluntary, involves an assessment of the risks that are inherent in 

a new product, a recommendation as to the rate of introduction and a sophisticated 

data collection system 

The process is confidential 

Method 

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The details of a new product are submitted to the advisory group and, with the 

manufacturer (including their lead surgeons and design team), a risk assessment is 

made. 

After contracts for data collection and analysis have been signed, a rich 

mixture of data is collected and held in a separate area in the England, Wales 

and Northern Ireland National Joint Registry (NJR). The NJR picks up the 

implant from its component number and replicates it into the BC repository. 

Patients are appropriately consented for their data to be analysed. 

Timely reviews of the data, with the BC Rapporteurs, the lead surgeon(s) and the 

manufacturers are scheduled on the basis of the perceived risk and the usage. 

Recently, user group meetings have been held during the BOA congress. They have 

been very popular 

The expenses of the advisory group are indirectly met by the taxpayer. The 

manufacturer pays for the data collection and analysis. 

252

Results 

The majority of new devices and modifications to existing devices are now being 

introduced into the UK via this system 

Experienced orthopaedic surgeons have enthusiastically volunteered to join the 

advisory group. 

A number of implants have not been introduced to the UK market following a BC 

assessment. 

To date,13 companies have a contract involving 30 different implants and 6125 

procedures are logged with BC involving 395 registered surgeons 

Conclusion 

There is now evidence that Beyond Compliance might well fill the gap between the 

CE mark and the ODEP benchmarks. 

The Association of British Healthcare Industries (ABHI) has stated that all new implants 

should go through the “Beyond Compliance” process 

Paper 296 

Presenter: L Di Mascio 

Authors: KV Brown, C Galli, L DiMascio 


Abstract title: The Treatment Of Perilunate Injuries In A Major Trauma Centre. 

Perilunate injuries are rare and outcomes are improved by early diagnosis and 

treatment. With the shift of polytrauma management in the United Kingdom (UK) to 

Major Trauma Centres (MTC) there is a need to develop a clear and methodical 

approach to the emergency and definitive management of perilunate injuries in 

order to optimise outcomes. Perilunate injuries admitted to the Royal London Hospital 

between October 2011 and February 2015 were retrospectively identified. All 

definitive surgical procedures were performed by the senior surgeon (LDM), specialist 

hand therapists supervised the patient rehabilitation. Outcomes were assessed prior 

to final discharge by measurement of grip strength and completion of Mayo Wrist 

and QuickDASH scores.We identified 16 perilunate injuries in 15 patients (all male). 

The injury was isolated in 4 cases (26.66%), associated with neurovascular injury in 

6 cases (37.5%), associated with other system injuries in 8 cases (53.33%). There 

were 4 associated median nerve injuries (25%),1 ulnar nerve injury (6.25%) and 

1 combined median and ulnar nerve injury (6.25%). The median time to reduction 

was 6 hours (range 1 hour – 12 days), the median time from reduction to definitive 

fixation was 8.5 days (range 4 hours – 15 days). A combined dorsal and volar 

approach was performed in 15 cases; in 1 case an acute four-corner arthrodesis 

253

was performed (dorsal approach alone). There were 4 complications (25%); 3 

cases of premature k-wire loosening and the acute four-corner arthrodesis failed, 

subsequently undergoing a total arthrodesis. The median length of follow up was 85 

weeks (range 187 – 2 weeks). Final radiographs showed mid carpal arthrosis in 

one patient (significant initial osteochondral injury to the capitate). The mean carpal 

height ratio was 0.53.The median difference in grip strength between the hands was 

6.1 Kg (range 0-15.2). The median Mayo Wrist score was 72.5 (range 15-90) and 

the median QuickDASH score 2.3 (0-72.7).We have demonstrated that satisfactory 

outcomes can be achieved, even in the most severe perilunate injuries, if treatment 

is prompt and follows a clear management protocol. Following reduction, a delay 

in definitive treatment of up to 14 days does not appear to have a deleterious effect 

on outcome. Poorer outcomes are expected in the presence of significant associated 

osteochondral injury to the carpus, and in the presence of scaphoid fracture with 

associated scapholunate ligament injury. 

Paper 297 

Presenter: PH Naude 

Authors: P Naude, S Roche, B Vrettos, J du Plessis, R Dachs, F Montoya 


Abstract title: Prospective comparison of the impact of different angles of 

inclination used in the beach chair position on cerebral oxygenation 

There have been devastating reports of patients suffering permanent neurological 

damage following surgery in the beach chair position. 

Positioning patients in the beach chair position for surgery has come under increasing 

scrutiny during the last few years. Recent research have indicated that there may be 

an inherent risk involved with this practice. However, performing shoulder surgery in 

the beach chair position has many benefits for the orthopaedic surgeon involved. 

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Previous research have shown that placing patients in the beach chair position 

does lead to periodic decreases in cerebral oxygenation and that these cerebral 

desaturation events may place patients at risk for neurological damage. During these 

studies patients were placed at 70-90˚ of inclination, which is far more upright than 

we generally use in our practice. 

We postulated that placing patients at lower angles of inclination in beach chair may 

be protective of cerebral oxygenation. 

50 consecutive patients presenting for shoulder surgery were randomised to 2 groups. 

The control group patients were placed in the normal position used by the surgeon 

for the procedure and this angle was measured. The patients in the trial group were 

all placed at 30 . 

Cerebral oxygenation were measured with the INVOS system along with the other 

standard measurements in theatre. The 2 most important parameters measured were 

mean arterial pressure and cerebral oxygenation levels. 

254

In our study 7% of all patients suffered a cerebral desaturation event, which is 

considerably less that shown in previous research. 69% of patients had decreases in 

mean arterial pressure that required intervention. This is in line with previous studies. 

In conclusion, positioning patients at a lower angle of inclination leads to fewer 

cerebral desaturation events when compared to previous studies. 

Paper 298 

Presenter: TR Sluis-Cremer 

Authors: M SOlomons, T Sluis Cremer, D McGuire 


Abstract title: Retrospective review of outcomes following Total Wrist Arthroplasty 

with the Motec Device. 

The surgical management of end stage wrist arthropathy is an evolving challange. 

Arthrodesis, which is performed ten times more commonly than arthroplasty, offers a 

permanent pain free solution but this comes at the cost of motion. Limmitted carpal 

fusion maintians range of motion but relies on an intact distal radius articular surface 

and is prone to progressive degeneration. The goal of total wrist arthroplasty (TWA) 

is a stable, pain free joint with normal range of motion and is free of complications. 

Unfortunately complications do arise and these include aseptic loosening, infection, 

stiffness/impingement, implant failure and ongoing pain. We present a retrospective 

review of 16 consecutive TWA’s (in 15 patients) using the Motec ball and socket 

type cementless arthroplasty with a mean follow up of 28 months. Ten of the 15 

were rheumatoid arthritis patients while the remainder were post traumatic or 

degenarative conditions. Radiological and clinical data including range of motion, 

PRWE, QuickDASH and VAS was anylised. Twelve of the 16 wrists resulted in good 

to excellent results with 5 patients continuing to work in a high demand environment. 

Predictors of a worse outcome include the degree of pre-operative joint destrucion, 

inflammatory arthritis and a proximal implant (and therefore the centre of rotation) 

which was placed laterally (radial side) or proximally. In order to restore normal wrist 

kinematics the centre of rotation should closely match the native wrist. Complications 

in our patient group included one revision due to impingment and one patient with 

suspected distal component aseptic loosening which is yet to undergo further surgery. 

Paper 300 

Presenter: P Hoerner 

Authors: P.Hoerner 


Abstract title: Evaluation of an antimicrobial surgical glove to inactivate live 

human immunodeficiency virus following simulated glove puncture 

255

1.Purpose of the study Percutaneous injuries associated with cutting instruments, 

needles, and other sharps (eg, metallic meshes, bone fragments, etc…) occur 

commonly during surgical procedures, exposing members of surgical teams to the 

risk for contamination by blood-borne pathogens. The basic transmission risk factor is 

correlated with the quantity of inoculated viruses. Surgical gloves worn as a barrier 

to prevent contamination do not protect against needles penetrating the skin and 

the efficacy of such passive layers in preventing virus transmission is questionable. 

This study evaluated the efficacy of an innovative integrated antimicrobial glove to 

reduce transmission of the human immunodeficiency virus (HIV) following a simulated 

surgical-glove puncture injury. 2.Description of methods A pneumatically activated 

puncturing apparatus was used in a surgical-glove perforation model to evaluate 

the passage of live HIV-1 virus transferred via a contaminated blood-laden needle, 

using a reference (standard double-layer glove) and an antimicrobial interlayer 

shielded surgical glove. Viral viability was assessed by observing the cytopathic 

effects in human lymphocytic C8166 T-cell tissue culture. Concurrent viral and cell 

culture viability controls were run in parallel with the experiment’s studies. 3. Summary 

of results Mean HIV viral loads (log10TCID50) were reduced by 96% following 

passage through the antimicrobial surgical glove compared to passage through the 

non antimicrobial glove. 4. Conclusion Sharps injuries in the operating room pose a 

significant occupational risk for surgical practitioners, especially in Southern African 

Countries due to the high prevalence rate of HIV. In traumatology procedures, patients 

with high viral loads could expose the surgical team to real risks of contamination. 

The findings of this study suggest that an innovative antimicrobial glove was effective 

at significantly (P < .01) reducing the risk for blood-borne virus transfer in a model 

of simulated glove perforation. These new results are consistent with those already 

published (Surgery 2013;153:225-33, Nature Mat, Vol3, N°5, May2004). In a 

risk assessment approach, this new glove could help to improve the level of protection 

of protection for healthcare workers exposed to sharp injuries with blood from HIVinfected 

patients. 

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Paper 305 

Presenter: PW Jordaan 

Authors: P Jordaan, D McGuire, M Solomons 


Abstract title: Surface Replacement Proximal Interphalangeal joint (SR-PIPJ) 

arthroplasty – A CASE SERIES 

Surface replacement (SR) proximal interphalangeal joint replacement consists of 

a cobalt-chrome alloy component articulating with an ultra-high molecular weight 

polyethylene component. After experiencing a high rate of subsidence and 

complications with a pyrocarbon implant, our unit has changed to the cemented SR 

system in the hope of decreasing these complications. The main aim of this study was 

to determine whether this change in practice has led to a decrease in subsidence and 

complications. A retrospective chart review was performed including 43 joints in 28 

256

patients. Subsidence was noted in 26% of the joints and complications in 31% of the 

joints. Even though subsidence remains a problem, the change in implant has led to 

a decrease in subsidence and other complications. 

Paper 308 

Presenter: CR Oosthuizen 

Authors: CR Oosthuizen 


Abstract title: Constitutional Knee Wear patterns and incidence for Partial Knee 

replacement 

Purpose 

Wear patterns are due to the constitutional alignment and the constitutional kinematics. 

The success and the longevity of the Partial knee can be enhanced with the correct 

evaluation of the wear patterns of the knee caused by the morphology, stability and 

the kinematics. 

This should be evaluated and the relevant resurfacing done with the least invasive 

prosthetic that is suitable. 

Methods 

Aetiology of Degenerative osteoarthritis will be noted. 

Method: The tibial plateau was divided in three thirds to ascertain the wear pattern. 

Results 

527 Medial Tibial specimens were evaluated to confirm the wear pattern as published 

by White and Goodfellow in 1986. The above cases were an average age of 64 with 

majority males at 56% (n=293) and females at 44% (n=234) at the time of the operation. 

The clinical picture will be illustrated. 

The incidence of Anteromedial proper 20.9% (n=110) (anterior third) 

Central proper wear 64.3% (n=339) (central third) 

Anteromedial undefined 9.3% (n=49) (combined anterior and central) 

Posterior 4.48% (n=25) (Intact ACL) 

AVN 0.7% (n=4) 

147 Lateral Tibial specimens were evaluated and the clinical picture illustrated. The average 

age of all cases was 65. Majority were females at 78.91% (n=116) at an average age 

of 66 and males 21.09% (n=31) at an average age of 63 at the time of the operation. 

Anterior 4% (n=6) 

Central 71.4% (n=105) 

Posterior 23.8% (n=35) 

AVN 0.8% (n=1) 

Prosthesis used on these patients. 

257

Conclusion 

The aetiology and pathology must be identified for optimum surgical decision in PKA. 

Paper 309 




Abstract title: The results of the Cementless Partial Knee Arthroplasty (PKA) and 

ACL reconstructions 

Purpose 

A Comparison with Cementless PKA without ACL Reconstruction and Cementless PKA 

with ACL Reconstructions according to the SF36 scoring method 

Methods 

The study reviewed a total of 527 cases over 72 months (2009-2015) of Cementless 

PKA with ACL Reconstruction accounting for 2.27% (n=12) consisting of a period of 

28 months 

Results 

1. Cementless PKA cases with an average age of 64, majority of these cases were 

males at 56% (n=293) at an average age of 64. Females were 44% (n=234) at an 

average age of 64 at the time of the operation. From the 527 cementless PKA cases 

there were ACL Reconstructions to a total of 2.27% (n=12). 

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a) The average SF36 score for the 527 cementless PKA cases increased from 21 at 

Pre-Operation to 41 after 4 months Post-Operative. 

2. ACL Reconstruction cases (n=12) with an average age of 56 at the time of the 

operation, consisted of only males. From the 12 ACL Reconstruction cases, there was 

only 1 complication 8.33% that occurred. The average time that ACL Reconstruction 

needed to be performed after PKA is 7 months later. 

a) The complication from ACL Reconstruction was Dislocation. 

b) The average SF36 score for the 12 ACL reconstruction cases increased from 24 at 

Pre-Operation to 44 after 4 months Post-Operative. 

Conclusion 

The SF36 scoring for ACL reconstruction had greater improvement from Pre-Operation 

to Post-Operative than the Cementless as indicated above as well as the Oxford 

Domed Lateral PKA or Cemented PKA. 

258

The SF36 scoring for Domed Lateral PKA increased at an average of 15 Pre-Operative 

to 37 Post-Operative. 

The SF36 scoring for Cemented PKA increased at an average of 20 Pre-Operative 

to 37 Post-Operative. 

Paper 310 




Abstract title: Results of Lateral Domed Oxford Partial Knee Arthroplasty (PKA) 

Purpose 

147 Consecutive Lateral Domed clinical results since inception from 2009 to 2015. 

Method 

The study reviewed a total of 147 cases with Oxford Domed Lateral PKA. 

Results 

1. The average age of all cases was 65. Majority were females at 78.91% (n=116) 

at an average age of 66. Males 21.09% (n=31) average age of 63 at the time of 

the operation. There were complications total of 17.69% (n=26). 

a) 46.16% of complications occurred within the first 6 months from operation, 

26.92% from 6 to 12 months, 26.92% after 12 months from the date of operation. 

b) Minor complications 23.08% (n=6) consisted of: 

● Arthroscopy: Medial Meniscal Tear 7.7% (n=2) 

Medial side defect due to a fall 3.85% (n=1) 

● Sepsis 3.85% (n=1) 

● PFJ Pain 3.85% (n=1) 

● Incarceration of patella 3.85% (n=1) 

c) Major complications at 76.92% (n=20) were the following: 

● AVN Medial 7.69% (n=2) 

● Medial Compartment OA 7.69% (n=2) 

● Dislocation 57.69% (n=15) 

● Lateral subsidence of tibia 3.85% (n=1) 

d) Average SF36 score increased from 15 at Pre-Operation to 37 after 4 months 

Post-Operative. 

Conclusion 

Dislocation in a Domed Lateral PKA is higher at 10.20% (n=15/147) than in Cemented 

PKA 1.1% (n=6/530) and Uncemented PKA 0.75% (n=4/527) respectively. 

Lateral PKA failures is higher at 13.6% (n=20/147) than in Cemented Medial PKA 

3.58% (n=19/530) and Uncemented PKA 1.14% (n=6/527) respectively. 

In Lateral PKA, 90% failures occurred within 12 months post op and were corrected 

with: 

a) Revision to Poli → 70% (n=14/20) 

b) Revision to TKA → 20% (n=4/20) 

c) Revision to Medial PKA → 10% (n=2/20) 

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Paper 311 




Abstract title: Comparison of Cemented with Uncemented Partial Knee Arthroplasty 

(PKA) results 

Purpose 

A Comparative study to compare the results of cemented and uncemented Medial 

PKA over a 15 year period. 

Methods 

Study reviewed total of 1057 cases with Cemented PKA over 13 years (2000- 

2013) accounting for 50.1% (n=530) and Uncemented PKA over 6 years (for 49.9% 

(n=527)). 

Results 

1. Cemented PKA cases accounted for 50.1% (n=530) with average age of 66. 

Majority females at 56% of cemented PKA (n=295) average age 66. Males 44% 

(n=235) average age 65. From 530 cemented PKA cases, complications total of 

9% (n=46). 

a) 52% of complications occurred after 24 months from the date of operation. 

b) Minor complications 5.09% (n=27/530) consisted of: 

● Arthroscopy: 

-Lateral Meniscal Tear 14 

-Impingement 2 

-Synovitus & RA 3 

-Heamatrosis 2 

● Clinical on X-Ray: 

-Lateral Degeneration 3 

-Loss of full extension 2 

-Infection 1 

c) Major complications at 3.58% (n=19/530) of Cemented complications were the 

following: 

-Dislocation 6 

-Lateral Degenerative changes 8 

-Loose femoral prosthesis 5 



e) At a failure rate of 3.58% (n=19/530), 42% of cases failed within 12 months post 

op. The failures were able to be corrected with: 

68.4% (n=13/19) → Revision to Poli, 26.3% (n=5/19) → Revision to TKA and 

5.3% (n=1/19) → Revision to Medial PKA 

2. Uncemented PKA cases accounted for 49.9% (n=527) with average age 64. 

Majority males 56% (n=293) at average age 64. Females 44% (n=234) at average 

age 64 at the time of the operation. From 527 uncemented PKA cases complications 

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260

total of 6.64% (n=35/527). 

a) 51.42% of complications occurred within first 6 months from operation, 22.86% 

from 6 to 12 months, 25.72% after 24 months from the date of operation. 

b) Minor complications 4.36% (n=23/527) consisted of: 

● Arthroscopy: 

-Impingement 3 

-Lateral meniscal tear 5 

-Heamatome 3 

-Synovitis 2 

● Clinical on X-Ray: 

- Loss of full extension 3 

- Infection 2 

- Lateral degeneration / condylar damage 2 

- Discoid Meniscus 1 

- Lateral OA 2 

c) Major complications at 2.28% (n=12/527) were: 

-Dislocation 4 → 1 x ACL, → 3 x Poli changes 

-Tibia fracture 7 →3 x High BMI’s, →3 x Cases fell (6 corrected with ORIF, 1 

corrected with TKA) 

-Subsidence on tibia & pressure on lateral side at ACL insertion 1 



e) At a failure rate of 1.14% (n=6/530), 83% of cases failed within 12 months post 

op. The failures were able to be corrected with: 

83.3% (n=5/6) → Revision to Poli, 16.7% (n=1/6) → Revision to TKA 

Conclusion 

Cemented PKA lead to more loose prosthesis complications and dislocations where 

Cementless experienced more tibia fractures. 

The overall failure rate in a Cemented PKA is higher at 3.58% (n=19/530) than in 

Uncemented PKA 1.14% (n=6/527). 

Failure to be corrected with a TKA in a Cemented PKA is higher at 0.94% (n=5/530) 

than in Uncemented PKA 0.19% (n=1/527). 

In Cemented PKA, 42% failures occurred within 12 months post op and were 

corrected with: 

a) Revision to Poli → 68.4% (n=13/19) 

b) Revision to TKA → 26.3% (n=5/19) 

c) Revision to Medial PKA → 5.3% (n=1/19) 

In Uncemented PKA, 83% failures occurred within 12 months post op and were 

corrected with: 

a) Revision to Poli → 83.3% (n=5/6) 

b) Revision to TKA →16.7% (n=1/6) 

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Paper 312 




Abstract title: Comparison between the published “X-Ray Knee 

Instability and Degenerative Score” (X-KIDS) and the new “Knee 

Arthroplasty Grading System” (KAGS) 

Purpose 

The X-KIDS (without PFJ) and KAGS (with PFJ) are compared for efficacy in predicting 

the required prosthesis: 

1) Independantly a PKA or TKA is predicted in 94% of knees in both and are better 

than the stress views as a standalone at 90% accuracy. 

2) The KAGS incorporates the PFJ with a 91% direct conformity to X-KIDS. 

3) The PFJ does have a decision influence and is incorporated by KAGS. 

Method 

Two new visual tools were developed to improve the decision for PKA or TKA when 

contemplating an Arthroplasty. 

Both tools require bone-on-bone wear and assessment for instability with the patella 

assessed only in the KAGS. 

Results 

Study reviewed 352 knee X-ray sequences with the X-KIDS and compared results with 

the new KAGS. 

Radiographic Imaging: 

1. AP, LAT and Skyline 

2. a) 15° PA - medial wear 

b) 45°PA - lateral wear 

3. Varus and Valgus stress in 20° flexion 

Scoring Formula: 

A) X-KIDS: Maximum 10 points can be accrued with X-KIDS (N 3 3 +O1 +S 1 2 ). 

1. X-KIDS of 3 and 4 points = PKA 

2. X-KIDS of 5 is considered for a PKA or TKA (Clinical finding dependant) 

3. X-KIDS > 5 points = TKA 

B) KAGS: Consist of 4 Grades 

Average age: 352 patients, 65 years. Females (54.55%), average age 65 (n=192). 

Male patients 65 (n=160). Medial PKA accounted for 69.88% (n=246). TKA 

accounted for 15.63% (n=55) and Lateral Domed accounted for 14.49% (n=51). 

1. Medial PKA achieved 93.09% consensus with X-KIDS. In 4.06% the score did 

not conform to the procedure due to PKA + ACL reconstruction and 2.85% of PFJ not 

evaluated. Medial PKA achieved 99.59% consensus with KAGS. In 0.41% the score 

did not conform to the procedure due to patient preference. 

2. In Lateral PKA, 98.04% achieved consensus with X-KIDS and KAGS. In 1.96% the 

score did not conform to the procedure due to incorrect scoring. 

3. In TKA, 80% achieved consensus with X-KIDS. In 20% the score did not conform 

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262

to the procedure due to patient preference (7.27%), clinical decisions (10.91%) 

(Valgus/Wedge 5.4%, PFJ 3.62%, Scope Defect 1.8%), RA (n=2) (3.64%). TKA 

achieved 78.18% consensus with KAGS. 21.82% did not conform as TKA but due to 

preference (5.45%), clinical decisions (12.73%), RA (n=1)(1.82%) and PFJ (1.82%) 

4. The KAGS illustrate the tri-compartmental degeneration better and does have an 

influence in 4% of the final decision due to the PFJ evaluation. 

Conclusion 

X-Ray imaging is the gold standard for OA evaluation and X-KIDS and KAGS are 

different from all previous evaluation systems, as it incorporates the stability of knee 

ligaments and the severity of the weight-bearing OA. 

The X-KIDS can be used as classification of OA knee degeneration and a reference 

to improve research on Arthroplasty selection. 

KAGS overall is an intuitive tool as all evaluated X-Rays agreed 94.31% to 

performance. 

X-KIDS agreed without skyline x-rays at 93.09% to performance. 

Paper 313 


Authors: H.H. Wu, K.R. Patel, A.M. Caldwell, M Liu, D.W. Shearer, J Hahn, J 

Larouche, R Gosselin, S Morshed 


Abstract title: A Clinical Research Course for International Orthopaedic 

Surgeons: Two-Year Outcomes 

Introduction: Despite the growing burden of traumatic orthopaedic injury, few 

initiatives exist to promote orthopaedic research in low-to-middle income countries 

(LMICs) that addresses this issue. Thus, the purpose of this study was to design and 

implement a one-day course to teach orthopaedic surgeons practicing in LMICs how 

to conduct clinical research. 

Methods: In this prospective observational study, orthopaedic surgeons from LMICs 

with no formal research training were recruited to attend the Institute for Global 

Orthopaedics and Traumatology (IGOT) International Research Symposium in San 

Francisco. The one-day course combined didactic lectures with “break-out sessions” in 

which participants were divided into teams to design a research proposal and present 

the idea to the rest of the class. Participants reported competency and productivity 

in clinical research in a pre-course assessment. A survey was also given immediately 

and two-years post-course to evaluate instructional materials and impact of the course 

on research productivity, respectively. 

Results: 33 participants representing 10 different LMICs from Africa and Asia 

attended the 2013 course. They rated 7/10 instructional quality criteria to be a 

mean of 4 or greater on a Likert scale of 5 (Excellent). Post-course participants were 

significantly more confident in their ability to “Develop a Feasible Research Question” 

(3.8vs.3.1; p=0.04) and “Write a Research Grant” (3.4vs.2.8; p=0.04) than 

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efore the course. At two-years post-course, participants reported starting 25 research 

projects, authored 6 “accepted or published manuscripts” (vs. 1 before the course; 

p

compared to non-collaborative studies. In addition, the majority of collaborative HIC 

authors were academically-affiliated (88.1%) and practiced either in North America 

(37.0%) or Europe (34.2%) 

Conclusion: Orthopaedic studies conducted in LMICs rarely attain high levels of 

evidence. However, studies completed through academic collaboration between HIC 

and LMIC investigators are more likely to achieve Level I or Level II evidence through 

prospective, controlled designs. Future investigation is needed to determine how to 

improve collaboration in international orthopaedic research and whether partnerships 

between LMIC and HIC academic institutions are sustainable. 

Paper 316 

Presenter: TP Pikor 

Authors: T.D. Pikor , M. Carides 


Abstract title: A modified algorithm for the treatment of acute scaphoid 

fractures and scaphoid non-unions 

Introduction 

The scaphoid is the most commonly injured carpal bone. The majority of injuries 

are falls on an outstretched hand and affect young patients with high functional 

demands. Early return to function is a priority in these patients. 

Due to the idiosyncratic blood supply of the scaphoid, as well as the intra-articular 

nature of the fractures, non-unions complicate about 10-20% of acute fractures. 

Inadequate treatment commonly results in poor outcomes and reduced functional 

ability. 

Management of scaphoid fractures and scaphoid non-unions are complex and 

challenging. 

Aim 

To describe a simple algorithm that assists in the management of acute scaphoid 

fractures and scaphoid non-unions. 

Method 

Scaphoid non-unions were classified according to Slade and Dodds. (2009) 

A literature review was performed to assess current treatment options of acute 

scaphoid fractures as well as non-unions. 

Clinical and radiographic data of a single surgeon’s series of scaphoid non-unions, 

treated with percutaneous fixation without bone graft as well as internal fixation 

with bone graft, was reviewed to assess outcome of treatment and compared to the 

literature review. 

The combined results were incorporated into a single comprehensive treatment 

algorithm. 

265

Conclusion 

The described algorithm assists in the management of acute scaphoid fractures and 

scaphoid non-unions. 

Paper 317 

Presenter: TD Pikor 

Authors: M. Carides, T.D. Pikor 


Abstract title: PERCUTANEOUS FIXATION IN PATIENTS WITH DELAYED 

PRESENTATION AND ESTABLISHED NONUNION OF SCAPHOID 

FRACTURES 

Introduction and Aims 

The surgical treatment of fractures of the scaphoid with delayed presentation or 

with established non-union pose a formidable challenge with reported failure 

rates between 15% and 45%. The aim of this study is to report the results of 

percutaneous versus open fixation with bone grafting of these fractures. 

Method 

34 Consecutive patients who underwent surgery between 2009 and 2013 for 

delayed presentation and established non-union of scaphoid fractures have been 

reviewed retrospectively. There were 27 males and 7 females with a mean age of 

31 years 

(15 to 66). The mean delay from time of injury to operation was 12 weeks (4 

weeks to 11 months) in the percutaneous fixation group and 19 months (5 months 

to 6 years) in the open fixation group. 19 Patients were treated with percutaneous 

screw fixation alone and 15 patients underwent open reduction and internal fixation 

supplemented with autogenous corticocancellous iliac bone graft. The classification 

of Slade and Dodds (2009) was used as a guide for surgical treatment and the 

Mini-Acutrak headless compression screw was used as the fixation device in all 

cases. 

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Results 

Patients underwent final clinical and radiological assessment with plain radiographs 

6 months following their surgery. There was one failed union in the percutaneous 

fixation group and there was one failed union in the open fixation group. One 

patient in the open fixation group was lost to follow up. No serious complications 

were recorded in either group. 

266

Conclusion 

The success of percutaneous internal fixation for acute fractures of the carpal 

scaphoid may be extended to include scaphoid fractures with delayed presentation 

and fractures of the scaphoid with established nonunion. However, appropriate 

patient selection is necessary to ensure optimal outcomes. 

Paper 318 

Presenter: M Laubscher 

Authors: M Laubscher, S El-Tawil, I Ibrahim, C Mitchell, PJ Smitham, P Chen, D 

Goodier, J Gorjon, R Richards, SJG Taylor, P Calder 

Disclosure: Yes: Research funding provided by Innovate UK: Technology-inspired 

innovation Strand 2 (Collaborative research & development), Project SmartFix, Ref 

101500. Commercial sponsor: Smith and Nephew Inc, Memphis, TN 

Abstract title: Measurement of forces across a TSF during activity 

Purpose 

Little is known about the forces carried by the Taylor Spatial Frame (TSF) hexapod 

fixator. Our aim was to measure the TSF resultant force and how this changed during 

the consolidation phase of treatment. 

Methods 

Five patients undergoing correction of tibial deformities were recruited. Measurements 

were taken at 2, 4, 8 and 12 weeks post-correction during various activities. 

Instrumented struts incorporating strain gauges measuring axial force were temporarily 

used each time. Strut forces and lengths were used to determine frame kinetics. The 

resultant axial fixator forces and moments were calculated relative to sitting. Ground 

reaction forces (GRF) were measured using the treadmill force plates. 


Due to the subjects’ varying confidence in weight bearing the forces varied both 

inter- and intra- activity and over post-corrective time. Variation in individual strut 

forces produced a resultant force and bending moment across the fixation. Analysing 

the GRF date over post-correction time we found an increase in weight bearing of 

the frame limb, both in terms of peak force and also stance time during gait cycle. 

As the healing bone assumed more load over time there was a reduction in the 

force and bending excursions across the frame (calculated from the strut forces) as 

a percentage of GRF, achieving a minimum by 8 weeks. Combining the GRF data 

and the reduction in frame forces shows that the force through the tibia as a ratio of 

force through the frame limb is increasing throughout time, peaking at 8 weeks post 

correction. 

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Conclusion 

Instrumented TSFs are a useful means of assessing the forces acting during 

healing. Monitoring of these forces can help determine optimal removal. 

Paper 322 

Presenter: M Bhandari 

Authors: I.S. Aleem, I. Aleem, N. Evaniew, J. Busse, M. Yaszemski, A. Agarwal, T. 

Einhorn, M. Bhandari 

Disclosure: Yes: MB has received honorariums from Smith & Nephew, Stryker, 

Amgen, Zimmer, Moximed, Bioventus, Merck, Eli Lilly, Sanofi and research grants 

from Smith & Nephew, DePuy, Eli Lily, Bioventus, Stryker, Zimmer, Amgen 

Abstract title: Efficacy of Electrical Stimulators for Bone Healing: A 

Meta-Analysis of Randomized Sham-Controlled Trials 

Purpose: Electrical stimulators are commonly used to accelerate fracture healing, 

resolve nonunions or delayed unions, and to promote spinal fusion. The efficacy of 

electrical stimulator treatment, however, remains uncertain. We conducted a metaanalysis 

of randomized sham-controlled trials to establish the effectiveness of electrical 

stimulation for bone healing. 

Methods: We searched MEDLINE, EMBASE, CINAHL and Cochrane Central 

to identify all randomized sham-controlled trials evaluating electrical stimulators in 

patients with acute fractures, non-union, delayed union, osteotomy healing or spinal 

fusion, published up to February 2015. Our outcomes were radiographic nonunion, 

patient-reported pain and self-reported function. Two reviewers independently 

assessed eligibility and risk of bias, performed data extraction, and rated overall 

confidence in the effect estimates according to the Grading of Recommendations 

Assessment, Development and Evaluation (GRADE) approach. 

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Results: Fifteen randomized trials met our inclusion criteria. Electrical stimulation 

reduced the relative risk of radiographic nonunion or persistent nonunion by 35% 

(95% CI 19% to 47%; 15 trials; 1247 patients; number needed to treat = 7; p < 

0.01; moderate certainty). Electrical stimulation also showed a significant reduction 

in patient-reported pain (Mean Difference (MD) on the 100-millimeter visual analogue 

scale = -7.67; 95% CI -13.92 to -1.43; 4 trials; 195 patients; p = 0.02; moderate 

certainty). Limited functional outcome data showed no difference with electrical 

stimulation (MD -0.88; 95% CI -6.63 to 4.87; 2 trials; 316 patients; p = 0.76; low 

certainty). 

Conclusion: Patients treated with electrical stimulation as an adjunct for bone 

healing have a reduced risk of radiographic nonunion or persistent nonunion and less 

pain; functional outcome data are limited and requires increased focus in future trials. 

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Paper 326 

Presenter: A Parr 

Authors: A Parr, W Bryceson, D Brooks 


Abstract title: The efficacy of radiofrequency ablation in the 

management of Morton’s neuroma 

Background 

Morton’s neuroma is a common cause of forefoot pain. Outcomes of conservative 

therapy are mixed and many patients undergo operative intervention. Radiofrequency 

ablation has recently gained favour as a treatment option, although the optimal 

regime is unknown. This study investigates the effectiveness of 2 versus 3 cycles of 

radiofrequency ablation for the treatment of Morton’s neuroma. 

Methods 

We surveyed a cohort of patients with Morton’s neuroma who had progressed to 

radiofrequency ablation after failed conservative treatment. Patients received either 

2 or 3 cycles of radiofrequency ablation by a single surgeon. We assessed patients 

based on their change in numerical pain rating scale, symptom improvement, 

complications and progression to surgical excision through a series of telephone 

interviews. Outcomes between the two treatment arms were stastically compared. 

Results 

Twenty eight patients were included in the study. Eighteen patients with 21 neuromas 

received 2 cycles and 10 patients with 11 neuromas received 3 cycles. Mean 

time of follow up was 12.9 months. Overall 88% of patients were either very or 

moderately satisfied with their outcome. In patients who received 2 cycles mean 

numerical pain scores decreased from 7.9 +/- 1.1 to 3.4 +/- 2.4 post procedure. 

Three patients progressed to operative excision. In patients who received 3 cycles, 

numerical pain scores decreased from 8.0 +/- 1.0 to 1.5 +/- 2.0 post procedure. 

One patient progressed to operative excision. Patients who received 3 cycles had 

reduced medium term pain post operatively compared to 2 cycles (3.4 +-2.4 vs 1.5 

+- 2.0, p = 0.011). 

Conclusion 

Radiofrequency ablation provides a high rate of patient satisfaction in the treatment 

of Morton’s neuroma with few side effects. It appears that 3 cycles may be superior 

to 2 cycles but a randomised controlled trial will be required to confirm these results. 

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Paper 327 

Presenter: ST Jerry 

Authors: STJ Tsang, LA Mills, J Frantzias, J Baren, JF Keating, AHRW Simpson. 


Abstract title: Exchange nailing for femoral diaphyseal fracture nonunions: 

Risk factors for failure. 

The aim of this study was to identify risk factors for failure of exchange nailing for 

femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with 

femoral diaphyseal non-unions treated by exchange nailing, of which six were open 

injuries. The median time to exchange nailing from primary fixation was 8.4 months. 

The main outcome measures were union, number of secondary fixation procedures 

required to achieve union and time to union. Multiple causes for non-union were found 

in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical 

procedures were required in nine (22.5%) cases, one of whom (2.5%) required the 

use of another fixation modality to achieve union. Union was ultimately achieved 

with exchange nailing in 34/37 (91.9%) patients. The median time to union after 

the exchange nailing was 9.4 months. Cigarette smoking and infection were risk 

factors for failure of exchange nailing. Multivariate analysis found infection to be the 

strongest predictor of exchange failure (p

(34.4%) of infected non-unions healed after one exchange nail procedure. Union was 

ultimately achieved in 89 (87%) cases with repeated exchange nail +/- bone grafting 

only. The median time to union after exchange nailing was 8.7 months. Univariate 

analysis confirmed that an oligotrophic/atrophic pattern of non-union, a bone gap of 

5mm or more and infection were predictive for failure of exchange nailing (p

Conclusion: We showed that our bioreactor is able to guide differentiation of TPC 

into neo-tendon tissue. Autologous tendon cells from biopsy could generate neo-tendon 

tissue in bioreactor system, which hold potentially promising for tendon recosntruction. 

Paper 338 

Presenter: MH Zheng 

Authors: M H Zheng, A Wang, T A. Bucher, T Wang, J R. Ebert, W Breidahl, G C. 

Janes 

Disclosure: Yes: Shares held in Orthocell 

Abstract title: AUTOLOGOUS TENOCYTE THERAPY FOR TREATMENT OF 

TENDINOPATHY: FROM BENCH TO BEDSIDE 

Purpose of Study: Tendinopathies and tendon injuries are the most common soft 

tissue disorders. Currently available conservative treatments are not satisfactory. 

We and others have observed that elevated rates of apoptosis and autophagy of 

tenocytes leading to depletion of the functional tenocyte pool in the region of the 

tear may account for fatigue of the normal healing response. On the basis of the 

pathology studies, we proposed that restoration of the population of functional cells 

capable of synthesizing ECM and repairing the damaged tissue within the tendon 

might be an effective therapeutic strategy for tendon repair. 

Description of Methods: Based on previous pre-clinical cell tracking and animal 

studies, we have developed protocol for the autologous tenocyte injection technique 

(ATI). Patients with chronic, refractory tendinopathy were recruited for study. Patients 

with lateral epicondylitis , gluteal tendionpathy, rotator cuff tendon tear, Achilles 

tendinopathy who have failed for previous injection therapies were recruited into the 

case cohort. A tiny needle tendon biopsy (most often the patellar tendon) was used as 

the source material for autologous tendon cells. The cells are isolated from the tendon 

tissue by enzymatic digestion and expanded in vitro in a GMP-certified laboratory. 

Cell characterisation were conducted to examine the purity, potency, identify and 

viability. Cells are reconstituted in an assembly medium containing autologous serum 

and implanted in the site of tendinopathy by ultrasound-guided injection. Maximum 

follow up of these patients with functional score and MRI were 5 years. 

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Summary of Results: Clinical outcomes were assessed from baseline up to 5 years 

post-treatment. Significant improvements were observed for all of site specific functional 

scores including QuickDASH, UEFS, Oxford hip score VAS maximum pain score and 

grip strength starting from one month post-treatment. These improvements were 

maintained for up to 5 years post-treatment. MRI scores were significantly improved 

up to 12 months post-treatment, and demonstrated tendon in-fill and reduction in 

the extent of tendinopathic lesions in LE, rotator cuff and Achilles but less in gluteal 

tendinopathy. 

272

Conclusion: In conclusion, autologous tendon-derived cells offer a strong advantage 

for tendon tissue regeneration. ATI, the first homologous cell therapy technique 

developed for the treatment of tendinopathy, has the potential to address this unmet 

clinical need by replenishing the pool of functional tenocytes in the site of tendinopathy, 

facilitating structural repair as well as improving pain and function. 

Paper 340 

Presenter: AA Van Zyl 

Authors: AAvan Zyl 


Abstract title: SAVING THE PIRIFORMIS TENDON DURING POSTERIOR 

APPROACH THA - A seven year follow up. 

The posterior approach long been associated with higher dislocation rates compared 

to antero-lateral approach. Resuturing of the posterior structure especially the piriformis 

tendon significantly reduced dislocation rates to comparable rates of antero-lateral 

approaches. 

A recent paper on saving the piriformis tendon has indicated higher stability of THA 

with the posterior approach. 

We investigated saving the piriformis tendon to see if this is possible in all cases 

and if it makes the procedure more difficult. We also report on follow-up, especially 

regarding stability of the hip. 

We report on a 7 years follow-up of 906 posterior approach THA 

– 37% male and 63% female patients. 

Average age 65.6 range. Age 20 – 93 years. 

64% Patients were Charnly grade A or B and 36% grade C. 

Pathology: OA 79%, AVN 7%, Femur neck fracture 8.8%. 

Most hips (84%) had a 28mm head, (3.7%) a 32mm head, (4.7%) a 36mm head 

and (2.2%%) large metal on metal heads (46 – 54mm). 

10 of the hips were resurfacing arthroplasties. 

Complications: 

1. 4 patients (0,47%) dislocated the hip 

2. A dysplastic hip had transient sciatic nerve paresis 

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3. The piriformis tendon pulled out of the muscle belly in one patient that had 

previous proximal femoral osteotomy 

CONCLUSIONS 

1. Saving the piriformis tendon is possible with all THA as well as resurfacing. 

2. It only very slightly made the THA procedure more difficult. 

3. It definitely increased posterior stability as well as aiding in reattaching the 

rest of the posterior structures. 

Paper 352 

Presenter: D Spengler 

Authors: D.M. Spengler 


Abstract title: Musculoskeletal Care for Patients in the United States: 

Which way will the Pendulum Swing? 

The purpose of this presentation is to highlight the past and present status of 

musculoskeletal (MSK) care for patients within the United States that is relevant to 

orthopaedic surgeons. The important issues of medical student education and resident 

education will be examined. The evolving public perception of our profession will be 

discussed along with the evolving decline in job satisfaction among many in our own 

profession. In addition, the effects of emerging health care changes on orthopaedists 

due to the Affordable Care Ace (ACA) will be illuminated. My hope is to stimulate 

and motivate residents, fellows and faculty members to understand the importance 

of the complex issues that our profession faces. We must urge all to take ownership 

and represent Orthopaedics in their communities, in medical schools, to their patients 

and especially to be “at the table” for political advocacy. As an Orthopaedic Political 

Action Committee member elegantly stated, “…if you are not at the table, you will 

likely be on the menu…” 

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The methods used to synthesize appropriate information from the myriad of data 

available has been garnered through the prism of my 50 years in Medicine including 

26 years as Chair of a Department of Orthopaedics. The material that I chose to 

develop my summary and recommendations was based on factual information from 

peer reviewed publications. Unfortunately most of the recommendations currently 

espoused by non-physician administrators are not based on true quality oriented 

outcome metrics. As I will elaborate in the presentation, much of our clinical time 

is now occupied by menial computer tasks and phone calls questioning various 

diagnostic studies and treatment procedures. Some doctors have suggested that 

we are now serving as medical record documenters and billing coordinators for 

insurance companies. Compelling data demonstrate that 40% of a physician’s time is 

spent in front of a computer while only 12% of time is spent face to face with patients! 

274

Based on this study, I recommend the following: 1) Engage with Orthopaedic 

Political Action Committees (PAC’s) 2) Identify areas in Medical Centers and Hospitals 

where costs can be reduced and re-allocated to patient care support areas 3) 

Become involved with your institutional technology group to focus on optimal patient 

care. An example would be to encourage secure computer cross talk so patient 

information can be obtained from computers outside your direct network 4) Lobby 

curriculum committees at Medical Schools to enhance MSK teaching, 5) Additional 

recommendations during talk. 

In conclusion, I remain an optimist and believe that the pendulum will swing in a 

positive direction to enhance patient care, physician satisfaction and MSK education. 

Good news, Medicine still ranks as the most prestigious profession in a recent 2014 

Harris/Nielsen poll. Engage and buck up! 

Paper 353 


Authors: I. Vadiee, D. Walmsley, J.P. Waddell 


Abstract title: The Effect of Distal Femoral Bone Graft on Blood Loss in 

Primary Total Knee Arthroplasty 

PURPOSE: 

The average hidden amount of blood loss in total knee arthroplasty is significant. 

Surgeons have implemented multiple strategies to minimize post-operative blood loss 

in these patients. One of the simple procedures recommended in occlusion of the 

femoral intramedullary canal with intra-operative autologous bone plugs. The goal 

of this study is to evaluate the effectiveness of sealing the distal femoral canal with 

autologous bone graft in reducing hemoglobin drop in the immediate post-operative 

period. 

METHOD: 

A prospective study that included 200 total knee arthroplasty patients divided into 

two groups (100 patients in the bone graft sealed group and 100 patients in the 

unsealed canal group). Hemoglobin levels were measured pre-operatively, 24 and 

72 hours post-operatively. Transfusion rates between the two groups were also 

collected as were short term post-operative complications. 

RESULTS: 

No statistical difference was found with regard to the hemoglobin values between 

the unsealed and the sealed group. Furthermore the transfusion requirements were the 

same as were short term complications including infection and hematoma formation. 

CONCLUSION: 

The use of an autologous bone plug to seal the intramedullary femoral canal during 

total knee arthroplasty does not decrease blood loss in the post-operative period. 

While this procedure is innocuous it also appears to be ineffective and therefore 

should not be compensated. 

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Paper 354 


Authors: G.M.T. Hare, K. Pavenski, E. Schemitsch, J.P. Waddell 


Abstract title: The Effect of Tranexamic Acid on Transfusion Rates, 

Length of Hospital Stay in Total Joint Arthroplasty 

Purpose: 

Anemia is associated with increased risk of organ injury and mortality in non-cardiac 

surgery. Studies have demonstrated that preoperative administration of tranexamic 

acid (TXA) may reduce red blood cell (RBC) transfusion. 

Methods: 

With institutional ethics approval we retrospectively assessed the impact of a quality 

initiative to use a protocol for pre-operative TXA administration in patients undergoing 

total hip and knee arthroplasty between January 1, 2012 and April 30, 2014. 

Patients with known risk factors for thrombosis or seizure were excluded. 

Results: 

We assessed a total of 2,173 patients and observed an overall increase in TXA 

utilization from 37% to 95%. This resulted in an overall reduction in RBC transfusion 

rate from 9% to 5% for all procedures (p

Paper 356 


Authors: D. Walmsley, Z. Morison, A. Nauth, M. McKee, J.P. Waddell, E. 

Schemitsch 


Abstract title: A Case-Control Study of Total Hip Arthroplasty After Failed Proximal 

Femoral Fracture Fixation 

PURPOSE: 

This study investigates the clinical and radiographic outcomes in patients who have 

undergone THA after failed fixation of proximal femoral fractures. 

METHOD: 

This retrospective case-control study compared findings of patients who underwent 

THA after failed open reduction internal fixation (ORIF) of a proximal femoral fracture 

to primary THA for osteoarthritis. Forty patients received a THA after failed internal 

fixation of a proximal femur fracture. Patients were matched for date of operation, 

age, gender, and type of implant to control for confounding effects on outcomes. 

The outcome measurements included length of surgery, drop in hemoglobin, 

length of stay, transfusion rates, complications, dislocations, revisions, and clinical 

outcome scores at latest follow up. Statistical analysis was performed using 

the Student t-test and Chi-squared test with significance set at a P value

CONCLUSION: 

Conversion to THA after failed fixation of proximal femur fractures results in comparable 

clinical results to primary THA but with an increased operative time, blood loss, and 

blood transfusion rate. 

Paper 357 

Presenter: R Leighton 

Authors: R.K. Leighton, J. de Dios Robinson, K. Trask, Y. Bogdan, P. Tornetta III 


Abstract title: Periprosthetic Fractures in Patients on Long Term Bisphosphonates: 

A Multicentre Retrospective Review 

Ross K. Leighton MD; Juan de Dios Robinson MD; Kelly Trask BEng, MSc, CCRP- 

Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada. 

Yelena Bogdan MD; Paul Tornetta III MD- Boston University Medical Centre 

Purpose 

Patients on long-term bisphosphonate therapy are presenting with impending or 

complete periprosthetic fractures which are radiographically identical to atypical 

femoral fractures. We attempt to define the characteristics of periprosthetic fractures in 

patients on long-term bisphosphonates and compare these to atypical femoral fractures 

(AFF). We also describe how they present differently from the usual periprosthetic 

fracture and provide a guide to their diagnosis and treatment. 

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Methods 

All bisphosphonate-related fractures in 15 centres over a ten-year period were 

reviewed. Inclusion criteria were ASBMR Task Force radiographic criteria for atypical 

fracture, long-term bisphosphonate treatment, surgical treatment and six months followup 

or to union or revision. 

Data collected included demographics, medications, prodromal pain, mechanism of 

injury and fracture characteristics. Complications of interest included pneumonia, MI, 

PE, wound infections, death, revision surgery, and time to union. 

Results 

191 patients with AFF were identified, including 21 periprosthetic fractures (PPF). 

All of the PPF patients had prodromal pain. Average age was 80 years for PPF 

and 72 years for AFF. Incidence of prior fragility fractures was low (AFF=19% and 

PPF=18%). Patients had a higher BMI in the PPF group versus the AFF group (33 

vs. 28). Bisphosphonates were discontinued in 55% of the AFF patients following 

278

diagnosis, but only 12% of the PPF patients. Mortality and complications were similar 

to typical periprosthetic fractures. The difference in atypical versus typical PPF resides 

in the presentation of the patient and the fracture. Based on our review we developed 

an algorithm in conjunction with our endocrine and rheumatologic colleagues to aid 

decision making when dealing with this rare presentation. 

Conclusion 

Our review suggests that periprosthetic fractures in patients on long term bisphosphonates 

should be considered a subset of atypical bisphosphonate associated femoral 

fractures. This has implications for clinical decisions in terms of diagnosis, weightbearing 

protocols and treatment. 

Paper 358 


Authors: K. AlAbassi, R.K. Leighton, P. Duffy 


Abstract title: SI Screws—Two Is Better Than One—For Rotational Control and 

Maintenance of Reduction 

SI Screws—Two Is Better Than One—For Rotational Control and Maintenance of 

Reduction 

Khaled AlAbbasi MD; Ross Leighton MD; Paul Duffy MD 

Purpose 

To review all consecutive pelvic ring fractures with SI screw fixation at a level one 

trauma centre in the past 20 years to determine complications and outcomes. 

Method 

Eighty-two consecutive pelvic ring fractures were retrospectively reviewed following 

acute and delayed SI screw fixation for pelvic ring fractures with vertical and rotational 

instability. 

Results 

Lateral compression fractures were the most common, followed by anteriorposterior 

compression, vertical shear and combined. All were treated with 

S1 and/or S2 SI screws with S1 accounting for 90% of the screws performed. 

Three fractures treated with SI screws went onto nonunion but did not displace 

clinically so this made fusion of these areas much easier and did not involve 

complex osteotomies as has been mentioned and detailed in the past. 

279

Only one L5 nerve root injury and two S1 nerve root injuries (one early and one late) 

were present in this series with all types of fractures. The S1 nerve root improved 

but hypersensitivity remained. The L5 nerve root was brace-free at one year but 

only had 50% of normal strength and a very minor sensory deficit. One patient 

had irritation of the S1 nerve root occurring at two months following insertion and 

this improved with screw removal done within two weeks of the initial symptoms. 

Seventy-nine fractures treated with SI screws went onto solid union. Despite 

radiological and clinical union some of these patients still had significant 

complaints and remaining issues due to their pelvic injuries. Erectile dysfunction, 

dyspareunia, urinary issues (particularly in men) plus low back pain remain areas 

of consistent worry for the patients and demand our diagnostic skills and treatment 

plus those of our urological colleagues and rehabilitation and pain clinic experts. 

This union rate is marginally better than most in the literature and the two-screw 

construct is the only real difference with most large series. 

Conclusion 

SI screws have stood the test of time and remain the treatment of choice for posterior 

complex injuries of the pelvic ring. This series illustrates the safety and mechanical 

strength of the two-screw construct in pelvic ring injuries. The analogy to femoral 

locking nails is compelling; two screws are usually better than one for rotational 

control and superior axial strength. 

Paper 359 


Authors: R.K. Leighton, J. Robinson, V. Chatrath, S. MacDonald, K. Trask 

Disclosure: Yes: Synthes plates were used and given by company at no cost 

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Abstract title: Biomechanical Study To Determine Optimal Fixation For Vancouver 

Type B1 Periprosthetic Fractures 

Ross Leighton MD, Juan Robinson MD, Vikram Chatrath MD, Shelley MacDonald, 

Kelly Trask QEII Health Sciences Centre, Halifax, NS, Canada 

Purpose: Periprosthetic fractures are difficult to manage. A well-secured femoral stem 

in Vancouver B1 fractures limits plate fixation to unicortical screws or cables. The first 

technique limits the strength of the construct, while the second disrupts soft tissues and 

periosteal blood supply. Our hypothesis is that the 3.5mm Locking Attachment Plate 

(LAP) will increase the strength of the construct compared to other fixation methods. 

Methods: Thirty synthetic femurs were prepared to simulate a cemented Total Hip 

Arthroplasty (THA). A short oblique fracture was created just distal to the implant. 

Fourteen-hole 4.5 mm Dynamic Compression Locking Plates were applied to the 

femurs. All plates had bicortical screws distal to the fracture site. Proximally, the five 

280

constructs, described from greater trochanter to the fracture, are: 

Group 1: six 5.0 mm unicortical locking screws (ULS) 

Group 2: one 18-guage cerclage wire - three ULS - one 18-guage cerclage wire 

Group 3: one 3.5 mm LAP (2 screws) - three ULS - one 3.5 mm LAP (2 screws) 

Group 4: two ULS - one LAP device (2 screws) – two ULS 

Group 5: two ULS - one LAP device (4 screws) – two ULS 

Samples were loaded in axial compression and torsion using an Instron hydraulic test 

apparatus. Load versus displacement data was recorded and compared to determine 

the overall construct stiffness. Results were analyzed using ANOVA and the Student- 

Newman-Keuls test for multiple comparisons. 

Results: Group 1 was stiffest in torsion (p

Results: The mean follow-up was 36 months. Average preoperative retroversion 

measured with CT scan was 23.5°. In addition to statistically significant increases 

in forward flexion and external rotation, the VAS, WOOS and physical component 

summary of the SF-36 all improved significantly (p < 0.001). Twelve shoulders had 

osseous integration between the central peg flanges, six had bone adjacent to the 

central peg flanges but without identifiable osseous integration and one demonstrated 

osteolysis. The mean Lazarus score was 0.5. All had perfect seating scores. Two 

patients sustained a total of 3 episodes of prosthetic instability. 

Conclusions: Early results of a posteriorly augmented all polyethylene prosthetic 

glenoid component to address posterior glenoid loss in TSA are encouraging. 

Continued evaluation will determine prosthetic longevity and maintained clinical 

improvement. 

Level of evidence: Level IV, Case Series, Treatment Study 

Paper 363 

Presenter: MN Rasool 

Authors: MN Rasool 


Abstract title: Pyogenic osteomyelitis of the forearm bones in children 

INTRODUCTION 

The radius and ulna are rare sites for haematogenous osteomyelitis. Chronic infection 

can result in pathological fracture of the radioulnar joints due to unequal growth. 

Aim 

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To highlight the sequelae of osteomyelitis of the forearm bones in children. 

Methods 

Fourteen children, aged 1-10 years, with staphylococcal aureus pyogenic osteomyelitis 

of the forearm bones, were reviewed retrospectively. The radius was involved in 

seven patients, the ulna in six and both bones in one child. Three children had acute 

osteomyelitis; the remaining 11 had features of chronic osteomyelitis. 

Treatment 

The acute infections had incision and drainage and healed well. In eight patients 

with chronic osteomyelitis, treatment involved debridement and sequestrectomy, with 

resulting bone defects. Three children were referred with established defects from 

outlying hospitals. 

282

Iliac bone chips were used to fill defects

1.28mm). Fibrosis extended into the subcutis in a septolobular fashion in 95% of 

the cases. Significant atrophy of eccrine glands was seen in 98% (P = .001). Hair 

follicles were absent in 78%. The elastic fibres of clubfoot skin, stained with Elastic 

van Gieson staining (EVG), showed hypertrophy in varying degrees in all skin 

specimens. They were fragmented, with loss of their parallel arrangement. There was 

no significant inflammatory reaction in the dermis. The Pirani score was significantly 

increased (mean 7.8). 

Discussion: 

Fibrosis and thickening of the dermis was the most significant histopathological 

feature of the clubfoot skin. The elastic fibres were also abnormal. There was atrophy 

of the skin appendages due to the fibrosis. There was a strong correlation between 

the Pirani score and the severity of the deformity. Lack of a significant inflammatory 

reaction suggests that neither the serial manipulations of the foot, nor the repeated 

plaster cast changes, were responsible for the dermal fibrosis, which is probably 

present from birth and contributes to the deformity. 

Paper 365 

Presenter: V Finsen 

Authors: V Finsen, C Bendiksen Wold, H Russwurm 


Abstract title: CLUMSINESS. A COMPLICATION OF TRAPEZIECTOMY FOR ARTROSIS 

OF THE BASAL JOINT OF THE THUMB? 

Background: Because of favourable reports we changed from abductor pollicis 

longus suspension-arthroplasty to simple excision of the trapezium as our standard 

procedure for arthrosis of the basal joint of the thumb in 2010. We recently reviewed 

45 patients with 49 operated hands clinically 15-26 months after surgery and some 

patients told us spontaneously that they felt that the hand was clumsier than before 

surgery. 

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Methods: All 45 patients were contacted by telephone and answered a structured 

questionnaire. 

Results: 20 patients (21 hands) replied that they were clumsier than before surgery. 

They had trouble performing such activities as threading a needle, sowing, 

buttoning a blouse or shirt, turning over the pages of a newspaper, or picking 

up small objects. On a scale from 0 to 10 these patients reported a mean value 

of 7 (SD 2.0) for present clumsiness, compared to 1 (SD 2.4) for remembered 

preoperative clumsiness. Difficulty in picking up a matchstick from a flat surface 

was rated as 6 (SD 3.4), and with buttoning a blouse or shirt as 5 (SD 3.1). It 

made no difference if the patients were watching what they were doing or not. 

When compared to the 28 hands that were not reported as clumsy we found 

284

no significant difference in time since surgery, remembered preoperative pain or 

clumsiness, days of postoperative immobilization, present pain, adduction of the 

first ray, hyperextension of the thumb MCP joint, or radiological interval between 

the scaphoid and the first metacarpal. There was borderline significant differences 

in mean age at operation (p=0.09) and mean first ray abduction (p=0.07) and 

statistically significant mean differences at review in Quick-DASH and PRWHE scores, 

and power and key grip. For seven of the 21 hands reported as clumsy the patients 

stated that they would not have undergone surgery if they had known the outcome 

in advance. This was the case only for two of the 28 not clumsy hands (p=0.03). 

Discussion: We have not seen this complication after surgery for basal joint arthrosis 

reported in the literature. It would be useful if clumsiness were included in later reviews 

of the results after this type of surgery in order to determine whether it also occurs after 

suspension arthroplasty or is a problem particularly after simple excision of the trapezium. 

Paper 368 

Presenter: N Helmy 

Authors: Helmy N, Antoniadis A, Schaer, MO Camenzind RS 

Disclosure: Yes: Research grant from Mathys European Orthopedics 

Abstract title: No correlation of anatomically restored femoroacetabular offset to 

clinical results. Mid- term results of a short-stem in combination with a monoblock 

pressfit cup 


Investigate the ability of a short stem/monoblock combination for THA, to restore 

patients anatomy and correlate it to the clinical outcome in patients with the direct 

anterior approach 

Methods 

Prospective clinical study with 120 patients (56 female, 64 male) mean age 66 

(range, 43 – 87) mean follow-up (FU) of 21 (SD 4; median 24). Implants used were 

uncemented RM pressfit cup (Vitamys) and uncemented short-stem (Optimys) (Mathys 

Ltd. Bettlach, Switzerland). Femoroacetabular offset (FAO) was defined as the result 

of femoral offset (FO) and acetabular offset (AO). All radiological parameters were 

compared to the non-operated, healthy hip. Clinical parameters were: Harris hip 

score (HHS) and pain during rest and load (VAS). A sample size of 106 cases was 

calculated to have a power of 80%. 

Results 

HHS improved from 53 to 97 (p < 0.0001), VAS for rest decreased from 4.4 to 

0.3 (p < 0.0001), VAS for load decreased from 7 to 0.6 (p < 0.0001) and overall 

satisfaction increased from 3 to 9.3 (p < 0.0001). On average the healthy leg was 

285

1.0mm (SD 6.2) shorter than the operated side (p = 0.045). The FO decreased by 

a mean of 5.8mm (SD 7.3) (p

Background and Aims: 

In high income countries, survival rates of patients with osteosarcoma in excess of 

60% are well documented and limb salvage is considered standard-of-care. The 

sparse South African literature reflects dismal survival rates. The purpose of this study 

was to assess presentation characteristics, prognostic factors and long-term outcomes 

of children treated for osteosarcoma in order to plan improvements. 

Methods: 

Patient files were reviewed at three centres: Chris Hani Baragwanath Academic 

Hospital, Charlotte Maxeke Johannesburg Academic Hospital and Wits Donald 

Gordon Medical Centre. The following factors were analysed in relation to survival: 

sex, levels of alkaline phosphatase and lactate dehydrogenase, type of surgery and 

level of amputation. Statistical analysis was performed using Kaplan-Meier survival 

analysis and the Cox regression model. 

Results: 

A retrospective audit was performed on consecutive patients under the age of 18 

presenting to two state hospitals and one private hospital between November 1987 

and August 2013. 104 patients with histologically proven OS were identified, of 

which 56 were female, 48 were male and the median age at diagnosis was 13 

years (range 2.8 to 18 years). The median duration of presenting symptoms was 90 

days (range 14 – 420 days) and the majority of patients presented with elevated 

levels of alkaline phosphatase (AP) (75%) and lactate dehydrogenase (LDH) (64%). 

More than a third (36%) presented with metastatic disease. Definitive surgery was 

recorded in 57 patients and comprised 10 joint disarticulations (17.5%), 29 above 

knee amputations (50.9%), 3 below knee amputations (5.3%) and 15 limb salvage 

procedures (26.3%). Twenty eight (27%) patients were palliated medically, including 

13 (13%) who refused surgery. 

The 5 year overall survival (OS) rate was 37%, with an intent-to-treat analysis OS of 

48 %. High levels of LDH and AP did not confer poorer prognosis. There was not a 

statistically significant difference in survival between patients who had limb salvage 

versus amputation. 

Conclusion: 

The low rate of limb salvage procedures reflects the high number of patients who 

presented with large tumours and it is notable that limb salvage procedures did not 

affect prognosis adversely in this cohort. The OS is higher than that documented in 

other South African series but it is essential that every effort be made to improve this 

statistic. Education and outreach programmes are planned to increase appropriate 

referrals to specialist centres with the aim of improving both survival rates and quality 

of life. 

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Paper 373 

Presenter: N Morton 

Authors: N. Morton, H.M. Phen, J. Kassam, P. Sadigh, P. Bates 


Abstract title: A Retrospective Analysis of 304 Open Tibial Fractures: Adherence 

to National Guidelines vs Clinical Outcomes and the importance of ‘Orthoplastic’ 

Expertise. 

Intro: Severe open lower limb fractures require successful collaboration between 

orthopaedic and plastic surgeons to achieve the best possible outcomes. So-called 

‘BOAST4’ guidelines in the UK are now nationally embedded in the everyday 

management of open tibial fractures. 

Aim: This study investigates whether adherence to these national guidelines actually 

influences clinical outcomes and whether a trauma-dedicated plastic surgeon affects 

outcomes, independent of the guidelines. 

Methods: Retrospective review of prospectively collected data was carried out on 

304 open tibial fractures, treated over 4-years in a Level 1 centre. Data collection 

was ethically approved. 3 key guidelines were studied: 

· Antibiotics given within 3hours of injury 

· Wound debridement within 24hours of injury 

· Definitive wound cover within 72hours of injury 

Outcomes included infection (deep and superficial), bony union and flap failure. Subgroups 

were compared before and after recruitment of a trauma-specialised plastic 

surgeon. 

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Results: 51 patients (17%) were lost to long-term follow-up. Compliance to all 

guidelines was 54%. The commonest cause for non-compliance was failure to debride 

within 24 hours. Compliance regarding soft tissue coverage within 72-hrs was 81% 

and antibiotic compliance was 97%. 

Median length of stay was significantly shorter in compliant patients but bony union 

was unchanged. 

After correcting for ISS, there was no difference in deep infection between those 

debrided before or after 24 hours. 

Flap failure rate was 4.2% (3), all of which occurred in patients definitively closed 

>72 hours (p

closure wasn’t performed within 72 hours (p

equires sub-specialist skills in sepsis and reconstructive surgery. Through a staged 

approach and with the use of circular external fixation, sepsis can be cleared, union 

achieved, and upper limb function restored. 

Paper 375 

Presenter: MN Bismilla 

Authors: Mn.Bismilla, A.AIDEN, T.Sefeane 


Abstract title: outcomes of radial head replacement in mason 3 and 4 fractures 

Introduction 

Fractures of the radial head are classified according to the Mason System modified 

by Johnston. Fractures of the Mason Type 3 and 4 are complex and management is 

controversial. 

ORIF can be Techniquley Challenging and outcomes with radial head resection are 

poor. Studies have shown radial head replacement to have good outcomes in the 

short term. Limited long term follow up is available: 

METHODS 

The study is a retrospective review of Mason type 3 and 4 radial head fractures 

treated at a single Hospital between 2001 to 2013 with immediate prosthetic 

implantation. Orthopaedic records were reviewed in patients at least 12 months 

post surgery. Information from records regarding patient demographics and surgical 

procedures were recorded on a demographic and surgery form. Participants were 

contacted for permission to view files as well as to complete a questionnaire. The 

questionnaire was based on Mayo Performance elbow score. Participants were also 

physically examined and interviewed by the researcher by appointment. Outcomes 

function, range of movement, pain and instability were assesed. 

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Results: With a mean of 3 year follow up 15 patients were assesed. 12 patients had 

good to excellent outcomes with 3 patients having poor outcomes. One patient had 

a radial nerve palsy. 

Conclusion: Radial head replacement is a good option for complex mason 3 and 4 

radial head fractures. 

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Paper 376 

Presenter: A Chauhan 

Authors: A. Chauhan, K. Singisetti, Z. Abual-Rub, A. Middleton(AM) 


Abstract title: High risk of reoperation for metal work removal following medial 

distal tibia plating 

High risk of reoperation for metal work removal following medial distal tibia 

plating 

Purpose of study - Fractures of the distal third of tibia are difficult injuries to treat. The 

treatment options include closed reduction and casting, external fixation, intramedullary 

nailing, open reduction internal fixation, and minimally invasive percutaneous plate 

osteosynthesis (MIPPO). Surgical fixation remains controversial. Selection of surgical 

technique depends on fracture pattern, soft tissue injury and bone quality. Use of 

locking plates for stabilisation of distal tibia fractures has recently become popular but 

is associated with its unique problems. The aim of this study was to evaluate the rate 

of secondary surgical intervention and revision surgery following distal tibia fracture 

fixation with low profile distal medial tibia locking compression plate (LCP). 

Description of Methods - Retrospective analysis of case notes was performed for 

patients with distal tibia fracture treated by LCP. Fifty three cases of closed extraarticular 

distal tibia fractures were treated by low profile distal medial tibia LCP using 

MIPPO Technique over a period of 6 years. Inclusion criteria for the study was age 

equal or more than 15 years and closed extra-articular distal tibial fractures. Open 

injuries, intra-articular and pathological fracture types were excluded from the study. 

Fractures were classified according to AO classification. After closed or indirect 

fracture reduction techniques, fracture was fixed with a low profile distal medial 

tibial locking compression plate using MIPPO technique. Postoperatively, a standard 

follow up protocol was followed with non- weight bearing for first 6 weeks, partial for 

another 6 weeks, and full weight bearing allowed at 12 weeks. 

Summary of Results - Out of total of fifty-three patients(34 male, 19 female; average 

age: 46.75 years; range: 15 to 93 years), forty one(about 77%) underwent 

early(within 24 hours) while twelve patients(about 23%) had a delayed surgical 

intervention due to soft tissue swelling. Of these twelve patients, eight underwent 

surgery on day 4, three on day 5 and one patient on day 6. Complications were 

recorded in ten patients(18.86%). Three patients needed revision surgery including 

bone grafting. 14 patients (35%) had removal of metal work at a mean of 18 months 

due to either prominent or broken metal work and infection. 

Conclusion- We would like to highlight the high incidence of reoperation, particularly 

metalwork removal, and revision in our study. Preoperative counselling regarding 

the risk of revision and reoperation procedures is important and should form part of 

informed consent process. 

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Paper 377 

Presenter: P Favorito 

Authors: P. Favorito, G. Athwal, R. Meislin, C. Getz, D. Weinstein 

Disclosure: Yes: I am a consultant for both Depuy Synthes and Mitek Sports 

Medicine 

Abstract title: Early Problems and Complications after the Arthroscopic Latarjet 

Procedure: A North American Experience 

Purpose: The purpose of this study was to report on the intraoperative and early 

postoperative (

Paper 378 

Presenter: A Naidoo 

Authors: A Naidoo , MN Rasool 


Abstract title: Perthes Varizing Osteotomy 

Purpose of Study The aim of operative treatment of Perthes Disease is for containment 

of the femoral head and allowing it to develop by preventing further deformation. 

We evaluate the use of an open wedge varus osteotomy and bone graft stabilised 

with a plate in 14 children, and the radiological and clinical outcomes Materials 

and Methods Fourteen children between the ages of 6 and 10 years old with Perthes 

Disease were included in the study. They were treated between 2011 and 2015 by 

arthrogram, adductor tenotomy and Varizing osteotomy with opening wedge . An 

iliac crest graft was harvested and stabilised with a plate including epiphysisiodesis 

of the greater trochanter . A hip spica was applied for 6 weeks and thereafter 

weightbearing encouraged.Their clinical and radiological findings were assessed 

and documented preop and postop. Results There were 11 boys and 3 girls. The 

girls presented at an earlier age than the boys. Leg length discrepancy improved in all 

patients with a gradual improvement in range of movement of the hip. Radiographs 

showed containment of the head with remodeling as the head healed . One patient 

complicated with chondrolysis 5/12 post op. Conclusion The varizing osteotomy is 

a useful procedure for containment of the femoral head 

Paper 379 

Presenter: P Bates 

Authors: H Arshad, F Malagdela, P Bates, P Culpan 

Disclosure: Yes: Paul Culpan has a consulting contract with ITS 

Abstract title: Acute Fixation and Total Hip Replacement for the Management of 

Acetabular Fractures in Patients over 55 


Acute total hip replacement (THR) has become popular as a treatment for older 

patients with acetabular fractures as it enables earlier weight-bearing and return to 

good function. When THR is used for post-traumatic hip osteoarthritis, the procedure 

can be more difficult and there is an interval of pain, stiffness and poor function for 

the patient. For acute THR, there is controversy relating to higher complication rates 

including infection, loosening and revision surgery. We report the functional outcome 

and complications experienced by patients who sustained an acetabular fracture and 

underwent open reduction and internal fixation (ORIF) plus acute THR. 

293

Description of Methods 

A prospective review was performed in our Level-1 Major Trauma Centre of patients 

over the age of 55 sustaining an acetabular fracture (age range 55 to 98). Patients 

completed a Merle d’Aubigné (MA) questionnaire and the Short Form 36 Health 

Survey (SF-36) at their follow-up appointments. 

Summary of Results 

A total of 24 hips (22 patients) were treated with acute ORIF and THR with a mean 

age of 76.4 years. All of these patients had a combined fracture pattern. ORIF and 

THR were performed through a single Kocher Langenbeck (KL) approach or a Stoppa 

and a KL approach either under the same anaesthetic or as a staged procedure 

within 7 days. The mean follow-up for acutely-treated patients was 16 months (range 

10 to 40 months). The mean operative time was 255 minutes (range 180-390) and 

the mean intraoperative blood loss was 929 mL (range 400-2000). The majority of 

patients were independent ambulators at most recent follow-up. 

Conclusion 

Acute ORIF and THR is an effective treatment method for older patients who have 

sustained an acetabular fracture. This study suggests that the treatment is associated 

with a higher complication rate than elective primary THR surgery. Satisfactory 

outcomes were associated with adherence to the principles of THR for acetabular 

fracture. These include sufficient lateralisation of the centre of rotation, maximal 

bony contact with the acetabular implant, maximal fixation of implant to bone and 

restoration of stability. The cases illustrate that at least one of these principles was 

compromised in the patients with complications. We favour a trabecular metal system 

which offers versatility in acetabular implant positioning with independent adjustment 

of lateralisation, anteversion and closure. 

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Paper 380 

Presenter: M Al Muderis 

Authors: A Khemka, S Lord, S Wilmot, B Bosley, M Al Muderis 


Abstract title: EVALUATION OF BONE MINERAL DENSITY CHANGES AFTER 

OSSEOINTEGRATION – A CASE SERIES 

Background 

Approximately one third of all amputees suffer from chronic problems due to the 

socket interface of their prosthesis. These problems often cause serious limitations 

to patient’s mobility and quality of life. Despite new technologies in materials and 

sockets design, socket interface problems remain a significant burden. Studies have 

294

shown early bone loss, decrease in cortical bone width, ipsilateral hip arthritis and 

concomitant osteoporosis in an amputee due to the nature of the bony residuum and 

the lack of weight bearing through the residual bone. 

Osseointegration provides a direct anchorage of the artificial limb to the bone, via a 

transcutaneous connection. This technology is designed to eliminate socket interface 

problems by providing immediate mechanical stability with press-fit technique at 

implantation and long-term stability by osseointegration. Multiple studies have shown 

that osseointegration offers a superior biomechanical solution but there is limited 

evidence related to bone mineral density after osseointegration. 

Methods 

We present a retrospective case series of 12 unilateral trans femoral amputees 

who underwent osseointegration between 2012 and 2014 using a press-fit type of 

implantation. The bone mineral density (BMD) outcomes were measured baseline and 

a minimum of 12 months. 

Results 

12 patients were followed up for a median of 26 (range: 12 – 36) months. The 

mean improvement in the BMD and the T-score on the ipsilateral side was 0.12 gm/ 

cm 2 and 1 point respectively. The BMD and the T-score when compared between the 

affected and the normal side improved from a mean difference of 0.21 gm/cm 2 and 

2.25 points to 0.07 gm/cm 2 and 1.1 point respectively. 

Conclusion 

We propose that osseointegration with press-fit implantation for trans femoral 

amputees improves the BMD in the affected limb and makes it more comparable to 

the contralateral side as early as one year. 

Paper 381 

Presenter: M Al Muderis 

Authors: A Khemka, O Maograby, S Lord, Z Doyle, B Bosley, M Al Muderis 


Abstract title: Total Hip Arthroplasty By The Direct Anterior Approach Using A 

Neck Preserving Prosthesis – Clinical Outcomes and a Learning Curve 

Introduction 

Neck preserving prostheses (NPP) have been developed to retain the femoral 

neck, thereby minimise resection, restoring physiological loading of the 

femur, reproducing neck anteversion and potentially improving long-term survival of 

the implant when compared to conventional prostheses. Their success relies on the 

295

precise positioning and sizing but there is limited evidence about their safety and 

effectiveness. 

Method 

Our first 138 cases of total hip arthroplasty using a NPP by a single surgeon were 

analyzed prospectively. All patients with Dorr A or B type of proximal femur were 

included with no age restriction. All patients received a combination of the Trinity 

Acetabular Cup and the MiniHip Stem. The cohort was further subdivided into two 

groups of 69 patients each based on order of recruitment. Outcome assessment 

included clinical (Oxford Hip Score - OHS, Short Form 36 Health Survey – SF 36), 

radiological (horizontal femoral offset, radiolucency, bone resorption, stress shielding, 

subsidence, migration, dislocation and heterotrophic ossification) and operative 

evaluation (sizing, operative time, blood loss, and intra-operative fractures). These 

outcomes were measured for both sub groups and then compared and statistically 

analyzed. 

Results 

89 patients were followed up for a minimum of 24 (24 - 65) months. The OHS 

and the SF 36 (Physical Condition Summary) scores improved by 26 and 29 points 

respectively. Radiological follow up showed absence of radioloucency, osteolysis, 

stress shielding, migration and heterotrophic ossification in all patients. Major 

complications included 1 case of subsidence, 1 dislocation, and 5 intra-operative 

neck fractures. Further a comparative analysis the entire cohort suggested all major 

complications occurred in the first sub group. Additionally, the second sub group 

showed a significant reduction in operative time. 

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Conclusions 

We propose that using NPP utilizing the direct anterior approach is safe, effective 

and a reliable treatment for active patients but with a steep learning curve interrelated 

with familiarity of implant design and approach. 

Paper 383 

Presenter: J Stoney 

Authors: JD Stoney, RN De Steiger, L Kelly, SE Graves 


Abstract title: The Birmingham Hip Resurfacing (BHR) does not have a lower 

revision rate than the best conventional total hip replacements (THR) in men 

under the age of 65 in the Australian Orthopaedic Association National Joint 

Replacement Registry (AOANJRR) 

296

Introduction 

The BHR has a lower revision rate than many other brands of metal on metal hip 

resurfacing in the AOANJRR. It has been suggested that revision rates for the BHR are 

as good as or better than a conventional THR in the target demographic of younger 

male patients. 

Aim 

To compare the revision rate of the BHR to commonly used conventional THR in male 

patients under the age of 65 with osteoarthritis using data from the AOANJRR. 

Methods 

7371 BHRs implanted between September 1999 and 31 st December 2014 in 

men less than 65 were analysed and compared to the outcomes of commonly used 

cemented and cementless THR combinations. The primary outcome measure was 

time to first revision estimated using the Kaplan-Meier method and expressed as 

the cumulative percent revised (CPR). Hazard ratios derived from Cox proportional 

hazard models were used to compare rates of revision. 

Results 

253 out of the 7371 BHR prostheses were revised. The CPR for BHR at ten years 

was 4.1% (95% CI 3.6 to 4.7) and 5.7% (95%CI 4.9, 6.5) at 14 years. Over the 

same period 36390 THR were implanted and 1078 of these were revised. The 

CPR for all conventional THR at ten years was 4.9% (95% CI 4.5 to 5.2) and 6.5% 

(95%CI 5.7, 7.4) at 14 years. The difference was not significant (Hazard ratio(HR) 

1.11, P=0.174) The CPR for all conventional THR includes a number of prostheses 

with higher than anticipated revision rates. When the ten THR with the lowest revision 

rates were combined, the CPR was 3.8% (95% CI 3.3 to 4.4) at 10 years and 

4.8% (95%CI 3.7,6.1) at 14 years. The difference was not significant (HR=0.70, 

P=0.065) 

There were differences in the reason for revision and the types of revision performed. 

All BHR revisions were major revisions. The BHR was more likely to be revised for 

fracture, loosening or metal related pathology. Conventional THR had a mixture of 

major and minor revisions. Conventional THR were more likely to be revised for 

dislocation or infection. 

Conclusion 

The Birmingham Hip Resurfacing did not have a lower revision rate than the best 

conventional total hip replacements in men under the age of 65 in the AOANJRR. 

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Paper 384 

Presenter: N Helmy 

Authors: Helmy N, Fleck M, Camenzind R, Antoniadis A, Schaer M 

Disclosure: Yes: Research funding from Mathys European Orthopedics 

Abstract title: Factors influencing the stem migration rate after implantation of a 

short-stem hip implant 

Introduction 

Short-stem hip prostheses are designed to improve load transmission due to their 

metaphyseal anchoring. They furthermore preserve femoral bone stock. We evaluated 

a metaphyseal anchored short-stem hip implant using Ein Bild Roentgen Analyse 

femoral component analysis (EBRA-FCA). The aim of this study was to investigate 

the two year subsidence pattern and rates of the above mentioned cementless shortstem. 

Our hypothesis was that the stem shows acceptable subsidence rates that are 

comparable with other stems. 

Methods 

This prospective single-surgeon series was approved by the local ethical committee. 

Between March 2011 and August 2012, 71 consecutive patients (mean age at 

surgery: 63.9 years (range: 37.9 – 87.8 years)) were included into this study. The 

study sample included one bilateral and 70 unilateral hips. During this time, 31 left 

hips (43.1%) and 41 right hips (56.9%) were replaced. Subsidence was assessed 

using EBRA-FCA assessment 3, 12, and 24 months postoperative. 

Results 

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In 1 out if 72 hips one intraoperative complication occurred and treated accordingly 

(fracture). This case was not excluded in the follow-up. At last f- 

up 23.3+/-3.3 months postoperative, none of the implants had to be revised. Most 

of the migration occurred during the first 12 months postoperative. The average stem 

subsidence was -1.18 +/- 0.99 mm 3 months, -1.98 +/- 1.49 mm 12 months, and 

-2.38 +/- 1.96 mm at last follow-up 24 months postoperative. Five of these patients 

showed subsidence of more than 5 mm with the highest subsidence being -9.67 mm 

at last follow-up. These five stems were felt to be undersized by an order of 1-2 

stem sizes. Patients older than 65 years showed a non-significant higher migration 

compared to patients than 65 years (age 65 

years: 2.65+/-2.17, p=0.252) 

Discussion 

The short-stem hip implant showed a satisfactory degree of stability up to 2 years 

postoperative. The presented subsidence rate is comparable to conventional hip implants 

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We found undersized stem implantation to be one of the main factors for increased 

subsidence rates up to 2 years postoperative. Therefore, surgeons should be cautious 

not to implant undersized stems. Further studies are necessary to investigate long-term 

subsidence rates when using this implant. 

Paper 385 

Presenter: N Orpen 

Authors: Neil M Orpen 


Abstract title: Early results of a minimally invasive spinal fusion technique with 

mediolateral pedicle screws 

Introduction: As new techniques for minimally invasive fusion of the lumbar spine 

develop we are faced with the need to explore the outcomes both clinically and 

in comparison to what already exists in the literature for more conventional surgical 

procedures which essentially form the gold standard. It is important that in the quest 

for less invasive methods we don’t compromise clinical outcome or increase the 

surgical risks. 

Aim: We explore the early clinical outcomes of this newer technique using a 

mediolateral screw position for pedicle screws with a traditional inter body fusion 

for the management of patients with lower back pain and/ or sciatic pain, and 

specifically report surgical complications. 

Materials and Methods: The first 100 patients treated with this technique have been 

prospectively monitored regarding clinical progress using standard and recognised 

self assessed outcome tools using the British Spinal Registry. All patients completed 

ODI, VAS for pain, EQ-5D before surgery and then at intervals 6 weeks, 6 months, 1 

year and 2 years post operatively. Secondary assessments of surgical complications, 

revision surgery, operating time were also made. 

Results: This technique showed excellent results during follow-up with one revision 

operation during the follow-up period for a late repair of a pseudomengocoel. No 

patients underwent revision surgery for misplaced screws. Clinical improvement was 

progressive for back pain with continued improvement up to two years and early 

improvement in radicular pain was noted which was maintained at 2 years. 

Conclusion: This newer technique showed excellent results during this early follow-up 

assessment and proves to be a good alternative to traditional open posterior lumbar 

spinal fusion with short operating time, rapid recovery form surgery and no new 

or unexpected additional complications compared to traditional fusion techniques. 

Patients typically experience early improvement in radicular symptoms which is 

maintained over the longer term. Back pain improves continuously and progressively 

up till two years. 

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Paper 389 

Presenter: P Holland 

Authors: H. Ingoe, P. Holland, P. Cowling, P. Baker, L. Kottam, A. Rangan 


Abstract title: Intraoperative Complications During Primary Shoulder Arthroplasty 

Introduction 

The number of shoulder arthroplasties being performed is increasing, as evidenced 

by international shoulder registries. The incidence and predictors of intra-operative 

complications when implanting a primary shoulder arthroplasty are unknown. We 

report an analysis of complications and the associated risk factors from 13078 

arthroplasties from the National Joint Registry (NJR). 

Methods 

Applications were made to access anonymised NJR data on all patients who had 

undergone a primary shoulder arthroplasty between 1 st March 2011 and 31 st March 

2015. The outcome of interest being investigated was intraoperative complications 

as recorded on the NJR minimum data set. We performed two analyses; the first 

examined the incidence and predictors of any recorded complication; the second 

examined the incidence and predictors for only intraoperative fractures. Analyses 

were performed using multivariate binary logistic regression modelling. 

Results 

There were 3821 (29%) conventional total shoulder arthroplasties (TSA), 2415 (19%) 

resurfacing hemiarthroplasties, 4761 (36%) reverse TSA and 2081 (16%) stemmed 

hemiarthroplasties. There were 335 (2.6%) intraoperative complications of which 

213 (1.6%) were fractures. 

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The incidence of any complication and intraoperative fractures was lower in male 

patients (RR vs Females = 0.63 (p=0.002) and 0.51 (p=0.001) respectively). Patients 

undergoing surgery for AVN (RR = 2.33 (p=0.005)) or the sequelae of trauma (RR 

= 1.61 (p=0.04) had a higher risk of any complication compared to osteoarthritis 

and patients undergoing a stemmed hemiarthroplasty (RR = 1.78 (p=0.006) had a 

higher risk of complications compared to TSA. The incidence of any complication and 

intraoperative fractures was reduced when patients were undergoing a resurfacing 

hemiarthroplasty (vs TSA (both p

Discussion 

This is the largest study of intraoperative complications during primary shoulder 

arthroplasty to date. We found the incidence of intraoperative complications to be 

2.6%. 

We found several previously unidentified risk factors for complications. This will 

enable surgeons to make informed decisions about their practice and better inform 

their patients. It will also enable organisations reporting surgeons’ complication rates 

to accurately allow for risk adjustment. 

Paper 390 

Presenter: P Holland 

Authors: P. Holland, H. Ingoe, E Torrance, L. Funk 


Abstract title: Shoulder Injuries to Canoers and Kayakers 

Introduction 

Paddlers use their shoulders in a unique way and place high demands on them. This 

makes the shoulder the most commonly injured joint amongst paddlers. 

Aim 

We report the largest case series of serious shoulder injuries amongst paddlers so 

far, to establish common mechanisms and patterns of injury. We also discuss how the 

management of these injuries. 

Methods 

Fifty-five shoulder injuries to professional and recreational paddlers were reviewed at 

a mean follow up time of 45.4 months from first consultation (range 25 - 72 months). 

The patient cohort had a mean age of 36.22±15.22 and consisted of 56.36% 

males (n=31). Patient data was analysed with regards to Constant, QuickDASH and 

VAS satisfaction scores both pre- and post-procedure. 

Results 

The most common mechanism of injury was a capsize which accounted for 27% of 

injuries (n=15). The most common injury was a labral tear requiring repair, which 

accounted for 42% of injuries (n=23). A significant improvement in patient outcome 

scores was noted, with regards to QuickDASH (p=0.0162) and Constant shoulder 

scores (p=0.0078). Patients were able to return to a high level of paddling such as 

two slalom paddlers who returned to international competition; one of whom had 

bilateral surgery. 

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Conclusion 

Paddlers most commonly injure their shoulder during a capsize or roll. The most 

common injury is a labral tear. Surgical repair results in good outcomes and return 

to sport. 

Paper 391 

Presenter: S Campi 

Authors: S. Campi, H. Pandit, G. Hooper, D. Snell, C. Jenkins, C.A.F Dodd, R. 

Maxwell, D.W. Murray 

Disclosure: Yes: Some of the Authors receive financial support from Zimmer Biomet 

Abstract title: Ten-year results of minimally invasive cementless Oxford phase 3 

unicompartmental knee replacement. 

Introduction 

Cementless fixation is an alternative to cemented unicompartmental knee replacement 

(UKR), with potential advantages including avoidance of technical errors related to 

cementation, faster surgical time, reduced incidence of radiolucencies and improved 

fixation. However, no 10-year survival and outcome studies have been published so 

far. The aim of the study is to determine the complication rate, the clinical outcome and 

the 10-year survival of cementless Oxford medial unicompartmental knee replacement 

(OUKR). 

Methods 

This prospective study describes the outcome of 1000 consecutive cementless 

OUKRs implanted using a minimally invasive surgical approach for the recommended 

indications in two centres and followed up independently. Patients were clinically 

assessed using the Oxford knee score (OKS). Radiographs were assessed for 

progression of osteoarthritis in the retained compartments, the presence and extent of 

radiolucency and evidence of component subsidence and/or loosening. 

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Results 

The mean follow-up of was 6.2 years (range 3.8 to 11.3 years) with a follow-up of 

10 years for 62 knees. The mean Oxford knee score improved from 23.8 (SD 8.2) 

to 41.8 (SD 7.1) at the last follow-up (p < 0.001). Considering revisions for any 

cause, the survival at 10 years of follow-up was 97% (CI 95%: 90.7-100%). Twentytwo 

cases (2.2%) needed revision surgery, defined either as the exchange of an 

existing component or the addition of a new component. The most common reason 

for revision was progression of arthritis in the retained compartment in 9 cases (0.7%) 

followed by dislocation of the bearing in 6 cases (0.6%). Out of the 9 knees needing 

further surgery for progression of arthritis 5 were treated with revision to a total knee 

replacement (TKR) and 4 with addition of a UKR in the retained compartment. The 

302

6 cases of bearing dislocation were treated with insertion of a new bearing. There 

were two tibial fractures and two tibial component loosenings, all revised to TKR. 

Two further patients required revision to TKR, one for impingement caused by tibial 

component overhang and one for persistent pain. One patient had an acute tear of 

the anterior cruciate ligament (ACL) with bearing dislocation that was treated with 

ACL reconstruction and bearing exchange. 

Conclusions 

The results confirm that cementless OUKR is a safe and reproducible procedure in 

patients with end-stage anteromedial osteoarthritis of the knee, with excellent outcome 

at long-term follow-up. 

Paper 393 

Presenter: PH Maré 

Authors: P.H. Maré, D.M. Thompson, L.C. Marais, B. Sartorius 


Abstract title: Evaluating factors predictive of recurrence after proximal tibial 

osteotomy in early-onset Blount’s disease treated before the age of seven years. 

Background: Early-onset Blount’s disease treated by proximal tibial osteotomy is 

known to have a high recurrence rate. The aim of the study was to determine the 

recurrence rate in early onset Blount’s disease in a cohort of patients treated with a 

tibial osteotomy before the age of seven; and also to determine which factors were 

associated with recurrence. 

Methods: We reviewed the records of 20 patients, aged six years or below, with earlyonset 

Blount’s disease (35 involved extremities) treated by proximal tibial osteotomy. 

We determined the rate of recurrence and identified certain factors associated with 

recurrence. 

Results: 20 Patients were included in this study. The mean patient age was 4 years (2-6), 

14/20 patients were female. 25% (5/20) of patients were obese (BMI>95 th centile). 

At a median follow-up of 30 months (14-60) 40% (14/35) limbs had recurrent 

deformity. Univariate logistic regression revealed a significant association between 

obesity (p=0,038, OR 7.1, 95% CI 1,11-45,52) and recurrence. Medial physeal 

slope (MPS) was the most significant factor associated with recurrence (p=0.001, 

OR 1.2, 95% CI 1,1-1,4). Langenskiöld staging demonstrate a similarly significant 

association with recurrence (p=0.001, OR 6.3 95% CI 2,0-19,1). With multivariate 

logistic regression analysis only the MPS retained statistical significance (p=0.008, 

OR 1.4, 95% CI 1.08-1.72). 

Conclusions: Early-onset Blount’s disease has a high rate of recurrence following tibial 

osteotomy alone. Several factors have been shown to be associated with recurrence, 

of which the medial physeal slope (MPS) is the most statistically significant. Further 

303

esearch should focus on risk stratifying patients with early-onset Blount’s disease. 

Surgical strategies need to be developed to minimise recurrent deformity in at-risk 

patients. 

Keywords: Blount’s disease, Tibia Vara, recurrence, proximal tibial osteotomy, medial 

physeal slope 

Paper 394 


Authors: P.H. Maré, D.M. Thompson 


Abstract title: The treatment of early-onset Blount’s disease with lateral proximal 

tibial tension band plates 

Background: The standard treatment of early-onset Blount’s disease is proximal tibial 

osteotomy. A few reports have shown successful treatment with lateral proximal tibial 

tension band plates. The aim of the study was to determine the success rate of this 

treatment method in a cohort of patients with mild early-onset Blount’s disease. 

Methods: We retrospectively reviewed the records of 7 patients (8 involved extremities) 

with early-onset Blount’s disease treated with lateral proximal tibial tension band 

plates. These patients were selected for this treatment due to mild disease, identified 

by a metaphyseal-diaphyseal angle (MDA)< 20° and tibiofemoral angle(TFA) < 25°. 

We determined the success rate (defined as normal coronal lower limb alignment at 

latest follow-up). 

Results: The median patient age was 5 years (3-10). None of these patients were 

obese (BMI>95 th centile). All had Langenskiöld II or III disease. The median metaphyseal 

diaphyseal angle was 18,5° (16°-20°). The median tibial-femoral angle was 15° 

(10°-25°). At a median follow-up of 31 months (16-44 months) 62,5% (5/8) patients 

had normal lower limb alignment. Out of the 3 limbs that the treatment failed, two 

were overcorrected due to delayed removal. A single treatment failure was attributed 

to failure of the lateral tension band plate to correct the deformity due to distal screw 

pullout. 

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Conclusions: Mild Early-onset Blount’s disease can successfully be treated with lateral 

tension band plates in selected cases. Follow-up is critical to prevent overcorrection. 

Further research is needed to determine the effect of lateral tibial tension band plates 

on sagittal and rotational deformity in early-onset Blount’s disease. 

Keywords: Blount’s disease, Tibia Vara, Lateral tension band plates, 8-plates 

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Paper 396 

Presenter: JG Myburgh 

Authors: JG Myburgh, J van Rooyen, E Mennen, F DeV Theron, M Skeen 


Abstract title: TendonTransfers in Tetraplegic Patients, does it benefit the patients, 

the Pretoria Experience. 

Purpose of the study: Traumatic spinal cord injuries are life changing events, 

dramatically altering the individual’s ability to perform most of the normal activities 

of daily living. There has been an increase in Spinal cord injuries, leaving more 

patients Tetraplegic. Once these patients have completed their initial stabilization 

and rehabilitation phase, they want to be integrated back into their own lives and 

their social environment.The Tetraplegic patients have limited hand and upper limb 

function and desire better function to assist with the activities of living.The purpose of 

this study was to evaluate whether reconstructive upper limb surgery in Tetraplegic 

patients, followed by early focused rehabilitation, improves their functional outcome 

and upper limb function. 

Methods: Between 2010 and 2015, we performed combinations of upper limb 

reconstructive procedures on Tetraplegic patients. Each patient completed at least 

one year of rehabilitation before being considered for surgery. All patients were 

submitted to a pre- and postoperative clinical evaluation. This consisted recording of 

the patient’s functional needs and motivations (QIF-sf), motor and sensory assessment 

of the upper limbs and Capabilities of Upper Extremity evaluation (CUE). 

Results: The QIF-sf improved with 69%. The CUE improved with 29%. Post-operative 

Triceps function improved from 0 to 4/5 in 10 arms and 3/5 in 2 arms. Postoperative 

results indicated improved outcomes. 

Conclusion: Reconstructive upper limb surgery improves activities of daily living and 

upper limb function in Tetraplegic patients. 

Authors: J.G.Myburgh; J van Rooyen; E Mennen; F deV Theron; Melany Skeen 

Contact detail: 

Prof J.G.Myburgh 

Dep Orthopaedic Surgery 

University of Pretoria. 

Adress: P.O.Box 17464, Pretoria North, 0116 

E-mail: myburghhans@gmail.com 

Tel: 0832711629 

Paper 399 

Presenter: MAF Mohideen 

Authors: J.Davis,M.A.F.Mohideen,D.Badenhorst 


Abstract title: Retrospective review of the rate of success of closed reduction of 

cervical spine facet dislocation 

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Object:To determine the rate of successful reductions of cervical facet dislocations. 

Method: Retrospective case-note and imaging review of consecutive patients treated 

at a single centre, presenting with traumatic cervical facet joint dislocation for the 

period 2009 to 2015. 

Results: Eighty patients were identified with facet joint dislocations. Sixty five of these 

injuries were in males and 15 took place in females. The youngest patient was 

a 16 year old male and the oldest was a 76 year old female. There were 41 

unifacet dislocations and 39 bifacet dislocations. Forty seven patients were reduced 

successfully and 24 failed closed reduction. Thirty patients had injuries between C5 

and C6 and 17 were injured at C4-C5 level. Seven injuries involved the Cervico- 

Thoracic junction C7-T1. The amount of weights used ranged between 12 kg and 

31 kg. 

Conclusion: Successful reduction was seen in less +/- 60% of patients. Thirty percent 

of patients failed closed reduction. 

Paper 402 

Presenter: J Joubert 

Authors: J Joubert 


Abstract title: Total Hip Arthroplasty in Patients with Hip Arthritis Secondary to 

Legg-Calve-Perthes Disease: The Usage of a Direct Anterior Minimally Invasive 

Surgery Approach (AMIS) 

Legg-Calve-Perthes Disease (LCPD) is a well-established risk factor for the development 

of early osteoarthritis of the hip. Hip replacement arthroplasty has been demonstrated 

to be a reliable and effective intervention for patients with end-stage degenerative 

osteoarthrosis secondary to LCPD. However, the procedure is technically demanding 

with relatively high complication rates being reported in the peer-reviewed literature, 

mainly due to a complex three-dimensional pathomorphological deformities of the hip 

and previous childhood surgery. 

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Our hypothesis was that the surgical approach utilised influence the success of such 

demanding arthroplasty cases since it is directly linked to achieving goals such as 

leg-length restoration and preservation of the abductors (quite important for LCPD 

patients due the extensive muscular atrophy including the gluteal muscles). Therefore, 

the purpose of this study was to firstly address arthroplasty surgical concerns particular 

to the disease and secondly to test our hypothesis by evaluating whether the goals 

mentioned have been achieved. 

We reviewed 13 patients with a history of LCPD (10 males, 3 females; mean age 

47 years; range 16 – 76 years) on whom 15 total hip arthroplasties were performed 

from November 2010 to July 2015 . The direct anterior minimally invasive surgery 

306

approach and non-cemented implants were used in all cases. The patients were 

evaluated pre-operatively, post-operatively and at final examination. In 5 out of the 

15 implantations graft and screws were used. The follow-up ranged from 3 months 

to 5 years looking at both radiographic and clinical outcome parameters. 

Significant improvement of the gait pattern was noted and the following were recorded 

: Flexion: 60-100° (mean 86°) / Extension : 0-10° (mean 8,5°) / Abduction : 

10-40° (mean: 30,1°) / Adduction : 10-20° (mean : 10,7°) / Internal Rotation 

0-45°(mean: 14,2°) / External Rotation: 30-80° (55,3°). 

The radiographs revealed the following: Inclination: 32-49° (mean 38,6°) / 

Anteversion: 0-25° (mean 8,1°). The leg length discrepancies ranged from 0-5,3 

mm (mean 2,15 mm) – these were restored to a range of 0-2,1 mm (mean: 0,6 mm). 

Complications were limited to one trochanteric fracture and one haematoma ten days 

post-op. No neurological complications were experienced. 

In conclusion, our results make us to confidently state that the direct anterior minimal 

invasive approach utilised should be considered as a treatment option for osteoarthritis 

secondary to Legg-Calve-Perthes disease. 

Paper 406 

Presenter: F Ashton 

Authors: F. Ashton, M. Diament, J. Easby, D. Plews, A. Port, E. Kothmann 


Abstract title: Optimisation of pre-operative anaemia in elective arthroplasty 

surgery: Achieving fitness for referral 

Introduction 

Orthopaedic patients presenting on day of surgery with even mild uncorrected 

anaemia have greater perioperative morbidity and mortality. Those subsequently 

requiring perioperative blood transfusions are placed at even greater risk of adverse 

outcomes. These findings prompted us to introduce a formal anaemia pathway in 

our pre-operative assessment that ensures any degree of pre-operative anaemia is 

appropriately investigated, and optimised prior to elective arthroplasty surgery. 

Method 

Local audit during 2013-2014 demonstrated a persistent 16% anaemia rate within 

those patients presenting on day of surgery for elective hip and knee arthroplasty, 

despite existing pre-assessment processes. We introduced a formal pre-assessment 

anaemia pathway to guide identification and optimisation of thesepatients within 

primary or secondary care. Concurrently primary care colleagues were provided 

with an education package about the prevalence and importance of pre-operative 

307

optimisation of mild to moderate anaemia. Following this, we have assessed the 

impact of our pathway by reviewing the prevalence of anaemia in day of surgery 

admissions. 

Results 

Between July and September 2015 we prospectively reviewed 50 consecutive patients 

who underwent elective arthroplasty in a single orthopaedic centre. All patients were 

now found to have pre-operative haemoglobin levels within recommended trust levels 

(Men 130-180g/l; women 115-160g/l). We identified a mean day one postoperative 

haemoglobin drop of 17g/l (Mean postoperative Hb 118g/l in female 

patients and 127g/l in male patients). Only one female patient required a postoperative 

blood transfusion for symptomatic anaemia (Hb = 78g/l) on post-operative 

day 2(Hb 126g/l at pre-assessment). 

This represents a significant improvement in the fitness of patients presenting on the 

day of surgery, as well as a significant drop in perioperative transfusion. We further 

identified that none of the 50 had required referral back to primary care based 

on their pre-assessment blood results; a dramatic improvement from implementation 

figures. 

Conclusion 

The results demonstrate that the package of measures introduced to facilitate 

optimisation of pre-operative anaemia have been highly successful. Six-months after 

strict implementation of the pre-assessment anaemia pathway, patients now appear 

to be referred by their primary care doctors only after management of their anaemia, 

demonstrating the concept of ‘fitness for referral’. This shows good collaborative 

working between primary and secondary care with improvement in patient care and 

outcomes. This not only benefits the patient but improves efficiency in the surgical 

pathway. 

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Paper 407 

Presenter: D Simmons 

Authors: D.Y. Simmons, A.J.F. Robertson, G. Firth, Y. Ramguthy 


Abstract title: Feasibility of a Ponseti Tenotomy in the Outpatient Setting 

Introduction 

Ponseti described the tenotomy for idiopathic clubfoot performed as an outpatient 

procedure. However, in our hospital we have routinely done the tenotomy in theatre 

under general anaesthesia (GA). 

Both methods are reported to be safe. However, no study has compared the technical 

308

difficulty or the parents’ experience between the two. 

The aim of our study was to determine the technical difficulty, the parents’ experiences 

and satisfaction as well as the safety of the tenotomy performed in a busy state 

hospital outpatient versus theatre environment. 

Methods 

The study was prospective, randomized and Ethics approval was obtained. 

Children under 6 months presenting with idiopathic clubfoot were randomized into 

two groups. Group A followed our current protocol of tenotomy in theatre under GA. 

Group B had the tenotomy performed in the outpatient clinic under local anaesthesia. 

Each clubfoot was scored by the Pirani classification. Further data collected was: 

immediate and short-term complications; surgeon perception of difficulty on a scale 

out of 10 and parent perceptions, measured using visual analog scores. These 

questioned anxiety levels, convenience and general satisfaction of the procedure. 

Results 

Sixty two patients were included in the study. Thirty three were in Group A and 29 

were in Group B. The two groups were matched in terms of age, severity, number of 

plasters required and whether the clubfoot was unilateral or bilateral. 

The surgeons’ perception of technical difficulty was higher in Group B than in Group 

A (score: 4.3 versus 2.0 out of 10). Fifteen (52%) of the Group B cases were noted 

to be moving enough to make the procedure more difficult. Three (9%) of the Group 

A patients were woken prematurely and moved during the procedure. 

According to the visual analog scales, the parents’ anxiety and general satisfaction 

were equivalent between the two groups, with only the convenience of the procedure 

in Group B scoring better than in Group A. 

There were 5 (17%) minor complications in Group B and 3 (9%) in Group A. Three 

of the 5 Group B cases were performed by junior surgeons. The complication rate 

between the two groups was equivalent when performed by a senior surgeon. 

Conclusion 

Tenotomy done in the out-patient setting is feasible as it is a safe procedure. It is 

acceptable to parents and more convenient. However, it is a more technically 

demanding procedure in the outpatient setting and should be performed by a surgeon 

experienced with the procedure. 

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Paper 409 

Presenter: I El-Daly 

Authors: I. El-Daly, A. Ranganathan, A. Montgomery, P. Culpan, P. Bates 


Abstract title: Spinopelvic Dissociation: Have We Finally Got It Right 

Introduction Spinopelvic dissociation (SPD) is a rare, life threatening condition that 

results from discontinuity between the axial spine and the pelvic ring. With only 

63 cases documented in the literature, evidence is sparse and the vast majority of 

surgeons have limited experience in treating this condition. Joint operating between 

spinal and pelvic surgeons at our unit gives us a unique opportunity to develop 

a new form of fixation not previously described. Aim Present our novel reduction 

manoeuvre, minimally invasive surgical technique and operative experience, 

for the fixation of patients with SPD. Methods Retrospective review of 15 SPD 

cases over 24 months (2013 – 2015) treated operatively at The Royal London 

Hospital, England, UK (level one trauma centre). Results The mean age was 41 

years (range 18 – 78 years) out of ten males and five females. The most common 

mechanism of injury was a fall from height followed by road traffic accidents. 

All patients underwent percutaneous fixation. Thirteen patients had lumbopelvic 

fixation reinforced with an SI screw. Post-operative complications included two 

deep surgical site infection over the iliac screw head. Of the two treated without 

SI screw fixation one had metal work failure with loosening of the set screws and 

dislocation of the rods bilaterally. There was no mortality. Conclusion We treated 

15 patients with SPD over the course of two years, constituting a higher incidence 

than any other reported. In our experience, the novel reduction technique described 

was successful in all our patients without any subsequent loss of reduction or failure 

of fixation. Triangular osteosynthesis achieved the most stable fixation without any 

failure of fixation or hardware. 

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Paper 412 

Presenter: L Mokete 

Authors: L Mokete, J Pietrzak, D v d Jagt 

Disclosure: Yes: My institution has received support from Biomet South Africa in the 

past 

Abstract title: DOES EXPOSURE TO METAL IONS FROM LARGE DIAMETER METAL 

GENERATING HIP REPLACEMENTS CAUSE METAL HYPERSENSITIVITY? 

Introduction 

The popularity of second generation metal on metal (MOM) hip replacements 

has waned on account of early failures in part due to adverse reactions to metal 

ions generated by the bearings. Lymphocyte mediated response (type IV delayedhypersensitivity) 

to metal debris has long been postulated as a possible mode of 

failure of the implants. However, the role of hypersensitivity is poorly understood 

owing to a lack of robust metal allergy tests in the past. Allergy patch testing is the 

most readily available method of testing for metal hypersensitivity but it is of doubtful 

310

utility in the context of hypersensitivity in implants deep within the body. Lymphocyte 

transformation test (LTT) is better suited for the testing of metal induced hypersensitivity 

but the body of work to support its routine use remains limited. The aim of our study 

was to determine - using a validated optimized LTT (MELISA)- whether patients exposed 

to metal ions from large diameter metal ion generating hip replacements developed 

metal hypersensitivity over time. 

Method 

80 hips in 80 patients were randomized to either large diameter MOM or large 

diameter ceramic on metal (COM) articulation (Magnum C, Biomet). Specific 

exclusions included the presence of metal implants in the body and industrial exposure 

to metals. Whole blood was collected pre-operatively and at average 24 months 

post-operatively (18-28 months) for metal ion level analysis (Chromium, Cobalt and 

Molybdenum) and metal hypersensitivity using the MELISA test. 72 patients were 

available for follow-up, 39 MOM and 33 COM. 

Results 

Both MOM and COM hips showed a steady increase in blood metal ion concentrations 

during the study period. There was a significant difference (Wilcoxon rank sum test; 

p=0.040) in the median Chromium level for MOM (1.77 ug/l) compared to that of 

COM (1.04 ug/l). Incidence of hypersensitivity remained low with no significant 

change in metal hypersensitivity between pre-op and 24 month follow-up (using 

McNemar’s test for paired categorical data) in either group. 

Conclusion 

Despite evidence of metal ion generation and the use of a sophisticated 

hypersensitivity test, we failed to demonstrate development of metal hypersensitivity 

in this cohort of patients at average 24 months. The role of metal hypersensitivity as 

a mode of early failure of metal generating hip replacement articulations is limited. 

Paper 413 

Presenter: MA Akhtar 

Authors: M A Akhtar, C Honeyman, F Aziz, R Kalyan, W Hekal 


Abstract title: Gentamicin Fleece and the incidence of surgical site infections 

following spinal deformity surgery for adolescent idiopathic scoliosis 

Purpose: 

The incidence of surgical site infection (SSI) after spinal deformity surgery for adolescent 

idiopathic scoliosis ranges from 0.5–6.7%. Local application of antibiotics to the 

wound have been shown to reduce rates of SSI after spinal fusion. Our purpose was 

to study the incidence of SSI following deformity correction surgery with the use of 

Gentamicin fleece in addition to intravenous antibiotics. 

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Methods: 

We prospectively studied 70 patients undergoing spinal deformity correction surgery 

between December 2010 and August 2015 for the incidence of surgical site infection. 

All patients had a standardized antibiotics regimen pre and post operatively along 

with the addition of local antibiotics in the wound in the form of gentamicin fleece. 

Results: 

The mean age for 58 female and 12 male patients was 14.8 years (range 9-19). 

Types of curves were Double 57%, Thoracic 37%, Lumbar 3% and early onset 3%. 

The mean time from presentation to surgery was 1 year (range 0-4). The mean length 

of hospital stay was 6 days (range 4-15). The mean height gain was 4.2 cm (range 

1.5-7.6). There were no reported cases of surgical site infection in our cohort. 

Conclusions: 

Our incidence of SSI following spine deformity correction was 0%. We believe that 

addition of local antibiotics to a standardized antibiotics regimen can help to achieve 

this goal. We are currently measuring gentamicin levels in the drain fluid to confirm 

our observations. 

Paper 414 


Authors: M A Akhtar, C Honeyman, C Greenough, R Kalyan, W Hekal 


Abstract title: The Sky’s the limit: Raising the quality and scope of communication 

for children with scoliosis and their families using digital and social media 

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Purpose: 

Patients expect health care to meet their needs quickly and be tailored to their 

requirements. Modern Technology can help us to achieve this. Our purpose was to 

assess the use of digital & social media in educating patients and their parents to 

provide tailored care and personal support. 

Methods: 

A prospective observational study was conducted for 80 patients undergoing spinal 

deformity correction surgery. We used Facebook, Twitter, YouTube, mobile phones, 

emails and hospital website for the last 2 years to communicate, educate and support 

our patients with spinal deformity and their parents. An annual survey of 18 patients 

undergoing scoliosis surgery in 2014 evaluated the use and effectiveness of digital 

and social media. 

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Results: 

James Cook hospital scoliosis support on Facebook has 54 members who communicate 

and support each other. Twitter account @CHSpine has 71 followers and 97 tweets. 

Jodie’s scoliosis journey on YouTube had 713 views. We received 10 emails per day 

on average from parent/patient and 20 related to patient’s health, social care and 

education. We received on average 6 calls/texts per day. 100% patients and their 

families used at least one digital media and the most popular & useful media was 

emailing the specialist nurse for advice following surgery (88%). 

Conclusions: 

100% patients used at least one form of digital media. We believe that easy 

communication with health care professionals is an essential part of care provided to 

our patients to improve patient’s experience of health care. 

Purpose: 

Patients expect health care to meet their needs quickly and be tailored to their 

requirements. Modern technology can help us to achieve this. Our purpose was to 

assess the use of digital & social media in educating patients and their parents to 

provide tailored care and personal support. 

Methods: 

A prospective observational study was conducted for 80 patients undergoing spinal 

deformity correction surgery. We used Facebook, Twitter, YouTube, mobile phones, 

emails and hospital website for the last 2 years to communicate, educate and support 

our patients with spinal deformity and their parents. An annual survey of 18 patients 

undergoing scoliosis surgery in 2014 evaluated the use and effectiveness of digital 

and social media. 

Results: 

James Cook hospital scoliosis support on Facebook has 54 members who communicate 

and support each other. Twitter account @CHSpine has 71 followers and 97 tweets. 

Jodie’s scoliosis journey on YouTube had 713 views. We received 10 emails per day 

on average from parent/patient and 20 related to patient’s health, social care and 

education. We received on average 6 calls/texts per day. 100% patients and their 

families used at least one digital media and the most popular & useful media was 

emailing the specialist nurse for advice following surgery (88%). 

Conclusions: 

100% patients used at least one form of digital media. We believe that easy 

communication with health care professionals is an essential part of care provided to 

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our patients to improve patient’s experience of health care. 

Paper 415 

Presenter: S Roche 

Authors: R Dachs, M Fleming, D Chivers, H Carrara, J-P Du Plessis, B Vrettos, S 

Roche 


Abstract title: Total Elbow Arthroplasty: Outcomes after Triceps-detaching and 

Triceps-sparing approaches 

Background: Total elbow arthroplasty (TEA) is associated with high complication rates 

compared with other large-joint arthroplasties. The frequency and type of complication 

may differ, depending on the surgical approach. A comparison of outcomes with 

triceps-off and triceps-on approaches was investigated 

Methods: Seventy-three patients underwent 83 primary TEAs between 

2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 

had a triceps-on approach. Results were reviewed at a mean of 4.2 years. 

Cementing technique was graded according to Morrey’s criteria, and clinical 

outcomes were assessed by means of the Mayo Elbow Performance Score. 

Results: There was no statistically significant difference between the triceps-off and 

triceps-on groupswith regard to the patient’s age, gender, preoperative Mayo Elbow 

Performance Score or range of motion, or previous surgery on the affected elbow. 

Among patients who underwent a TEA for an inflammatory arthropathy, there was 

a significant difference in outcome between groups with regard to final flexion, 

extension, arc of motion, and pronation. Cementing technique in the triceps-off group 

was adequate in 70%. In the triceps-on group, cementing technique was adequate 

in 92%. The complication rate in the triceps-off group was 32.6% and included 

7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture 

developed deep infections requiring multiple further surgeries. The complication rate 

in the triceps-on group was 8.1% 

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Conclusions: A triceps-on approach in TEA results in consistently good clinical 

outcomes with no risk of triceps rupture, and the approach does not compromise the 

cement mantle. We believe that this approach will reduce complication rates in TEA. 

Paper 417 

Presenter: B Vrettos 

Authors: B Vrettos, A Vochteloo, R Dachs,S Roche 


Abstract title: Total elbow arthroplasty in bleeding disorders: a case series 

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Background: Total elbow arthroplasty (TEA) is a surgical option for an arthropathy 

secondary to a bleeding disorder. The literature consists of small case series. Our 

series provides further understanding into the outcomes of TEA in this population of 

patients. 

Methods: Five patients underwent 8 primary TEAs for a bleeding disorder. Average 

age at time of surgery was 47 years. Four patients had hemophilia type A and 1 had 

von Willebrand disease. Clinical outcomes were evaluated with the Mayo Elbow 

Performance Score (MEPS) and the visual analog scale (VAS) for pain. Follow-up 

radiographs were evaluated for signs of loosening and infection. 

Results: Revision surgery was performed in 3 TEAs. Two revisions were performed for 

aseptic loosening (104 and 118 months postoperatively). The third elbow underwent 

an excision arthroplasty for a deep infection 44 months postoperatively. Mean followup 

for the primary TEAs still in situ (5 elbows) was 114 months. The mean VAS score 

improved from 8 to 0 and MEPS from 35 to 95. The mean flexion arc improved from 

70 to 100, and rotation improved from 60 to 160. Mean follow-up for the revised 

TEAs (3 elbows) was 94 months. The mean VAS score improved from 7 to 0 and the 

MEPS from 40 to 85. The mean flexion arc improved from 60 to 95, and rotation 

improved from 70 to 160. 

Conclusions: Excellent clinical outcomes and an acceptable survival rate for TEAs, 

comparable with the nonhemorrhagic population, can be achieved in patients with 

bleeding disorders. Revision arthroplasty in this group of patients yields good clinical 

outcomes at medium-term follow-up. 

Paper 418 

Presenter: RP Dachs 

Authors: R Dachs, C Marais, J-P Du Plessis, B Vrettos, S Roche 


Abstract title: Post-traumatic Elbow Stiffness: Outcomes after Open Surgical 

Release 

Background: Stiffness is a common complication of elbow trauma. Outcomes of a 

cohort of patients who underwent an open surgical release for post traumatic elbow 

contracture were investigated 

Methods: A retrospective review was completed on thirty-five consecutively managed 

patients who underwent an open elbow release for post-traumatic stiffness between 

2007 and 2012. Pre-operative and post-operative range of motion (ROM), pain 

scores and functional outcomes were recorded 

Results: Mean follow-up was 31 months. The interval from injury to time of release 

was 26 months. An improvement in flexion arc from 49˚ to 102˚ was obtained. The 

improvement in flexion arc in patients with heterotopic bone was 61˚ compared to 

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45˚ in patients without heterotopic bone. The improvement in flexion arc was not 

affected by the presence of intra-articular fracture, previous surgery of the affected 

elbow or release performed after 2 years. There was an average of 25˚ loss of flexion 

arc when comparing immediate post-operative ROM and final ROM. Improvement 

in range of motion was seen up to 6 months post release, after which arc of motion 

plateaued. Release of the posterior band of the medial collateral ligament resulted 

in improved final flexion. Final elbow extension was greater if anterior release was 

performed from a lateral approach. In total, 74% of the cohort achieved a functional 

final flexion arc. The complication rate was 26%, and re-operation rate was 11%. 

Conclusions: Open release for post-traumatic elbow stiffness results in satisfactory 

functional outcomes in the majority of cases. However surgeons should be aware 

of the possibility of significant losses in ROM from intra-operative measures. Patients 

should be counselled regarding a significant re-operation rate, and that a functional 

arc may take 6 months to achieve.’’ 

Paper 419 

Presenter: N MOGALE 

Authors: N. Mogale, N. Briers, S.A.S. Olorunju, S. Matshidze 


Abstract title: The anatomical variations of the lateral circumflex femoral artery 

and the lateral femoral cutaneous nerve relating to the anterior approach of 

minimally invasive total hip arthroplasty 

The transformation of hip arthroplasty over the centuries is evidence of the ingenuity 

of medicine. This research investigated the anatomy underlying minimally invasive 

total hip arthroplasty when the anterior approach was used. The research focused 

on the relation of the lateral circumflex femoral artery (LCFA) and the lateral femoral 

cutaneous nerve (LFCN) to the various anatomical landmarks. The objective was to 

document any variations relating to the location and the branching pattern of the LCFA 

and LFCN. The study evaluated whether concerns relating to the LCFA and LFCN, 

when the anterior approach was used had any merit. In the study, 90 hips were 

dissected for the anterior approach with one complete hip replacement performed 

on the cadaver. Simulations of the anterior approach surgical incisions were carried 

out by the orthopaedic surgeon on 21 hips. The data analysis revealed significant 

differences for mean values from the pubic tubercle to the LCFA in the comparison of 

the samples 50 years. In this group, the p-value was also significant 

for the mean distances from the pubic tubercle to the straight head of the rectus femoris 

muscle. Statistical significance was found in the comparisons between male and 

female samples, comparisons per weight ranges and BMI. 

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Findings made in the study included the average distance of the LFCN from the ASIS, 

these measurements were documented as 13.6 mm on the left side and 12.6 mm 

on the right side. The study noted variations in the branching pattern of the LCFA and 

316

the area of origin of this vessel. The number of branches given off by the LCFA were 

also variable with as many as six branches documented for 3.3% of the study sample. 

The LCFN was also documented to course directly over the ASIS in 5.6% of the hips 

dissected. 

Paper 420 


Authors: R Dachs, B Vrettos, D Chivers, J-P Du Plessis, S Roche 


Abstract title: The Ulnar Nerve in Total Elbow Arthroplasty: Outcomes after In-situ 

Release 

Background: Ulnar nerve (UN) lesions are a significant complication after Total Elbow 

Arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a 

unit, which routinely performs in-situ release of the nerve without transposition, were 

investigated 

Methods: Eighty-three primary TEAs were retrospectively reviewed for the intraoperative 

management of the UN and presence of post-operative UN symptoms. 

Results: Three patients had documented pre-operative UN symptoms. One patient 

had a prior UN transposition. The nerve was transposed at time of TEA in 4 of 

the 82 remaining elbows (4.8%). The indication for transposition in all cases was 

abnormal tracking or increased tension on the nerve after insertion of the prosthesis. 

The incidence of post-operative UN symptoms in the transposition group was 50% 

(2/4). Both these cases were neuropraxias, which resolved in the early post-operative 

period. The remaining 78 TEAs received a full in-situ release of the nerve. The incidence 

of postoperative UN symptoms in the in-situ release group was 5.1% (4/78). Two 

neuropraxias resolved, whilst two patients (2.6%) continued to experience significant 

UN symptoms requiring subsequent transposition. Seven patients had pre-operative 

flexion of less than 100˚. Of these, 2 had an UN transposition at time of TEA. Two of 

the remaining 5 elbows with pre-operative flexion less than 100˚ had post-operative 

UN symptoms after in-situ release (40%), with 1 requiring subsequent UN transposition. 

Conclusions: A 2.6% incidence of significant UN complications post TEA compares 

favorably with systematic reviews. We do not believe transposition, which adds to the 

handling of the nerve and increases surgical time, is routinely indicated, and should 

rather be reserved for cases with significant limitation of pre-operative elbow flexion, 

or when intra-operative assessment by the surgeon deems it necessary. 

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Paper 422 

Presenter: AH Van Niekerk 

Authors: AH van Niekerk, JG Myburgh 


Abstract title: REVIEW OF THE KNOWLEDGE OF AUTONOMIC DYSREFLEXIA 

AMONGST PATIENTS AND HEALTHCARE PROVIDERS 

Dr. A.H. van Niekerk 

Prof J.G. Myburgh 

Purpose of the study: 

Awareness of the triggers of AD is the key to prevention. The current cognisance of the 

nature of this problem and potential risk among spinal cord injured (SCI) individuals 

is not known. 

The aim of the study was to assess the current knowledge of AD among participants 

Methods: 

Descriptive, cross-sectional study. A web-based questionnaire was distributed to 

members of the Southern African Spinal Cord Association (SASCA), casualty and 

rehabilitation centre doctors, registrars, specialists of various disciplines and nurses. 

Questionnaires were also distributed at the spinal outpatient and rehabilitation clinics. 

All prospective participants were informed about the nature of the study and anonymity 

was ensured. 

Results: 

From a sample size of 96 SCI individuals, 73% have spinal cord injuries at or above 

T6. 38.1% of patients had no prior knowledge of AD. Nasal congestion (54.1%, 

P- value 0.01), piloerection (41.9%, P-value 0.01) and sweating above the level 

of the injury (41.5%, P-value 0.01) were the most common symptoms frequently 

experienced in the high SCI group. A blocked catheter (62.7%), bowel impaction 

(62.5%) and UTI (61.7%) were the most common associated triggers. The diagnosis 

of AD was made in 30.3% of cases. 

A total of 98 medical personnel from various disciplines completed the survey, of 

which 12.9% had no prior knowledge of AD. Change in heart rate (43.5%), pounding 

headaches (41.7%) and profuse sweating (45.8%) above the level of the injury were 

the symptoms most often seen associated with an AD episode. Causes associated 

most frequently with AD are pressure ulcers (68%), pain below the SCI level (43.5%), 

blocked catheters (42.1%) and bowel impaction (40.5%). 92.8% agree that removal 

of the cause remains the most important treatment modality. 64.3% of doctors follow 

no protocol in the management of AD. 

Conclusion: 

The incidence of AD amongst our participants is higher than expected. The current 

level of awareness of AD among the SCI population is inadequate, despite current 

awareness campaigns. Most doctors have no clear guidelines in the management of 

AD, despite frequently encountering the condition. 

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Paper 423 

Presenter: AH Van Niekerk 

Authors: AH van Niekerk, JG Myburgh 


Abstract title: THE PERCEPTION OF SPINAL CORD INJURY AMONGST PATIENTS 

AND HEALTHCARE PROVIDERS 

Dr. A.H. van Niekerk 

Prof J.G. Myburgh 

Purpose of the study: 

The perception regarding quality of life and outcomes of spinal cord injury likely 

differs amongst healthcare providers compared to survivors of spinal cord injury. The 

nondisabled community often assume that quality of life is decreased following spinal 

cord injury. Reluctance with resuscitative efforts might be based on perceived quality 

of life following survival of a spinal cord injury. 

Methods: 

Descriptive, cross-sectional study. A web-based questionnaire was distributed to 

members of the Southern African Spinal Cord Association (SASCA), casualty and 

rehabilitation centre doctors, registrars, specialists of various disciplines and nurses. 

Questionnaires were also distributed at the spinal outpatient and rehabilitation clinics. 

All prospective participants were informed about the nature of the study and anonymity 

was ensured. 

Results: 

From a sample size of 96 SCI individuals, 72% sustained complete SCI with 40.6% 

cervical level SCI. 54% are currently single and 21% divorced, a third of which 

were divorced after sustaining a SCI. Motor vehicle accidents (39.3%), motorbike 

accidents (18.1%) and diving accidents (15.1%) were the most common mechanisms 

of injury. 

A total of 98 medical personnel from various disciplines completed the survey. 

75.8% of doctors feel that quality of life decreases after SCI and 51.7% would 

opt not to be resuscitated after personally sustaining a complete quadriplegic SCI, 

compared to 17.8% of patients. 63.1% of medical personnel feel SCI individuals can 

live a contented life, compared to 92.3% of patients. 79.4% of medical personnel 

feel that quality of life deteriorate over time after SCI, compared to 61.4% of patients. 

70% of medical personnel and patients agree that it is less likely for a spinal cord 

injured individual to find a committed partner or spouse. 

51.5% of doctors have been in a situation where a decision regarding resuscitation 

of a spinal cord injured patient had to be made. 

Conclusion: 

Perception amongst medical personnel regarding the quality of life of the spinal cord 

injured may influence their critical decision making. Healthcare providers’ attitude 

may affect the care they provide, and influence patients and their families in decision 

making. Healthcare providers must be aware of the outcomes and life satisfaction 

after sustaining a spinal cord injury. 

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Paper 426 

Presenter: MA Roussot 

Authors: MA Roussot, D McGuire, M Solomons 


Abstract title: Hand infections in patients with human immuno deficiency virus. 

Background 

Human immunodeficiency virus (HIV) is common in South Africa, affecting 

approximately 1 in 10 people in the general population. Currently the literature is 

deficient in providing evidence for a relationship between HIV infection, CD4 count, 

and the ability to clear sepsis. 

Purpose 

1. To determine if CD4 count plays a role in severity and resolution of hand infections. 

2. To determine the risk factors for poor outcome in patients with hand infections. 

Methods 

We conducted a prospective cohort study of 226 patients with human immunodeficiency 

virus treated for hand sepsis at our hand unit. Mechanism of injury, microbiological 

culture and sensitivities, and comorbidities were recorded. The severity of infection 

in terms of number of procedures, length of hospital stay, functional deficit and the 

need for ablation was determined. Significance testing with the Fisher’s exact test was 

conducted. 

Results 

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The prevalence of HIV in the study group was 24%, and 75% of these patients were 

previously undiagnosed. Staph aureus was the offending organism in the majority of 

cases, however, diabetics and patients with HIV showed an increased spectrum of 

organsims. Flucloxacillin provided inadequate cover in 40% of patients with HIV or 

diabetes. The majority of patients with hand infections were managed successfully 

with a single procedure in an outpatient setting, however, patients with bite injuries, 

diabetes, or HIV positive patients with a CD4 count < 150 had an increased rate of 

multiple procedures, prolonged hospital stays, functional deficit and ablation. 

Conclusion 

HIV is 2,4 times more common in patients with hand infections than the general 

population, and often diagnosed for the first time in the hand unit. Hand infections in 

patients with no comorbidities can be managed successfully with a single procedure 

as an out patient with flucloxacillin cover. Bite injuries and hand infections in patients 

with diabetes or HIV and a CD4 count < 150 require more agressive surgery, 

inpatient care, broad spectrum antibiotics, and are at higher risk of ablation. 

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Paper 427 

Presenter: HI Ingoe 

Authors: H. Ingoe, P. Holland, A. Rangan, R. Liow, J. McVie, E. Tindall 


Abstract title: Six-year Survival Analysis of a Shoulder Resurfacing 

Introduction 

Shoulder resurfacings represent approximately one third of primary shoulder 

arthroplasties and have the highest revision rates as evidenced by shoulder registries. 

Despite this, few survival analyses have been published. We present a survival 

analysis of the Global CAP prosthesis up to the end of year six. 

Methods 

Between 2006 and 2015 eighty-seven Global CAP shoulder resurfacings were 

implanted by three surgeons at two centres. Oxford Shoulder Scores (OSS), Quick 

Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and patient 

satisfaction scores were recorded. A life-table analysis as described by Armitage 

was undertaken, and the results are reported up to the end of year six which is the 

time point that sufficient patients reached to report a 95% confidence interval of less 

than 25%. Two survival analyses were performed; one where failure was defined 

as component exchange and one where failure was defined as reoperation for any 

reason. 

Results 

Eighty-seven Global CAP shoulder resurfacings were implanted in seventy-five 

patients. The cuff tear arthropathy prosthesis was used in ten shoulders. The mean 

age of patients at the time surgery was 69 years (range 41-87). Eight patients died 

and were withdrawn from the analyses in the year of their death. 

Survival at the end of year six with component exchange as the end point was 92% 

(95% CI 77-97) and survival with reoperation for any reason as the end point was 

83% (95% CI 67-91). Four shoulders underwent component exchange (one was 

revised to a conventional total shoulder arthroplasty; one was revised to a stemmed 

hemiarthroplasty and two were revised to reverse-polarity arthroplasties). Four 

shoulders underwent a reoperation without component exchange (one arthroscopic 

subacromial decompression and three arthroscopic capsular release). 

At a mean of 69 years (range 41-87) the mean OSS was 35 (range 0-48), the mean 

QuickDASH score was 26 (range 2.3 – 93.2) and the mean satisfaction score was 

73% (range 0-100%). 

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Conclusion 

This is the largest reported survival analysis with the longest follow up of the Global 

CAP shoulder resurfacing to date. This has shown that it has a similar survivorship 

and produces similar clinical results compared with other resurfacing arthroplasties. 

A wide range of clinical outcome scores were found, which is consistent with studies 

investigating other shoulder resurfacings. Future research should investigate the 

reasons for this to enable surgeons to optimise patient outcomes. 

Paper 428 


Authors: P.H. Maré, D.M. Thompson 


Abstract title: What is the value of temporary lateral growth-retardation in 

addition to proximal tibial osteotomy in preventing recurrence in early-onset 

Blount’s disease treated before the age of seven? 

Background: Early-onset Blount’s disease treated by proximal tibial osteotomy is 

known to have a high recurrence rate. Our own experience is a recurrence rate of 

40%. Several preoperative factors have been confirmed to predict recurrence in our 

patient cohort: most notably a medial physeal slope (MPS) angle above 60°. The 

aim of this study was to determine whether in patients with a MPS>60°, the addition 

of lateral growth retardation to the tibial osteotomy decreased the recurrence rate. 

Methods: We retrospectively reviewed the records of patients under 7 years with 

early-onset Blount’s disease and a MPS>60°. These patients were either treated with 

a proximal tibial osteotomy alone (Group A), or a proximal tibial osteotomy and 

lateral growth retardation (Group B). We then compared the two groups in terms of 

age, obesity, tibial-femoral angle (TFA), metaphyseal-diaphyseal angle (MDA), MPS, 

Langeskiöld stage and recurrence rate. 

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Results: There were 8 patients (12 extremities) in Group A. The median patient age 

was 5 years (4-6 years). 50% (4/8) of patients were obese (BMI>95 th centile). The 

recurrence rate in Group A was 92% (11/12 extremities). There were 9 patients 

(14 extremities) in Group B. The median patient age was 6 years (4-6 years). 33% 

(3/9) of patients were obese. The recurrence rate in Group B was 71% (10/14 

extremities). The two groups were statistically comparable in terms of TFA, MDA, 

MPS and Langenskiöld stage. Fischer’s exact test revealed no statistically significant 

difference in recurrence rate (p=0.33) between the two groups. 

Conclusions: In patients with early-onset Blount’s disease who have a high risk of 

recurrence the addition of lateral proximal tibial growth-retardation to a proximal 

realignment osteotomy did not have a statistically detectible effect in reducing 

recurrence. Additional surgical strategies need to be developed to minimise recurrent 

deformity in at-risk patients. 

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Keywords: Blount’s disease, Tibia Vara, recurrence, proximal tibial osteotomy, lateral 

tension band plate 

Paper 429 

Presenter: J Page 

Authors: J.Page, R.Venkataram 


Abstract title: Does increasing talar length prevent ATFL healing in children? 

Anterior talofibular ligament injuries in children are more common than expected. 

If inadequetely treated in the initial instance they often present late with symptoms 

of pain and instability. ATFL tears in adults can be treated by direct repairs of the 

ligament. However this is not the case in children who present late. 

Hypothesis: With growth the talar length increases preventing healing and future 

direct repair of the ATFL. 

Null Hypothesis: There is no change in the talar length with review of a normal 

population. 

Method: Retrospective study looking at ATFL injuries in children that had operative 

interventions. Patients below the age of 18 with symnptoms following a recorded 

traumatic episode in the past, and went on to have an ATFL reconstruction were 

included. Clinical data including imaging was reviewed. 

The talar length of a normal population was also reviewed (measured on the 

standardised lateral view of the ankle from the apex of the talonavicular convex 

articular surface to the posterior most edge of the talus) 20 Boys and 20 girls 

belonging to age groups of 6,10, 14 and 18 years of age (160 in total). This 

sample was from the local population using the PACS system. 

Results: 17 children had undergone ATFL reconstructions . Average age of the cohort 

was 14.5 with a range from nine to 18 years. Pain and instability of the ankle was 

the primary complaint. Intraoperatively, all children were noted to have an empty 

talofibular gutter with no signs of the ATFL ligament or residual stumps that were not 

reconstructable . 

The mean talar length in the 6, 10, 14 and 18 year old children was 41.22, 

49.04, 54.19, and 56.42 mm respectively. As expected the mean talar length for 

boys was consistently higher at all age groups compared to girls. Six-year-old boys 

had an average talar length of 42.38mm and for girls it was 39.83mm. The lengths 

increased to 50.52mm and 47.56mm, 56.14mm and 50.3mm, 59.9mm and 

52.94mm by the ages of 10, 14, and 18 years in the boys and girls respectively. 

Conclusion: ATFL injuries in children are a different clinical entity when compared to 

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adults. Talar length in children progressively increases with age given this fact if not 

immobilised the ends of the torn ATFL are dragged apart with growth. This increasing 

talar length explains the failure to heal. 

Paper 430 

Presenter: G Bourke 

Authors: G. Bourke 


Abstract title: CT Analysis of periprosthetic cysts in TAJR. Diagnosis and treatment. 

Total ankle joint replacement (TAJR) is becoming more common for the treatment of 

end stage ankle arthritis. With increasing numbers the treatment of complications is 

becoming more important and relevant. Periprosthetic cysts are a major problem in 

ankle arthroplasty and may result in pain or catastropihc failure. The best method of 

diagnosis and treatment is still not clear. 

The aim of this study is to demonstrate the superiority of Cat Scan (CT) compared 

to plain films in the diagnosis of periprosthetic cysts. It is also hoping to show how 

CT provides valuable information regarding the size, site and treatment of these 

cysts as well as important information regarding other causes of pain such as gutter 

imingement. 

CT and plain films were reviewed from 55 patients (57 ankles) implanted from 2001 

- 2010.Average follow up 5 years (18 months - 10 years). A 10 zone classification 

system was devised and the findings of CT compared to plain films. 

98% of patients had some form of osteolysis, 77% tibial and 80% talar lesions. 

Talar zones 5 and 9 were the most common and talar lesions were larger than tibial 

lesions. Most were progresive but rates of progression varied greatly. Two cysts were 

seen to regress. Heterotrophic ossification was comon especially posteriorly. 

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CT assesment was shown to be supperior to plain film assessment of peri prosthetic 

cysts. The plain film undercalls the size of the lesion. The CT provides an accurate 

assessment of the size, position and progression of the lesion as well as other important 

information when asessing a painful TAJR. 

More recently weight bearing CT has been adopted and this provides even more 

information of the true dynamic processes occurring with standing. Results of bone 

grafting procedures are discussed as case studies but insufficient numbers and follow 

up prevent any definitive comments on the best timing and type of grafting procedure 

to perform in the case of large and rapidly progressing cysts. 

My recommendation is for two yearly CT assessmet of all TAJR with more frequent 

imaging as cysts appear. 

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Paper 431 

Presenter: R Macnair 

Authors: R.D. Macnair, AM Hutchison, R.M. Evans, N.J. Owen, C. Topliss, P.R. 

Williams 


Abstract title: Delayed Achilles tendon ruptures. Does non-operative management 

work? 

Delayed Achilles tendon ruptures are difficult to manage, with surgical treatment 

generally advised. The purpose of this study was to report the outcomes of patients 

with a delayed presentation of an Achilles tendon rupture (2 weeks plus) treated 

conservatively with a dedicated management programme. 

Methods. We identified all patients with a delayed presentation who had been treated 

conservatively at our centre from 2008 – 2014. The conservative management was 

the same as for our acute Achilles ruptures: the Swansea Morriston Achilles Rupture 

Treatment (SMART protocol). This includes 1) an ultrasound examination followed by 

immobilisation in a position which allowed the smallest gap between the tendon ends 

2) referral to a dedicated Achilles tendon clinic and 3) strict rehabilitation guidelines. 

Outcome measures included complication rates (re-rupture / venous thromboembolism); 

Achilles Tendon Total Rupture Score (ATRS) and Achilles Repair Score (ARS); and 

muscle function dynamometry assessing plantarflexion torque of the ankle. MRI of 

ruptured and non-ruptured legs allowed measurement of Achilles tendon length. 

Comparisons between the two sides were made (2-tailed t-test). 

Results. 19 patients were assessed; 16 males, 3 females. The mean age was 60 

years (range 39-80). The mean delay from injury to starting treatment was 61 days 

(range 14-249) and the mean follow-up was 40 months (range 13-87). There were 

no re-ruptures. One patient had a pulmonary embolus. One patient went on to surgery. 

The mean ATRS was 65/100 (17-100), and ARS 71/100 (30-100). The mean 

plantarflexion torque for the injured side was 19.5 newton metres (N.m) (6.3-34.2, 

SD 8.2) and for the uninjured side 25.7 N.m (12.2-43.3, SD 9.1). The difference 

between the two sides was significant (t = 3.816 p = 0.001). The mean length of 

the injured Achilles tendon was 104.9mm (51.4-155.2) and uninjured 97.306mm 

(42.9-138.7). No significant difference (t = 1.684, p= 0.111). 

Conclusion. This comprehensive review of a conservative management regime for 

patients with a delayed presentation Achilles rupture using the dedicated SMART 

rehabilitation programme supports a satisfactory outcome in the majority of cases. 

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Paper 432 

Presenter: J Naude 

Authors: J.J. Naude, F.F. Birkholtz, P. de Lange 


Abstract title: The introduction of a new hexapod external fixator into a busy limb 

reconstruction unit: The first 100 frames. 

This study explores Hexapod based circular external fixators. Circular external fixators 

increasingly form a critical component of limb reconstruction services. It is also used 

for trauma and its sequelae such as non-unions, mal-unions, bone defects and 

infections. For the purposes of this study the first 100 cases of the Truelok Hex were 

analysed from a Pretoria Limb lengthening and reconstruction practice to determine if 

treatment goals were reached. 

A retrospective evaluation was performed of all the patients treated with the Truelok 

Hex over a 30 month period, from November 2012 to July 2015. A quantitative 

study was conducted of 100 limbs from 93 patients treated with this device in the 

unit. 

The main descriptive findings include that two thirds of patients were male and the 

average age was 33, ranging from 6 years to 64 years old. Of the 100 cases, six 

types of pathology were studied, namely acute fractures (35%), mal-unions (14%), nonunions 

(15%), deformity corrections (22%), arthrodesis (10%) and, pure lengthening, 

bone loss and equinus contracture treatment (4%) of cases. The two most common 

segments were the tibia (69%), and the ankle (17%). The average time in external 

fixation was 196 days (74 - 551) and the average follow-up period was 290 days. 

Six axis external fixation systems use software programs to calculate strut adjustments. 

In 31% of cases (such as fracture reductions, simple lengthenings and arthrodesis 

cases) this software was not used. Residual corrections were necessary in 19% of the 

cases where the first adjustment did not have an adequate correction. In 3% of the 

cases a third schedule was necessary. 

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The initial treatment goal was reached in 84% of cases. It was reached conditionally, 

after a second schedule, in 11% of cases. In 5% of cases the treatment goal was not 

reached. Of this 5% the average age of patients was over 50 years, 3 had diabetes 

mellitus, and one was on immunosuppressive therapy for an arthropathy. The study 

indicated no correlation between the pathology treated, the segment treated, the 

number of software programs used and poorer outcome. 

The findings indicated that treatment goals were reached in majority (95%) of 

complicated trauma and reconstruction cases with the Truelok Hex. Overall the device 

has met expectations and have performed well. However, it is imperative to take into 

consideration the capabilities and limitations of devices used in orthopaedics when 

making clinical decisions. 

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Paper 433 

Presenter: M van Niekerk 

Authors: Van Niekerk M, Moonda Z, Laubscher M, Kauta J, Maqungo S 


Abstract title: Epidemiology of low velocity pelvic gunshot wounds 

Purpose of study. 

We aim to provide an epidemiological report on a consecutive cohort of patients that 

sustained a trans-pelvic low velocity gunshot wound involving bone. 

Description of methods. 

We conducted a retrospective audit from medical records on consecutive trans-pelvic 

gunshot wounds over the period from June 2011 till October 2015. 

Summary of results. 

Forty three patients comprising of 2 females and 41 males, with an age average age 

of 28 years (range16-57). The average time from injury to admission was 2 hours 

and 10 min (30 min to 13 hours). Twenty six patients had an entry wound from the 

back, 11 patients from the front and 6 patients from the side. Thirteen had an exit 

wound and 30 patients had no exit wound with a retained bullet. Twenty seven entry 

wounds were on the right side and 18 on the left. Bone involvement comprised of 

23 ilium, 14 ischium, 7 pubis and 7 sacral fractures. Four bullets traversed the hip 

joint (2 washed out 2 not washed out). Eleven bullet tracts, not involving a joint were 

washed out. Twenty three patients underwent bowel surgery, of which involved 10 

large bowel, 14 small bowel, 5 extra-peritoneal rectal injuries and 6 intra-peritoneal 

rectal injuries. Eight patients underwent a colostomy. Six patients sustained urogenital 

injuries (2 intra-peritoneal and 5 extra-peritoneal bladder injuries). There were 4 deep 

infections and one patient died while in hospital from his injuries. 

Of the 4 patients that developed pelvic sepsis 3 underwent bowel surgery with all of 

them having sustained an extra-peritoneal rectal injury and requiring a defunctioning 

colostomy. The other patient sustained an extra-peritoneal bladder injury and 

developed a gram negative pelvic infection. One of the 4 patients whose bullet 

traversed the hip joint after passing through bowel developed sepsis despite a 

washout of the joint. 

Conclusion. 

Low velocity gunshot wounds involving the pelvis are increasing with young males 

comprising the predominant demographic. Most people are shot from behind, in 

keeping with running away from the scene. The majority of bullets were retained 

suggesting the use of a low velocity firearm. 

327

From our limited numbers it seems like an extra-peritoneal injury to the bladder or 

bowel involving bone frequently led to ongoing septic complications despite surgical 

and medical care. 

Paper 434 

Presenter: A Smit 

Authors: A. Smit, C.M. Anley 


Abstract title: Ligament reconstruction of the unstable CMC joint: An alternative 

surgical technique 

Purpose of the study: Recent biomechanical studies have highlighted the importance 

of the Dorso Radial Ligament (DRL) in the stability of the thumb CMC joint. When 

indicated, the surgical proceadure commonly used for the management of patients 

with CMC instability is an Eaton Littler (EL) procedure. However the standard EL, 

performed through a volar approach does not address the DRL instability. The aim of 

this study is to present the results of and to describe an alternative technique of base 

of thumb stabilisation with an additional trapezial tunnel for the FCR sling, resulting in 

improved stability. 

Description of methods: 8 patients diagnosed with thumb CMC instability in the 

abscence of OA underwent ligament reconstuction, as described by the senior author. 

This is a retrospective review of these patients including demorgraphic information 

and assessment of function via a QuickDASH and ROM. 

Summary of results: 8 Patients (5M, 3F) with an average age of 30.1yrs (18-41) 

were followed up at an average of 17 months. At follow-up the average QuickDASH 

score was 13.95 (0-30.8) and all had a Kapanji score of 9 or 10 and extension of 

he thumb off the table. Six patient were happy or very happy with the results. Of the 

remaining 2 patients, 1 had various other associated injuries and the other was an 

injury on duty patient. One patient had a mild tansient irritation of the the superfical 

radial nerve. 

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Conclusion: Combining the EL stabilisation with a trapezial tunnel, through a single 

volar approach, may address combined dorsal and volar instability of the thumb CMC 

joint more effectively. Our early results of this two-tunnel technique, incorporating the 

trapezium and the metacarpal base, are encouraging. 

Paper 437 


Authors: G Abbas, M Mullins , D Woodnutt 


Abstract title: Trunnionosis at heterogeneous coupling in large head metal on 

metal total hip replacement 

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Introduction and aims 

Heterogeneity of trunnion couples of the femoral component in total hip replacement 

has become popular with advantages of allowing the better bearing surface qualities 

of chromium (Cr) cobalt (CO) alloys, for example. The introduction of a modular 

interface to femoral stems comes with the potential for corrosion at the trunnion 

through Mechanically Assisted Crevice Corrosion (MACC). Corrosion at the trunnion 

(Trunnionosis) has been suggested to be influenced by material combinations and 

femoral head size. We assessed the effect of trunnion couple and head size on 

trunnionosis using plasma metal ions in large head metal on metal arthroplasty 

procedures. 

Methods 

A continuous cohort of 572 cases of large head (>36mm) metal on metal hip 

arthroplasty was reviewed over a period of 14 years in a single arthroplasty unit. 

We identified 34 tunnion combinations implanted by 14 different surgeons. 489 

patients were available for clinical, biochemical and radiological assessment. 

Survival analysis was estimated using the using Kaplan Meier method. Polynomial 

regression analysis was used on the correlation of head size to Co:Cr ratios. 

Results 

At a mean of 74 months (2-151) follow-up, the survival (Kaplan Mier analysis) was 

82.7% (75-90.5%). Average Harris hip Score (HHS) was 86.3 at a mean of 46 

months post-surgery. There were 9 deaths (3.3%) and 41 (7.2%) revisions with 

18 demonstrating either increased metal wear or overt Adverse Metal Reactions 

(including trunnionosis) In all Trunnionosis related failures, there was differential 

increase of plasma cobalt (Co) compared to chromium (Cr) ions (2.10 compared to 

1.47, p

Paper 440 


Authors: A. Chauhan, P. Karpe, M.C.Killen, R. Limaye 


Abstract title: Results of Calcaneal Osteotomy and Flexor Digitorum Longus 

transfer in Stage II Acquired Flatfoot Deformity 

Purpose of Study- Acquired flatfoot deformity (AFFD),often due to posterior tibial 

tendon dysfunction(PTTD), is commonly seen in foot and ankle clinics. It presents as 

progressive flattening of foot with increased load on first metatarsal, plantar medial 

rotation of talus, decreased medial arch height, midfoot abduction and heel valgus. 

Initially classified by Johnson and Strom(1989) and modified bt Myerson(1996), 

Haddad et al(2011)recently subclassified stage II into five subtypes; IIB being flexible 

forefoot supination. Medial slide calcaneal osteotomy alone or with flexor digitorum 

longus(FDL) transfer, lengthening of lateral column, and lengthening of gastrocnemius, 

all have been used alone or in combinations. Purpose of this study is to present our 

results of stage IIB AFFD managed with medial slide calcaneal osteotmy and FDL 

transfer. 

Description of methods- This retrospective study included 23 patients with 

symptomatic stage IIB AFFD operated between 2012 to 2015. Inclusion criteria 

were assymetrical flat foot with supination deformity of forefoot,pain and swelling 

on medial ankle,inability to perform single heel raise,markedly reduced or absent 

strength of inversion(MRC

Abstract title: Supramalleolar Osteotomy: A Joint-Preserving option for advanced 

ankle osteoarthritis 

Purpose of Study - Until recently, arthrodesis and ankle replacement have been the 

mainstay for advanced ankle osteoarthritis. Supramalleolar osteotomy provides a jointpreserving 

option for patients with eccentric osteoarthritis of ankle, particularly those 

with varus or valgus malalignment. Purpose of this study is to evaluate radiological 

and functional outcomes of patients undergoing shortening supramalleolar osteotomy 

for eccentric(varus or valgus) ostearthritis of ankle. 

Description of methods - This pospective study included patients with eccentric 

osteoarthritis of ankle from 2008 to 2015 who failed inital conservative management 

for atleast six months and underwent supramalleolar osteotomy. Preoperative standing 

anteroposterior and Saltzman view radiographs were taken to evaluate degree of 

malalignment requiring correction. Patients were assessed in clinics for range of motion 

in ankle and outcomes using American Orthopedic Foot and Ankle Society(AOFAS) 

scores. Radiological and Clinical outcomes were assessed at 3,6 and 12 months 

follow-up. Radiographs were reviewed for time to union. 

Summary of results - Over a period of seven years(2008-2015), thirty three patients 

underwent this surgery and were followed for an average of 25 months(Range 22-30 

months). Mean radiological union time was 8.6 weeks(Range 8-10 weeks), without 

any case of non-union. There was a statistically significant(P

Method: An analysis of consecutive patients undergoing diagnostic ankle 

arthroscopy with either ligament reconstruction or supramalleolar osteotomy by a 

single surgeon over a 12 month period. A retrospective review of the incidence of 

any complications was undertaken. 

Results: 104 patients underwent diagnostic ankle arthroscopy in the 12 month 

period. All patients completed routine 6 weeks, 3 months and 6 months followup. 

The overall complication rate was 3.8%. The incidence of neurological 

complications in our series was 0.96%, with a superficial peroneal nerve injury 

occurring in one patient. 

Conclusion: Thorough knowledge of the underlying anatomy, preoperative marking 

of the superficial peroneal nerve and careful placement of the anterolateral portal 

can reduce the rate of iatrogenic neurological injury during ankle arthroscopy. 

Paper 449 

Presenter: P Karpe 

Authors: M Killen, P Karpe, R Limaye 


Abstract title: Venous Thromboembolism Following Ankle Arthroscopy 

Background: The number of ankle arthroscopies being performed is increasing for 

both diagnosis and treatment of intra-articular pathology. Venous thromboembolism 

is an uncommon complication following ankle arthroscopy, but can have 

devastating outcomes. Publication of procedure-specific studies evaluating rates of 

post-operative thromboembolism is lacking, and current guidelines reflect this. 

Aim: To evaluate the incidence of thromboembolism in a consecutive series of 

patients undergoing diagnostic ankle arthroscopy, with intervention requiring 

immobilisation in a non-weight bearing cast post-operatively. 

Method: An analysis of consecutive patients undergoing diagnostic ankle 

arthroscopy with either ligament reconstruction or supramalleolar osteotomy 

by a single surgeon over a 12 month period. A retrospective review of the 

incidence of any complications was undertaken, with a particular focus on venous 

thromboembolism. 

Results: 104 patients underwent ankle arthroscopy during the 12 month period. 

All patients completed routine follow-up at 6 weeks, 3 months and 6 months. The 

overall complication rate was 3.8%. The incidence of venous thromboembolism in 

our series was 0.96%. 

Conclusion: Our incidence of venous thromboembolism with standard use of low 

molecular weight heparin in all patients is lower than previously published. Larger 

trials will aid in identifying whether chemoprophylaxis is required in all those 

undergoing ankle arthroscopy with post-operative immobilisation, or just patients 

with additional risk factors. 

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Paper 451 

Presenter: A Weusten 

Authors: A Weusten, B Purushothaman, M Webb, S Bonczek, J Ramaskandhan, A 

Nanu 


Abstract title: Decision making on timing of surgery for hip fracture patients on 

clopidogrel 

Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to 

orthopaedic surgeons. The aim of this study was to determine whether delay to theatre 

for these patients affects a drop in haemoglobin levels, need for blood transfusion, 

length of hospital stay and 30-day mortality. A retrospective review of all neck of 

femur patients admitted at two centres in the North East of England over 3 years 

revealed 85 patients. 

Patients were divided into two groups: Treatment with clopidogrel alone (C) or with 

aspirin (CA). 

Haemoglobin drop was significantly different in the CA group that was operated 

on early (CA1) versus delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl 

respectively (p=0.01). The mean inpatient stay in group C was 

35.9 days versus 19.9 days (p=0.002). Length of stay in group CA2 (26.7 days) 

was significantlylonger than for CA1 patients (14.1 days) (p=0.01). There were no 

significant differences in mortality or wound complications. 

Hip fracture patients on clopidogrel can be safely operated on early provided they 

are medically stable. Bleeding risk should be borne in mind in those patients on dual 

therapy with aspirin. 

Paper 453 

Presenter: J Carpenter 

Authors: J.E. Carpenter, A.L. Taylor, C.B. Robbins, A. Bedi, J.J. Gagnier, B.S. Miller 


Abstract title: Do Statin Medications Affect Clinical Outcomes in Patients Treated 

Surgically for Rotator Cuff Tears? 

Background: 

Elevated serum lipids have been associated with both rotator cuff tears and poor 

tendon-to-bone healing. Statin medications, commonly prescribed to lower lipids, 

may also have beneficial effects on muscle, and might therefore alter the biology of 

rotator cuff disease. The objective of this study was to compare clinical outcomes of 

the surgical treatment of rotator cuff tears in patients who were and were not taking 

statin medications. 

333

Methods: 

A prospective cohort of patients with full-thickness rotator cuff tears was analyzed 

in order to evaluate the effect of statin use on the outcome of rotator cuff repair. 

Patients taking a statin medication were compared to patients who were not on 

statins. Patients completed assessments at baseline, 4, 8, 16, 32, 48 and 64 weeks. 

Outcome measures included the Western Ontario Rotator Cuff Index (WORC), the 

American Shoulder and Elbow Surgeons (ASES) Shoulder score and a Visual Analog 

Scale (VAS) for Pain. In addition, patients’ serum lipid profiles were assessed at the 

time of study enrollment. A pre-hoc power analysis was performed. Generalized 

estimating equations used for longitudinal modeling of the primary outcomes. 

Results: 

30% of 124 subjects were taking statins at the time of enrollment. Patients on 

statin medication were older (60.4 vs 56.6 years, p=0.024) and had a higher 

Functional Comorbidity Index (1.38 vs 0.88, p=0.043) than those not on 

statin. Patients on a statin had lower HDL levels at baseline (46.71 vs 54.28, 

p=0.044) and lower (better) baseline WORC scores (1147.76 vs 1295.06, 

p=0.045). The two groups were not statistically different at baseline for other 

lipid markers (total cholesterol, LDL, triglycerides), BMI or size of rotator cuff tear. 

Subjects on a statin reported no statistically significant difference in WORC, 

ASES or VAS scores over time when compared to the non-statin controls 

(p=0.457, p=0.535, p=0.915). Males reported better outcome scores than 

females, and smokers reported scored worse outcomes than non-smokers. 

Conclusions: 

Controlling for demographic and clinical covariates, neither statin use nor lipid 

levels were associated with clinical outcomes in patients treated surgically for rotator 

cuff tears. Similar to previous studies, females and smokers reported lower clinical 

outcome scores. 

Paper 455 

Presenter: J Carpenter 

Authors: J.E. Carpenter, C.B. Robbins, A. Bedi, J.J. Gagnier, B.S. MIller 


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Abstract title: Surgery Improves Quality of Life in Patients with Rotator Cuff Tears 

Background: 

Health related quality of life (HRQoL) is a type of measure being increasingly used 

within orthopaedic research. For those with rotator cuff disease there is a paucity 

of information on how operative or non-operative interventions affect long-term 

quality of life. The objective of this research project was to examine the HRQoL 

334

etween an operative and non-operative cohort as well as determinants that 

influence quality of life (QOL) outcomes for those with full thickness rotator cuff tears. 

Methods: 

Patients with full thickness rotator cuff tears were invited to participate in a prospective 

cohort study. Participants (N=212) completed pain VAS, shoulder activity level, 

functional comorbity, WORC and ASES instruments, and the Veterans Rand VR-12 

at baseline, 4, 8, 16, 32, 48, and 64 weeks. Generalized estimating equations 

were used to examine the effects of demographic and clinical factors on quality of life 

longitudinally from baseline to 64 weeks 

Results: 

The sample consisted of 126 males and 86 females with a mean age of 60 ±9.6. 

There were 93 non-operative and 119 operative subjects. There was significant 

improvement in HRQoL scores for the surgical group, but not for the non-surgical 

group. Factors predictive of higher Mental Component Summary Scores were nondiabetic, 

non-smoker, lower functional comorbidity, higher baseline pain (all p

Methods: 

We looked into clinical practices across two sites in our trust. The inclusion criterion 

were patients admitted with spondylodiscitis over six years. Exclusion criteria included, 

previous spinal instrumentation and incomplete documentation and laboratory results. 

We noted the nature and duration of symptoms; if blood culture/biopsy were 

performed at presentation; duration of antibiotics and final outocome. Overall, 78 

patients were identified of whom 8 were excluded. 

Results: 

Overall, 40% with suspected spondylodiscitis had blood cultures in A&E prior to 

antibiotics; blood cultures were positive in 37%. Nearly 80% were diagnosed with 

discitis on MRI scan, whilst 81% of those who received IV antibiotics were treated 

for 6 weeks or less. Duration between symptoms and presentation ranged between 

two weeks and a month. 

Conclusions: 

1) Cultures/biopsy prior to initiation of antibiotics is poor 

2) Poor identification of causative organisms in cultures may be due to community 

antibiotics for mistaken diagnoses 

3) The majority of patients had shorter than expected courses of IV antibiotics 

4) There is a significant variation in presentation from onset of symptoms 

Thus, these conclusions have assisted us in creating a simplified algorithm. Key points, 

include: 

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1) If spondylodiscitis is suspected, the patient must have bloods, including cultures, 

urine dip and a full neurological examination 

2) If neurological deficit is present, antibiotics should be started, neurosurgeons 

contacted and an urgent MRI spine performed 

3) If no neurological deficit is present, haemodynamic status should be assessed; 

if unstable: requires antibiotics, neurosurgical opinion and imaging within 2 hours; 

if stable: requires imaging within 6 hours +/- biopsy if indicated by imaging; 

antibiotics should be held until after the biopsy 

4) Combination therapy Vancomycin and Ceftriaxone should be used unless 

aetiology known from blood cultures or previous cultures 

We believe our simplified guidelines and local education about the topic are vital 

to ensure early recognition and treatment of patients with suspected spondylodiscitis. 

336

Paper 462 

Presenter: GJ Della Rocca 

Authors: PRAISE Investigators, S. Sprague, M. Bhandari, G.J. Della Rocca, J.C. 

Goslings, R.W. Poolman, K. Madden, N. Simunovic, S. Dosanjh, E.H. Schemitsch 


Abstract title: PRevalence of Abuse and Intimate partner violence Surgical 

Evaluation (PRAISE): A multi-national screening study in orthopaedic fracture 

clinics 

Background: Intimate partner violence (IPV) is a leading cause of non-fatal injury to 

women. Musculoskeletal injuries, often managed by orthopaedic surgeons, are a 

highly prevalent manifestation of IPV, second only to head and neck injuries. We 

evaluated the 12-month and lifetime prevalence of IPV in women presenting to 

orthopaedic fracture clinics. 

Methods: The PRAISE investigative team (80 investigators) conducted a cross-sectional 

study of 2,945 female patients at 12 orthopaedic fracture clinics in Canada, the 

United States (USA), the Netherlands, Denmark, and India. Study subjects anonymously 

answered questions about IPV and completed two previously validated questionnaires 

regarding IPV. We conducted a multivariable logistic regression analysis for the 

purpose of investigating risk factors associated with IPV. 

Findings: One in six women (16·0%, 95% Confidence Interval (CI): 14·7-17·4%) 

disclosed a history of IPV within the preceding 12 months, and one in three women 

(34·6%, 95% CI: 32·8-36·5%) had experienced IPV at some point during their 

lifetimes. Forty-nine women (1·7%, 95% CI: 1·3-2·2%) presented to their current 

clinic visit with injuries that were a direct consequence of IPV. Of these 49 women, 

only seven (14·3%) were asked about IPV by a healthcare provider during their visits 

for treatment. Increased risk for experiencing IPV in general or, specifically, physical 

abuse, was seen in women with low incomes, those in shorter-term relationships, and 

those who lived in Canada or the USA. 

Interpretation: PRAISE is the largest screening study conducted to date in orthopaedics, 

and represents one of the only studies in orthopaedics to evaluate risk factors for 

IPV. Based upon our study results, orthopaedic surgeons should be confident in the 

assumption that one in six women presenting for care of musculoskeletal injuries have 

a recent history of physical abuse, and that one in 50 injured women will present with 

injuries caused by IPV. Our findings merit serious consideration for optimizing fracture 

clinics in order to identify, respond to, and provide referral services for victims of IPV. 

Paper 463 

Presenter: K Daly 

Authors: J.Dabis, M.Warlow, A.Overton M.Farrar, D.Barnes, J.Norman, Y.Gelfer 

and K.Daly 


337

Abstract title: IMPROVING QUALITY AND CONSISTENCY OF CARE IN 

SURGERY FOR INFANT HIP DYSPLASIA: IMPACT ON LENGTH OF STAY 

The aim of this study was to describe improvements in a care pathway for infants 

having surgery for hip dysplasia and demonstrate the impact on the length of stay 

over a period of 10 years. 

We performed a retrospective analysis of two cohorts of patients from our DDH 

database who were treated with primary open reduction with or without femoral 

derotation osteotomy or innominate osteotomy. Development of the pathway has 

been an iterative process involving observations by the surgical team and feedback 

from anaesthetics, junior doctors, nursing staff and parents. The key elements of the 

contemporary pathway are: 

• Establish clear parental expectation of process and discharge date 

• High volume caudal block with levobupivacaine and clonidine 

• “Right first time” spica 

• Avoiding opiates perioperatvely 

• Dose of NSAID intraoperatively 

• Regular NSAID and Paracetamol post op 

• Regular low dose Diazepam to reduce hypnagogic spasms, continued after 

discharge as required 

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• Hip spica information sheet 

We had data on 22/38 patients between 2004/08 (Group A) and 19/22 patients 

in 2014/15 (Group B). The groups were comparable in terms of surgery performed. 

There were no readmissions. In group A there was one early re-dislocation and one 

sciatic nerve palsy which resolved. In Group B there were one early re-dislocation. 

The average length of stay in-group A was 2.59 days and in Group B was 1.23 

days. This was of statistical significance, p

Paper 464 

Presenter: JF Van Der Merwe 

Authors: J. F. van der Merwe, W van der Merwe, J. D. Arndt 


Abstract title: The Effect of Popliteus Tendon Division in Total Knee 

Athroplasty 

Introduction The popliteus tendon may be divided during total knee arthroplasty of 

the varus knee in one of two scenarios: as treatment for the tendon snapping over 

the prosthesis or inadvertently. Only a few in vivo studies have been done on the 

effect of its division. None of these used an accurate measuring tool to determine 

the resultant instability. We used computer assisted surgery (CAS) to determine 

the amount of instability caused by dividing the popliteus tendon during normal 

arthroplasty surgery. Methods 15 successive TKR’s in 14 patients with osteoarthritic 

Varus knees were performed using CAS. The gap balancing technique was used. 

The gap information was recorded in millimeters at 0°, 30°, 45°, 60° and 90° 

of flexion with varus and then valgus stress. The popliteus tendon was then divided 

and the same gap information was recorded and compared with the previous 

values. With regards to follow up, the study population completed the KOOS data 

form pre op, 6 weeks- and at 6 months post op and compared to a control group 

in which popliteus was not divided. Results For the different tests of flexion, the 

mean increase in gap size varied from 0mm to 0,967mm. The biggest difference 

in gap size was noted at 90°flexion. The standard deviation of differences ranged 

from 0,327 to 1,172 Conclusion Dividing the popliteus tendon intra operatively in 

varus osteoarthritic knees during total knee arthroplasty does not lead to significant 

immediate instability. KOOS follow up results at 6 months post op are comparative 

to a control group in which the tendon was left intact. 

Paper 465 

Presenter: WA Wallace 

Authors: W A Wallace, N Alfahad, A Bhattacharya, K Kumar 

Disclosure: Yes: Consultant for JRI Orthopaedics Ltd 

Abstract title: Harmonisation of Outcomes following Shoulder 

Replacement Surgery 

Background: Around the world different surgeons are reporting their outcomes following 

shoulder replacement using different shoulder scoring systems. As a consequence it 

has been very difficult to compare the outcome of shoulder replacement in the UK; 

typically using the Constant Score (CS) or Oxford Shoulder Score (OSS) with Europe; 

typically using the CS or the Disabilities of the Shoulder and Hand Score (DASH) and 

with the USA; typically using the Simple Shoulder Test (SST), American Shoulder & 

Elbow Society Score (ASES) or the University of California Los Angeles Score (UCLA). 

Methods: In 2015 Booker et al reported on a method of categorizing outcome 

339

following shoulder replacement into 5 categories – Poor (CS69) (see Booker et al 

World Journal of Orthopedics 2015 6; 2: 1-8). 

In 2015 Alfahad et al 2015 have identified how the Constant Scores can be 

converted to the other 5 scoring systems following an analysis of 6 different shoulder 

scores on 200 different patients. The following equations develooped from that study 

have allowed the following conversions to be calculated:- 

OSS = 0.3927 x CS + 11.646 

SST = 1.0294 x CS- 8.2678 

ASES = 0.8592 x CS + 9.997 

UCLA = 0.2717 x CS + 7.1451 

DASH = -0.7826 x CS + 75.159 

Results: Using the equations established above, the equivalent scoring values for 

Poor, Fair, Good, Very Good and Excellent have been calculated for the Oxford 

Shoulder Score, the Simple Shoulder Test, the American Shoulder and Elbow Score, 

the University of California Los Angeles Score and the Disabilities of the Shoulder and 

Hand Score as follows:- 

For OSS 39 

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For SST 63 

For ASES 69 

For UCLA 26 

For DASH >52; 44-52; 29-43; 21-28;

Abstract title: Distal Radius Fractures fixation with PEEK plate Compared 

To Volar Locking Plate- A Prospective, Randomized Controlled Study 

Objective: Assess and compare the functional and radiological results in patients 

treated with the Carbon fiber reinforced radiolucent PEEK plate compared to 

conventional Volar Locking Plate 

Method: All patients who presented to our institution with displaced intra- articular 

distal radius fractures and met the inclusion criteria were invited to take part in the 

study. The patients were randomly allocated to two groups, those who underwent 

distal radius fixation using the CFR-PEEK plate and those who underwent fixation using 

a volar locking plate. The patients were then asked to follow- up at 2 weeks, 6 weeks, 

3 months, 6 months and one year. The radiological parameters, i.e radial height, 

inclination and tilt were compared as well as the functional outcomes by means of 

DASH score. Incision size and tourniquet times were recorded. Complications were 

reviewed. 

Results: Currently we have included 21patients in the PEEK plate group and 21patients 

in the volar plate group. At 6 months the average DASH scores are 19.9 and 24.4 

respectively. Average union period is 5.5 weeks. The radiological parameters are 

statistically comparable. . There were no complications in either group. 

Conclusion: 

Volar CFR- PEEK plate fixation of distal radius seems to compare to volar lock plating in 

terms of radiological outcomes as well as functionally. The CFR- PEEK plate group has 

advantage of ability to see the union of fracture through the plate and relative ease 

by which the intra-articular step or fracture line can be identified. Added advantage 

in PEEK plate is no chance of cold welding and relative easier to remove implant if 

required. 

Paper 469 

Presenter: A Ikram 

Authors: A.Ikram, C Anley, D Van der Spuy 


Abstract title: Nerve Transfers for C5/6 Brachial Plexus Injury, our 

experience with Dorsal Approach and 1-2 yr results. 

Aims of study: 

Assess the functional results of double or triple nerve transfers for the C5/6 Brachial 

Plexus injury. 

341

Method: 

All adult patients who presented to our institution in last two years with loss of C5 

and C6 after the Brachial plexus Avulsion injury and where primary repair was not 

possible underwent the Nerve transfers to reconstruct the shoulder abduction, external 

rotation and elbow flexion as a single or two stage procedure. 

Dorsal approach to the spinal accessory nerve was used for neurotisation to the SSN, 

Radial nerve branch to the long head of triceps was used to restore the axillary nerve 

function and single fascicle of ulnar nerve to the wrist flexor was utilized to target the 

MCN nerve to the biceps muscle. 

The patients were follow- up at 6 weeks, 3 months, 6 months, 1 year and 2 years. 

The muscle charting was done with MRC grading. 

Results: 

We currently have done 9 patients with C5/6 Brachial plexus injury which received 

double or triple nerve transfers and early results shows the return of biceps function an 

average of 5 months, the shoulder abduction and external rotation functional recovery 

is incomplete. 

Conclusion: 

Loss of shoulder abduction, external rotation can be reconstructed as a single stage 

procedure from the dorsal approach to the spinal accessory & radial nerve, and 

Oberlin transfer for elbow flexion from volar approach. 

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Paper 470 

Presenter: A Parker 

Authors: A. Haldar, J. Davidson, A. Parkar, S. Khan, S. Kantharuban, A. Sharma, J. 

Miles, JM. Jagiello, R. Pollock, R. Carrington, WA. Aston, J. Skinner, TWR. Briggs 


Abstract title: 35 Years of Multiple Revision Hip Arthroplasty: A 

Specialist Joint Reconstruction Unit’s Experience 


Incidence of revision total hip arthroplasty is increasing worldwide and rerevision 

surgery is also a growing phenomenon. Yet little is known about patients 

who have undergone multiple revision hip surgeries. Our centre is a specialist joint 

reconstruction unit with a concentrated experience in this area. 

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The purpose of this study was to establish the indications for multiple revision hip 

arthroplasties and assess time between revisions. 


Only patients who had a history of multiple (two or more) revisions after primary hip 

surgery were included, a revision being defined as a completed single or two-stage 

revision. 

Data was collected retrospectively from the hospital notes of a sample of patients who 

had revision hip surgery at our centre between January 2003 and July 2015. 


A sample of 143 patients underwent multiple hip arthroplasties, but only 101 had 

complete data. The oldest primary total hip arthroplasty was performed in 1971 and 

the most recent in 2010. The oldest revision hip was implanted in 1980 and the most 

recent in July 2015. 

First revision surgery was performed for aseptic loosening in 68 cases (67.3%), 

infection in 12 cases (11.9%) and for dislocations in 10 cases (9.90%). Mean time 

to first revision was 7.39 years post-primary total hip arthroplasty. 

Second revision surgery was performed for aseptic loosening in 55 cases (54.5%), 

infection in 25 cases (24.5%) and dislocations in 11 patients (10.9%). Mean time 

from first to second revision for all causes was 6.00 years. 

Third revisions were for infection in 11 of 28 cases (39.3%), aseptic loosening in 9 

cases (32.1%) and dislocations in 3 cases (10.7%). Mean time to third revision was 

5.82 years. 

Fourth revisions were caused by infection and aseptic loosening in 2 cases apiece 

(33.3% each) and dislocations in 1 instance (16.7%). Mean time from third to fourth 

revision was 2.98 years. 

One patient required six revisions for aseptic loosening initially and infection latterly. 

Another patient underwent seven single-stage revisions for combinations of loosening 

and dislocation. 

Conclusion 

Our results highlight the increasing burden of infected joint replacements in multiply 

revised hips. Infection as a cause for revision doubled from first to second revision 

and almost doubled again from second to third revision. Our results also highlight the 

decreasing time interval to subsequent revisions. 

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Paper 471 


Authors: Mr P Karpe,Ms M Claire,Mr M Chauhan,Mr Limaye 


Abstract title: EARLY RESULTS OF ROTOGLIDE JOINT ARTHROPLASTY 

FOR TREATMENT OF HALLUX RIGIDUS 

Background: Hallux rigidus is a degenerative condition characterized by pain, 

reduced range of motion and proliferative osteophyte formation. Historically, 

arthrodesis has proven to be the most reliable procedure for providing pain relief. 

However, many active patients find the thought of loss of motion in exchange of pain 

relief unacceptable. The aim of our study is to evaluate results of Rotoglide prosthesis 

for treatment of hallux rigidus. 

Aim: To evaluate radiological and functional outcomes of patients undergoing 

Rotoglide Joint arthroplasty for treatment of moderate to severe hallux rigidus. 

Method: Between Jan 2013 to Jan 2015, a total of 31 toes in 27 patients with MTP 

arthritis of the MTP joint underwent arthroplasty with Rotoglide implant. The Roto-glide 

Great Toe system is a 3-part Anatomical Great Toe system that incorporates a sliding 

and rotating meniscus. All patients were evaluated clinically and radio graphically 

at 3,6,12 and 24 months follow up. Postoperative satisfaction and function were 

assessed according to American Orthopaedic Foot and Ankle Society Score (AOFAS). 

Results: Mean follow-up was 10 months (range 2 month to 26 months) 

Mean preoperative AOFAS score improved from 34.7(range 17- 59) pre-operatively 

to 82.2(range 61-93) at final follow up. The average MTP ROM improved from 

5 degrees (range 5- 15) to 35 degrees (range 30-50) postop. 1 patient needed 

revision at 12 months due to severe ongoing pain and stiffness and was revised to 

removal of implant, impaction bone grafting, and fusion using plate and screws. The 

second patient developed hallux valgus at the end of 14 month from the original 

surgery and was treated with the correction of hallux valgus with a basal osteotomy. 

The MTP joint was not revised as the joint looked satisfactory. One patient developed 

superficial infection that settled with oral antibiotics. There was no evidence of any 

radiological loosening of the implant in any other patient. 

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Conclusion: Rotoglide total first MTP joint prosthesis yielded good functional outcome 

and high patient satisfaction level with low early complication rate. Preservation of 

joint movement and good pain relief with early mobilization were the advantages of 

this procedure 

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Paper 472 


Authors: Mr P Karpe,Ms M Claire,Mr M Chauhan,Mr Limaye 


Abstract title: Shortening Scarf osteotomy for Correction of severe 

hallux valgus. Does Shortening Affect The Outcome? 

Introduction/Aim 

Scarf osteotomy allows displacement in different directions making it versatile in 

correcting severe hallux valgus deformities. The large contact areas make it inherently 

stable. It is the translation and shortening of the Scarf osteotomy allows correction of 

severe hallux valgus deformity. Some studies raise concern of the shortening with a 

demonstrable relationship with postoperative transfer metatarsalgia. 

The purpose of this prospective study is to evaluate anatomical and functional 

outcomes of patients undergoing shortening Scarf osteotomy for severe hallux valgus 

deformities. 

Materials and Methods 

From September 2009 to July 2010, 15 patients (20 feet) with a mean age of 

58 years underwent shortening Scarf osteotomy for severe hallux valgus deformities 

(inter-metatarsal angle (IM) of >15 o or hallux valgus (HV) angle >35 o ). All patients 

had primary operations that failed a conservative line of management. Patients with 

severe hind foot deformities and osteoarthritis were excluded. 

Outcome measures were pre and postoperative AOFAS scores. Subjective evaluation 

was also carried out with patients at every follow up to record their satisfaction 

between very unsatisfied, unsatisfied, satisfied or very satisfied. 

Mean follow-up was 25 months [22-30]. 

All patents underwent were operated by a single foot and ankle surgeon. The amount 

of shortening needed was decided using the ms point and making use of the maestro 

cut. A maximum shortening of 10 mm was done in every case. 

Results: 

All patients had primary surgeries with 20 operated feet. The osteotomies united in 

all patients. 

Statistical analysis was done using the SPSS software. Student t-test was done to 

assess the level of significance (p value). 

345

The mean intermetatarsal angle improved from 19.03 0( 13.4 – 26.2) preoperatively 

to 10.02 0( 8.0 – 13.7) postoperatively (p < 0.001). The mean hallux valgus angle 

also improved from 43.17 0( 27.4 – 68.2) preoperatively to 13.57 0( 3.0 – 37.4) 

postoperatively (p < 0.001). 

The mean AOFAS score improved from a preoperative 29.75 (14-60) to postoperative 

82.80(55-100). The mean improvement was 53.05 (p < 0.001). Subjective 

questionnaire revealed all patients rating their satisfaction to either satisfied to very 

satisfied. None of the patients had symptoms of transfer metatarsalgia at the final 

follow up. 

Conclusions: 

Based on our results, we recommend shortening Scarf osteotomy as a viable primary 

option for treating severe hallux valgus deformities with no significant concern of 

transfer metatarsalgia. 

Paper 473 

Presenter: GB Firth 

Authors: GB Firth, L Wood, Y Ramguthy, J Potterton 


Abstract title: Single-event multilevel surgery (SEMLS) in walking 

children with spastic diplegia in South Africa: A Pilot study comparing 

outcome in children with CP and HIV encephalopathy 

1. Purpose of Study: 

A prospective pilot study was performed to determine the outcomes of SEMLS in 

children with Cerebral Palsy (CP) and HIV encephalopathy and to determine the 

differences between the two groups. 

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2. Description of Methods: 

Ten children underwent SEMLS at a single Institution in South Africa and received a 

structured physiotherapy rehabilitation programme either at a local clinic, hospital or 

a special needs school (five children, with a school physiotherapist) peri-operatively. 

The patients were reviewed at three time periods – T1 (Pre-operatively), T2 (Six months 

post-operatively) and T3 (Mean 19.4 months (Range 12-31)). The primary outcome 

measures were the Gross Motor Function Measure (GMFM), the Functional Mobility 

Scale (FMS) and the Edinburgh Visual Gait Score (EVGS). 

3. Summary of Results: 

Ten consecutive children with spastic diplegia were enrolled (six with CP, four with 

HIV encephalopathy). The mean age at surgery was 118.4 months (Range 78- 

173). Six children had a Gross Motor Function Classification System (GMFCS) 

346

of II (One HIV Encephalopathy) and four children had a GMFCS of III (Three HIV 

Encephalopathy). An average of 6.7 procedures were performed in each child as 

part of the SEMLS procedures (Range 4-8). The patients with HIV Encephalopathy 

had a lower pre-operative GMFM score (Mean 61.3, Range 50.9-69.6) compared 

to the CP patients (Mean 71.9, Range 50.1-83.0). The GMFM scores showed 

an overall improvement in all patients with a mean pre-operative score of 67.7 

(Range 50.1-90) and a mean final follow-up score of 70.3 (Range 47.5-92.1). 

The patients with HIV Encephalopathy had a lower pre-operative FMS (Mean 8.8, 

Range 3-15) compared to the CP patients (Mean 15.2, Range 4-18). There was an 

overall improvement in the FMS scores at final follow-up with a pre-operative mean 

of 12.6 (Range 3-18) and a mean final follow-up score of 13 (Range 3-18). There 

was an overall slight deterioration in the EVGS with a pre-operative combined score 

of 16.9 (Range 4-24) and a final follow-up score of 13.2 (Range 4-22). There was 

no significant difference seen comparing the outcomes of the CP group and the HIV 

encephalopathy group. 

4. Conclusion: 

Although improvements were seen in the average GMFM and FMS at final follow-up, 

a slight deterioration was seen in the EVGS. Further research is required regarding 

the outcome of SEMLS in the HIV encephalopathy group and the CP group in an 

African setting. 

Paper 474 

Presenter: JRT Pietrzak 

Authors: JRT Pietrzak, DR van der Jagt, L Mokete 


Abstract title: Antibiotic Prophylaxis for Patients with Joint 

Replacements prior to Dental Procedures. South African Current 

Practice and Recommendations. 

Antibiotic prophylaxis prior to dental and other procedures when patients have joint 

replacements in situ remains controversial. Recommendations seem to generally be 

intuitive and not based on any sound scientific evidence. Recently, the American 

Academy of Orthopaedic Surgeons altered their previous standpoint and suggested 

that orthopaedic surgeons review their current practice of routine prescription of 

antibiotic prophylaxis. 

We conducted an electronic survey of members of the South African Orthopaedic 

Association to determine the opinion of the average orthopaedic surgeon in South 

Africa in respect of this prophylaxis. 111 surgeons responded. 

73% of respondents were of the opinion that patients with joint replacements in 

situ should take antibiotic prophylaxis prior to undergoing any dental procedure. 

65% of surgeons were of the opinion that this prophylaxis should be life-long. 59% 

347

of surgeons recommended that prophylaxis start before the procedure, at 24% at 

the same time as the procedure. 35% of surgeons recommended prophylaxis with 

every dental procedure, and 61% only with more invasive procedures. We also 

show that working in private practice and greater surgical experience increases the 

likelihood that orthopaedic surgeons will prescribe prophylactic antibiotics prior to 

dental procedures. 

Scientific evidence linking bacteraemia from dental procedures with infected prosthetic 

implants is limited, however 19% of orthopaedic surgeons reported managing an 

infected implant as a result of dental surgery. 

We reviewed the scientific literature and could find no evidence to substantiate the 

practice of using antibiotic prophylaxis prior to dental or any other procedures in 

those patients with joint replacements in situ. We recommend that these patients do 

not use antibiotic prophylaxis prior to dental and other procedures, except in those 

patients with-in two years of the index procedure, where the implant –bone interface 

may not yet have matured, and those that may be immune-compromised. 

Paper 475 

Presenter: GB Firth 

Authors: Dr GB Firth, Dr J Du Plessis, Dr J Schutte, Dr M Camacho, Dr Y Ramguthy, 

Dr D Simmons, Prof A Robertson 


Abstract title: Effect of a Polyvalent Pneumococcal Vaccine on the 

Epidemiology of Acute Osteo-articular Sepsis in a Setting with a High 

Prevalence of Paediatric HIV Infections 

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1. Purpose of Study: 

There is limited information on osteo-articular infections in children infected with 

human immuno-deficiency virus (HIV). The purpose of this study was to determine the 

effect of HIV on the epidemiology of osteo-articular infections in a setting with a high 

prevalence of HIV infection and assess the impact of a polyvalent Pneumococcal 

vaccine. 

2. Description of Methods: 

A retrospective evaluation of children presenting with acute septic arthritis or 

osteomyelitis was undertaken in two time periods at two Academic Hospitals. The 

first period was between June 2005 and July 2009. The second time period was 

between August 2009 and March 2015. The division of the two time periods coincided 

with the introduction of a polyvalent Pneumococcal vaccine in the study 

population as part of the South African extended programme for immunisation (EPI). 

Standard departmental protocols for the management of osteo-articular infections, 

including testing for HIV were practised. 

348


Overall 235 children with osteo-articular infections were included in the study. This 

included 46 (19.6%) episodes in HIV infected children, 175 (74.4%) in HIV noninfected 

children and 14 (6%) in whom the HIV status was unknown. The median 

age of the children was 30.6 months (Range 9.2-82.9 months) in the first time period 

and 61 months (Range 1.0-192.0 months) in the second time period and did not 

differ by HIV status. In all culture positive cases, Streptococcus Pneumoniae was 

identified in 8 of 12 (66.7%) HIV infected children compared to 3 (9.7%) of 31 non 

HIV infected children (p


Six patients (five girls) with nine implant migrations were identified and included. 

Mean age at time of implant insertion was 7.2 years (Range 4-10 years). Of the 

nine TBP that presented with the complication four were inserted into the medial distal 

femur (two bilateral cases), two in the medial proximal tibia (one bilateral case), 

one in the lateral proximal tibia, one in the medial distal tibia and one in the lateral 

distal tibia. The mean time from insertion to detection of complication was 24 months 

(Range 9-54). The mean time to final follow up after detection of the complication 

was 23.6 months (Range 6-76). Two implants were removed, two required corrective 

osteotomies, four were revised with TBP’s and one was observed. None of these 

patients developed physeal growth arrest at final follow up as assessed on X-Rays. 

4. Conclusion: 

The use of TBP for guided growth in patients under ten years of age with rickets, 

neurofibromatosis or conditions producing osteopenia have an increased risk for 

implant migration. In these cases it is important to confirm that the epiphyseal screw 

has a good purchase with adequate length. These patients should be monitored 

closely for early detection of this complication. 

Paper 482 

Presenter: AR Hassan 

Authors: A. Hassan, D. Ferguson, J. Rudd, M. Mussa, S. West 


Abstract title: A 9-Year Review Of Primary Hip Arthroplasty And Their 

Post-Operative Outcomes In An Obese Cohort. 

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Purpose: Obesity is an increasing epidemic affecting 24% of men and 26% of 

women. An increased BMI poses additional risks for the patient from an anaesthetic 

perspective and technically can be more difficult for the operating surgeon. There is 

variable evidence regarding the post-operative outcomes in obese patients (BMI>30) 

undergoing primary hip arthroplasty. 

The objective was to investigate the peri-operative outcomes following primary hip 

arthroplasty in an obese cohort. 

Methods: We carried out a retrospective review of 60 patients undergoing total hip 

replacement from July 2004 - April 2013. The following data was analysed: patient 

demographics, duration of operation, blood loss, post-operative complications, 

duration of stay and pre and postoperative mobility. 

Results: Of the 57 complete data sets, 59.6% (34) were female and 40.4% (23) 

were male. The mean age was 60.3 (37-92) with mean BMI 40.6 (35-72). Mean 

operative duration was 64.3 minutes (39-108). The mean intra-operative blood loss 

350

in 17 patients was 723.4mls (250-1524mls) with 5 patients requiring post-operative 

blood transfusions. The mean hospital stay was 6.5 days (2-25). 43 patients 

were mobilising satisfactorily at a 6 week review, 13 independently, the remainder 

with aids. Post-operative complications were encountered in 23 patients, which 

included 8 leaking wounds requiring higher than average length of stay. There were 

6 documented wound infections, 1 requiring washout and debridement. Revision 

surgery was performed in 2 cases, the first 3 months post-op for acetabular component 

breakdown (catastrophic failure of ceramic liner), the second 18 months post-op for 

failure of full union Corail stem and loose proximal segment. There was one periprosthetic 

fracture requiring fixation 11 days post primary procedure. There was 

variable prescription of DVT prophylaxis - 31 patients were prescribed Enoxaparin 

40mg OD, 5 were prescribed 40mg BD, 7 were prescribed Rivaroxiban 10mg OD 

and in 14 cases there was no documentation of any DVT prophylaxis. 

Conclusions: Recent published studies have shown no significant relationship 

between obesity and complication rate in total hip arthroplasty. Despite this 

our study demonstrates a high rate of morbidity in this cohort undergoing primary 

hip arthroplasty. There is also a significant correlation of high BMI with operative 

duration, perioperative blood loss and length of stay. Although this obese cohort 

had increased perioperative complications, a good functional outcome was achieved 

as a result of their operative procedures. 

Paper 484 

Presenter: P Schneider 

Authors: P.S. Schneider, H. Johal, M. Zhang, D.A. Hart, A.D. Befus, P.T. Salo, C. 

Fan, X. Liang, K.A. Hilderbrand 


Abstract title: The Dose Response Effect of Ketotifen Fumarate on Post 

Traumatic Joint Contractures 

Purpose: Post-traumatic joint contracture (PTJC) is a debilitating complication of intraarticular 

injury. Prior research in a rabbit model has shown the mast cell stabilizer, 

ketotifen fumarate, can reduce PTJC. This study aimed to quantify the effect of a 100- 

fold dose range of ketotifen on PTJC and joint capsule fibrosis. 

Methods: An in-vivo model of knee PTJC was created using intra-articular injury and 

internal immobilization in skeletally mature New Zealand White rabbits. Five groups 

were studied (n = 10 per group): a non-operative control group (Non-OP), a PTJC 

group with no ketotifen (operative contracture group - OP), and three PTJC groups 

with ketotifen doses of 0.01-mg/kg (KF 0.01), 0.1-mg/kg (KF 0.1), and 5.0-mg/ 

kg (KF 5.0) injected subcutaneously twice daily for eight weeks. After eight weeks, a 

hydraulic materials testing machine quantified PTJC and posterior knee joint capsules 

were harvested for immunohistochemistry (IHC), Western blot gel electrophoresis, and 

reverse transcription-polymerase chain reaction (RT-PCR) quantification of α-Smooth 

351

Muscle Actin (SMA), Collagen type 1 (Col 1), and mast cell (MC) tryptase. Cell 

counts for myofibroblasts, MC, and Substance P (SP) containing nerve fibers were 

calculated. Statistical analysis used a one-way analysis of variance (ANOVA) with 

Tukey’s post-hoc analysis. 

Results: Five rabbits were excluded due to complications. Relative to the Non-OP, 

the OP group had an average flexion contracture of 39° ± 10°, while contracture 

severity was reduced to 34° ± 7° (p = 0.32), 21° ± 12° (p = 0.016) and 15° ± 

11° (p = 0.001) in the KF 0.01, KF 0.1, and KF 5.0 ketotifen groups, respectively. 

Using IHC analysis, there were statistically significant decreases in myofibroblast, 

mast cell, and SP counts between the OP group and KF 0.1 and KF 5.0 groups (p < 

0.05). There were no differences between the Non-OP and KF 5.0 groups; KF 0.1 

and KF 5.0 groups; and the OP and KF 0.01 groups for myofibroblasts, MC, and 

SP (p > 0.05). The Western blot gels also showed a dose-response effect of ketotifen 

on SMA, Col 1, and MC tryptase levels with a significant decrease between OP and 

KF 5.0 groups. The RT-PCR analysis for SMA and Col 1 followed a similar pattern. 

Conclusion: Ketotifen is a promising agent to translate into clinical trials. Using this 

rabbit model, increasing doses of ketotifen were associated with decreasing knee 

joint flexion contractures and decreasing numbers of myofibroblasts, mast cells, and 

SP containing nerve fibers in the joint capsule. 

Paper 485 


Authors: P.S. Schneider, B.A. Cotton, R.D. Husdon, M. Galpin, T.S. Achor, J.W. 

Munz, M.L. Prasarn, A.M. Choo, J.L. Cary 


Abstract title: Use of Thrombelastography in Predicting Venous 

Thromboembolic Events and Response to Femoral Reaming in 

Orthopaedic Trauma Patients 

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Purpose: Trauma-induced coagulopathy (TIC) is associated with increased venous 

thromboembolic (VTE) events. Reamed intramedullary nails (rIMN) are standard of care 

for femur fractures. However, reaming stimulates the immune system and controversy 

exists regarding timing of rIMN in polytraumatized patients. Rapid thrombelastography 

(r-TEG) is a whole blood assay that identifies hypo- and hypercoagulability. 

Methods: A retrospective review of 9090 consecutive trauma patients aged 18-85 

years defined 2 cohorts, one with extremity abbreviated injury severity (eAIS) scores 

≥ 2 (ORTHO) and one with eAIS scores were < 2 (non-ORTHO). Univariate analyses 

were conducted followed by purposeful regression analysis. Next, a prospective 

cohort study of patients with femur fractures amenable to fixation with a rIMN or 

reamed cephalomedullary nail (rCMN) was completed, with r-TEG measurements 

on arrival (arrival r-TEG), 1-hour pre-femoral reaming (pre r-TEG), 1-hour post-reaming 

352

(post r-TEG), and 24-hours post-reaming (24-post r-TEG). Statistical comparisons 

between groups used the Wilcoxon rank-sum test. 

Results: 1818 patients were included; 310 ORTHO and 1508 non-ORTHO. On 

arrival, ORTHO patients had lower systolic blood pressure (115 vs. 130), higher 

pulse (107 vs. 95), worse base deficit (-5 vs. -2), more hypocoagulable rTEGs (alpha 

angle 71 vs. 73 and maximal amplitude (mA) 62 vs. 64); all p

Method: 

We retrospectively reviewed the clinical notes and X-rays of all female patients who 

had Latarjet procedures from 2001 with at least one year of follow up. Patients were 

identified from surgical databases in both state and private hospital practices of the 

3 senior shoulder surgeons. The patients were interviewed for an Oxford Shoulder 

Score (OSS), Western Ontario Shoulder Instability Index (WOSI) and Oxford Shoulder 

Instability Score (OSIS). 

A literature review was performed of the electronic database PubMed. 343 papers 

were assessed; of these 50 papers reporting clinical outcomes were reviewed in 

more detail. 

Results: 

There is no literature reporting the outcomes of the modified Latarjet procedure in 

female patients and no data comparing outcomes to male patients. Literature was 

found to suggest anatomical differences in the osseous structure of the shoulders of 

female and male patients. 

32 female patients were identified in our surgical databases. 19 of these were 

available for telephonic follow-up (59.4%), 10 had clinical notes for follow-up 

(31.3%) and 3 were lost to follow-up (9.4%). This left 29 patients available for review. 

There were 13 complications in 11 patients. These included 2 nerve injuries, 1 

superficial post-operative infection, 4 recurrent dislocations, 1 recurrent subluxation 

and 2 patients persistently apprehensive. 2 patients were symptomatic with graft 

fracture and 1 with graft resorption. 

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There was a total re-operation rate of 7.25% (4 of 29 patients). 31.6% of patients 

returned to sport. The median postoperative WOSI score was 433 (range 63-1927), 

OSS was 42 (range 33-48) and OSIS was 36 (range 12-47). The median subjective 

shoulder value (SSV) was 87% (range 5-100%). 

Conclusion: 

There is no published data comparing outcomes of the Latarjet procedure in males 

and females. Female patients had a lower post-operative return to sport and shoulder 

scores following the Latarjet procedure compared to literature reports. While female 

gender should not be a contraindication to the Latarjet procedure, patient selection in 

this group may need to be more stringent. 

Paper 488 

Presenter: Humza Osman 

Authors: M.N. Bence, J. Singh, M.A. Fazal 


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Abstract title: Outcomes from the use of the Corail uncemented stem 

for hemiarthroplasty in displaced intracapsular hip fractures 

Introduction 

Guidance from the National Institute for Health and Care Excellence (NICE) states that 

displaced intracapsular fractures of the femoral neck should be treated with cemented 

prostheses. In our institution, uncemented stems have been used when performing 

hemiarthroplasty due to the perceived risk from the use of cement. 

Objectives 

We performed a retrospective analysis of patients’ outcomes to ascertain whether the 

continued use of uncemented implants could be justified. 

Methods 

Between April 2014 and March 2015, 152 patients presented with hip fractures 

requiring hemiarthroplasty. All of the patients were treated with an uncemented Corail 

stem with a rating of 10A from the Orthopaedic Data Evaluation Panel (ODEP). 

Results 

The average age was 85 (SD 8.3, range 50-100). 42 patients were male and 110 

were female. The average time from admission to operation was 23 hours, with 86% 

of operations taking place within the 36 hour target set by the UK Department of 

Health Best Practice Tariff. The average length of stay was 15 days, with 48.7% of 

patients discharged to their usual place of residence. The 30 day mortality was 7.9%. 

Conclusions 

Our outcomes demonstrate that the Corail uncemented stem is a safe alternative to 

the cemented prostheses endorsed by NICE. Given that the 30 day mortality rate 

compares well with results from the National Hip Fracture Database and a satisfactory 

proportion of patients were discharged to their usual place of residence, continued 

use of this implant is justified. 

Paper 489 

Presenter: A Puddu 

Authors: A. Puddu 


Abstract title: Surgical management of advanced lumbar Tuberculosis 


Patients with advanced, active lumbar tuberculosis have extreme pain due to instability, 

positive sagittal balance and mild neurological deficit. We reviewed data pertaining 

355

to such patients treated with radical anterior debridement, strut grafting and posterior 

stabilisation to ascertain surgical parameters and short term outcomes. 


A retrospective analysis of prospectively maintained surgical and clinical data was 

performed. Pre- and post-operative radiographs were analysed. 

3. Summary of results. 

Seven patients (6 female and one male) were included in the case series. The 

mean age was 20 years and 5 months. Six were HIV positive with a mean CD 4 

of 

505 (265-830) x10 6 /L. 

L1 and L3 were involved in one patient each, L4 in 3 patients and L3/4 in 2 more. 

One patient was treated with a 2-stage procedure and the rest in a single setting. 

Total theatre time (for anterior and posterior procedures) was 205 (160-240) min and 

total blood loss was 750 (300-1250) ml. 

Pelvic incidence was 45° (27°-60°) and the lumbar lordosis was surgically increased 

with 13° (2°-55°) to 21° (5°-41°). Local kyphosis decreased with 20° (2-40°). 

Patients improved with 1 (0-2) Frankel grades before discharge from hospital and 

mobilised fully erect by day 5 (4-6) post operatively. 

All seven patients had histological results suggestive of tuberculosis. Six patients had 

positive PCR results with strains sensitive to Rifampin and Isoniazid. One PCR sample 

was not traceable. Three cultures were positive for TB. 

4. Conclusion. 

FREE PAPERS 

Radical anterior debridement, strut grafting and posterior fixation for advanced lumbar 

TB reliably restores erect ambulation and function. This is achieved by decompression, 

stabilisation and restoration of lumbar lordosis. By implication sagittal balance is 

restored. 

Paper 491 

Presenter: J van der Merwe 

Authors: J. F. van der Merwe, J. Ellis 


Abstract title: Obtaining optimum screw placement for revision 

acetabular prosthesis; using the sciatic notch as reference 

Introduction 

The safe zone for acetabular component revision has been described as the posterior 

superior quadrant. 

356

Using this zone avoids catastrophic vascular injury but does not describe a means of 

engaging the best possible bone. 

With revision surgery the quality of bone is usually compromised and locating the 

optimum bone is often difficult. The safe zone also can be misleading and of less 

value if centre of the hip is elevated. 

Contemporary teaching advises the use of one or two long home run screws. In 1968 

Ring described a thick bar of bone extending from the acetabulum to the sacrum. This 

bar of bone is situated just anterior and superior to the sciatic notch. We wanted to 

study whether use of this land mark made it possible to engage the same bar of bone 

for multiple screw fixation as in revision hip replacement and avoid neurovascular 

injury. 

Methods 

Sixteen hips from nine cadavers were dissected. A standard posterior approach was 

used. 

The acetabulum was then reamed to a predetermined size [66 mm], with extra effort 

to mimic normal wear and bone loss as would be found with revision surgery. A 

revision acetabular prosthesis was inserted. Using the surface markings as described 

for the safe zone and ignoring the sciatic notch, holes were drilled through the inserted 

cup into the posterior superior quadrant. 

Then, with the surgeon’s finger in the sciatic notch, 1-3 screw holes per hip were 

drilled anterior and superior to the sciatic notch, through the same inserted cup. 

The length of all the screws holes were recorded and plastic filament of appropriate 

length was inserted. The cadaver was then dissected to expose the rest of the pelvis. 

Protrusions of screws were noted with special attention to any penetration of 

neurovascular structures. The pelvis was then sectioned in the axial plane in 1 cm 

increments and screw hole position was recorded. 

Results 

In 2 hips the posterior border of the so called safe zone shifted to such an extent 

that the sciatic notch with its contents were penetrated when using the safe zone 

landmarks of the posterior superior quadrant. 

When using the anterior and superior to the sciatic notch approach, in 6 of the 16 

hips we were able to place 1 screw, in 8 of the 16 we were able to place 2 screws 

and in 2 of the 16 hips we were able to place 3 screws in the previous mentioned 

thick bar of bone, with no penetration of neurovascular structures. The screw hole 

lengths varied from 40 to70mm. 

357

Conclusion 

Using the sciatic notch as a guide enables the surgeon to engage a bar of bone for 

one or more long home run screws for revision acetabulum surgery. 

Acetabular bone loss can lead to shifting of the centre of the revision acetabular 

component making the use of the so called safe zone unsafe. 

Paper 493 

Presenter: W van der Merwe 

Authors: W van der Merwe 


Abstract title: Influence of coronal alignment on patient outcome and 

satisfaction after TKA! 

Background: The influence of coronal alignment on survivorship after total knee 

arthroplasty has 

recently been the subject of much debate. 

Proponents of more kinematic alignment claim to have better patient reported 

outcome and patient 

satisfaction after TKA 

Methods: A retrospective review was performed on patients who had undergone a 

posterior stabilised fixed bearing TKA by a single surgeon. Patients were divided into 

two groups: a kinematic group where postoperative alignment was within 3 degrees 

of the preoperative alignment and a second group where the alignment had been 

altered by more than 3 degrees. These 2 groups were then compared in terms of 

change in KOOS score after one year as well as patient satisfaction. 

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Findings: In 100 patients the coronal alignment was changed 3 degrees or less 

( kinematic) and in 89 patients the alignment was changed more than 3 degrees. 

There was no statistically significant difference in KOOS score between the two 

groups except in symptoms that improved more in the kinematic group at one year 

(P 0,03) The percentage of dissatisfied patients however was higher in the kinematic 

group, 8% compared to 2% in the group with a change of more than 3 degrees. 

Conclusion: Better subjective results after TKA with more kinematic alignment could 

not be demonstrated and paradoxically led to less patient satisfaction. Improving 

malalignment seems to improve patient satisfaction. 

Paper 496 


Authors: S Singh, G Abbas, P Roberts, D Woodnutt 

Disclosure: Yes: One of the senior authors is inventor of the Durom hip resurfacing 

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Abstract title: A Comparative Survival Analysis of Mode of Failure 

between Durom and Birmingham Hip Resurfacings in 840 hips 


In the early 2000s hip resurfacing became an established bone conserving hip 

arthroplasty option particularly for the fit and active patient cohort. The performance 

of second-generation metal-on-metal bearings had led to the reintroduction of hip 

resurfacing. The Birmingham Hip resurfacing (BHR) was introduced in 1997. This 

was followed by a number of different designs of the hip resurfacing. The Durom hip 

resurfacing was introduced in 2001. These two designs had different metallurgical 

properties, design parameters particularly clearance and different implantation 

techniques. Data from joint registries show that both prosthesis perform well. 

Our objective was to perform a retrospective survival analysis comparing the 

Birmingham to the Durom hip resurfacing and analyse the mode of failures of the 

cases revised. 

Description of Methods: 

Data was collected prospectively but analysed retrospectively. The two cohorts 

comprised patients treated by two senior surgeons at different units. The follow up 

range was 1 to 14 years with a mean of 10 years. The end-point was revision for 

any cause. However this was further substratified. 

Summary of Results: 

The outcome of all patients was known. The two cohorts exhibited no significant 

difference in demographics. No failures in either cohort were attributed to adverse 

reaction to metal debris. Revision for any cause was analysed by plotting Kaplan- 

Meier Survival curves. The Durom cohort (n=273) had 5 deaths and 9 revisions. 

The Birmingham cohort (n=567) had 5 deaths and 22 revisions. The Kaplan-Meier 

survival curves for the two resurfacing designs were different. The Durom cohort 

demonstrated a concave curve with more early failures. This was contrary to the 

BHR’s convex curve with higher incidence of late failures. We analysed the data by 

substratifying into failure of femoral or acetabular component and neck fractures. 

Conclusions: 

The Kaplan-Meier survival analysis demonstrates that the Durom hip resurfacings had 

a higher rate of early failure. However extrapolation of the curves suggests that the 

Durom may have a superior long term survival compared to the BHR. We postulate 

that this may be due to the femoral implantation technique with less late failures in 

Duroms and an apparent acceleration of failures in BHR cohort around the ten year 

stage. Joint registry data also reflect this pattern. 

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Paper 499 

Presenter: S Keays 

Authors: S L Keays, P. Newcombe, J. Bullock-Saxton, A.C. Keays 


Abstract title: A closer look at osteoarthritis following surgically and 

conservatively treated ACL injuries: A 10 year follow-up. 

Purpose of Study: Recent studies have highlighted the high incidence of osteoarthritis 

(OA) in relatively young sportspeople following anterior cruciate ligament (ACL) 

reconstruction. It is considered that patients with conservatively managed ACL 

deficient (ACLD) knees may develop less OA. To gain further insight, this prospective 

long-term study aimed to compare the incidence of tibiofemoral OA (TFOA) and 

patellofemoral OA (PFOA) between surgical and nonsurgical groups and uninjured 

sportspeople. The surgical group were sub-grouped according to graft site (bonepatellar 

tendon-bone [PT] and semitendinosus/gracilis [STG]), the non-surgical 

group according to residual instability (unstable, equivocal and stable). 

Description of Methods: Fifty-six ACL-reconstructed and 52 conservatively treated 

patients from a cohort of 297 were followed prospectively for 10 years (mean) 

post injury. Twenty nine patients received PT grafts and 27 received STG grafts. 

Fifteen of the non-surgical group were unstable, 27 were equivocal and 12 were 

stable. Thirty eight uninjured subjects matched for gender, age and sports were 

included. Assessment included stability tests (Lachman, Slocum Pivot shift, KT 1000 

and subjective), quadriceps and hamstring strength (Cybex 11) and radiology using 

4 x-ray views. X-rays were assessed based on the Kelgren Lawrence scale, by two 

independent radiologists. Chi-square analyses and ANOVAs were used to compare 

differences in OA between groups and subgroups. Disciminant analyses were 

conducted to assess the factors that influenced the development of OA in both groups. 

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Summary of Results: 48% of the surgical and 62% of the non-surgical groups 

developed TFOA. 36% of the surgical and 44% of the non-surgical developed 

mild PFOA. There was no significant difference overall between groups (p>0.05). 

However when comparing TFOA, a highly significant difference (p=0.012) was 

found between STG (33% OA) and PT (62% OA) groups and between STG and 

non-surgical groups. In addition when comparing non-surgical stability subgroups 

there was a significant difference in TFOA between the stable and the unstable group 

with 42% and 80% developing OA respectively (p=0.017). Discriminant analyses 

showed that factors common to the development of OA in both surgical and nonsurgical 

groups were meniscal injury/meniscectomy, time post- injury and older age 

at the time of injury. One subject in the uninjured group developed mild TFOA 

Conclusions: Contrary to expectations the conservatively managed patients did 

not develop less OA than the surgical groups. Surgical procedure, residual instability 

in conservatively management and meniscal injury affect the development of OA 

particularly of the TF joint. 

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Paper 500 


Authors: Muhammad Adeel Akhtar, Firas Yaish, Anthony Hui 


Abstract title: Magnetic Resonance Imaging (MRI) and Outcomes in 

Adolescents Undergoing Patellar Stabilization For Recurrent Patellar 

Instability 

Purpose: 

Recurrent patellar instability is common in young and active population and affects 

activities of daily living and participation in sports. Surgical treatment is indicated 

following the failure of the non-operative management. Our aim was to study the MRI 

findings and outcomes following surgery for patellar instability in adolescents. 

Methods: 

Patients undergoing patellar stabilization surgery under the age of 18 years between 

November 2008 and June 2014 under the care of a specialist knee surgeon at a teaching 

hospital were identified. Demographic details, MRI findings, type of stabilization, length 

of follow up, leg length discrepancy, malalignment and further instability were studied. 

Results: 

Total number of patients was 10. The mean age for 6 female (60%) and 4 male (40%) 

patients was 16 years (range 13-18). 1 patient had bilateral patellar stabilization. 

There were 8 (72%) Medial patellofemoral ligament (MPFL) reconstruction and 3 

patients (28%) had MPFL reconstruction and Trochleoplasty. The growth plate 

was open in 2 patients (20%) and closed in 8 (80%) on preoperative x-rays. 

7 patients had preoperative MRI scans, which showed that MPFL was intact in 4 

(57%), torn in 2 (29%) and lax in 1 patient (14%). MPFL was torn from patella and 

from both patella and femoral sites in 1 patient each. 6 patients (86%) had trochlear 

dysplasia, 1 patient (14%) had patella tilt and 1 patient (14%) had patella alta on 

MRI scan evaluation. The mean Insall-Salvati ratio was 1.24 (range 1.1-1.6). The 

mean follow up was 21 months (range 5-42 months). At the last follow up there 

were no further episodes of patellar instability, leg length discrepancy or patellar 

malalignment. 

Conclusions: 

We studied the MRI findings and outcomes following patellar stabilization in 

adolescents with patellar instability. Trochlear dysplasia was a common finding on the 

MRI scans in 86% patients. 3 patients (28%) required Trochleoplasty along with MPFL 

reconstruction for patellar stabilization. There were no further episodes of patellar 

361

instability. We recommend MPFL reconstruction +/- Trochleoplasty in symptomatic 

adolescents with patellar instability as we believe it is safe to breach the epiphysial 

plate during MPFL recon and this did not lead to growth arrest. 

Paper 501 


Authors: Farooq Aziz, Muhammad Adeel Akhtar, Waleed Hekal 


Abstract title: Percutaneous Balloon Kyphoplasty in the Management 

of Vertebral Column Fractures 

Purpose: 

Balloon kyphoplasty (BK) can relieve pain, facilitate early mobilization and prevent 

vertebral column deformity in patients with vertebral column fractures (VCF). Our 

purpose was to study the effectiveness of Balloon kyphoplasty in patients with vertebral 

column fractures. 

Methods: 

A retrospective analysis of 65 patients presented over two and half years with 118 

symptomatic VCF treated by BK. To assess fracture related pain, patient disability and 

quality of life VAS, ODI and SF-36 were used respectively. For deformity correction 

restoration percentage of vertebral body height (VBH), percentage of VBH height 

increased, reduction in Kyphosis (Cobb Angle) and Wedge Angle were calculated. 

Data was collected preoperatively and postoperatively at 12 months. 

Results: 

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Preoperative VAS was 8.5 which decrease to 4 with overall regression in 96.55%. 

ODI was 66.90% (17-100%) preoperative which decreased to 33.34% (2-84%) with 

regression in all. SF-36 showed mean improvement in physical component summary 

was 12.8 and mental component summary was 12.04. VBH restoration achieved 

was 19% anteriorly and 29% in centre. Percentage of VBH increased was 70% and 

79% anteriorly and in centre respectively. Reduction in Kyphotic angle from 12.8 

to 10.8 (16%) and Wedge Angle from 29.3 to 26.8 (9%). Asymptomatic cement 

leakage was observed in 21 levels (17%), no pulmonary embolism and adjacent 

vertebral fractures in 1 case. 

Conclusions: 

Balloon kyphoplasty alleviates pain and improves function, disability and quality of 

life. BK restore VBH and reduce deformity without notable complications and enables 

patients to return to their normal lives. 

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Paper 502 


Authors: Muhammad Adeel Akhtar, Richard Montgomery, Sanya Adedapo 


Abstract title: A SURVEY OF MANAGEMENT FOR DEVELOPMENTAL 

DYSPLASIA OF HIP FROM THE BRITISH SOCIETY FOR CHILDREN’S 

ORTHOPAEDIC SURGERY MEMBERS 

Purpose: 

Developmental Dysplasia of the Hip denotes a spectrum of disorders ranging from 

mild dysplasia to irreducible dislocations. There is no gold standard treatment but 

different treatment options are available to manage DDH. The aim of our survey was 

to study the current practice to manage DDH in UK by the members of the British 

Society for Children’s Orthopaedic Surgery. 

Methods: 

An online questionnaire link to ask about the management of DDH was emailed to 

204 members of the British Society for Children’s Orthopaedic Surgery. The response 

rate was 39%. 

Results: 

73% respondents have a local screening programme, 19% screen only high risk 

children and 8% had no screening programme. Pavlik harness was used by 87% 

respondents for Graf Type 2, 96% for Graf type 3 and 90% for Graf type 4. 14% 

respondents will only observe for Graf Type 2. 36% respondents will follow up 

children every week, 45% every 2 weeks, 3% every 3 weeks, 9% every 4 weeks, 

4% every 6 weeks and 3% will decide the follow up according to severity of DDH 

and treatment.1.3% respondents will follow up these patients for 6 months, 13% for 

12 months, 10.5% each for 24 months, 36 months, 48 months and 50% until skeletal 

maturity. After the failure of initial splintage, 7% respondents will consider surgery 

immediately, 13.5% at 3 months, 36.5% at 6 months, 4% at 9 months, 28% at 12 

months, 5.4% according to HIP-OP Trial and 5.6% according to the situation. 

Conclusions: 

There was no consensus about the treatment of DDH. 73% respondents have a 

local screening programme. The most common splintage method used was Pavlik 

harness. 45% respondents will follow up children every 2 weeks following the start of 

treatment. 50% respondents will follow up these patients until skeletal maturity. 36% 

respondents will consider surgery at 6 months following the failure of splintage. This 

survey highlights the fact that the management of DDH is an art based on the scientific 

evidence, parent’s choice and personal expertise. 

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Paper 503 


Authors: Muhammad Adeel Akhtar, Rebecca Tate, Ian Curzon, Richard Montgomery 


Abstract title: Central Acetabular Roof Defect – More Than Just a 

Normal Variant? 

Purpose: 

Central acetabular roof (CAR) defects have been assumed to be anatomical variants. 

The defects tend to be bilateral but not symmetrical. The aetiology is unknown but 

they are believed to be developmental in nature. It is conceivable that a defect in the 

acetabular roof might cause degenerative change in later years. Our purpose was to 

study the natural history of patients with CAR defects on MRI scan. 

Methods: 

We studied 8 cases in the last 8 years with consistent radiological appearances of 

a defect in the roof of the acetabulum on MRI scan. In each case hip pain was a 

predominant feature of long duration without history of trauma and sufficiently severe 

to trigger investigations. Demographic details were collected along with MRI findings, 

length of follow-up and treatments offered. 

Results: 

The mean age at first presentation was 13.4 years (range 9-17 years). 7 patients 

were female. 80% patients had bilateral symptoms. 2 patients continued to have 

persistent severe symptoms and required further treatment including Hip arthroscopy 

and steroid injections with short term benefits. 

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Conclusions: 

We suggest MRI scan to carefully study these defects in adolescent patients which 

might be responsible for their symptoms in the absence of any other hip pathology. A 

long term follow up with more cases is needed to confirm our observations. 

Paper 505 


Authors: Muhammad Adeel Akhtar, Brent Ascherl, Ian Curzon, Sheamus Fitzgerald, 

Anthony Hui 


Abstract title: Magnetic Resonance Imaging (MRI) Evaluation of 

Recurrent Patellar Instability 

364

Purpose: 

Recurrent patellar instability is common in young and active population and affects 

activities of daily living and participation in sports. Surgical treatment is indicated 

following the failure of the non-operative management. MRI scan is used to evaluate 

the status of MPFL and trochlear dysplasia. Our aim was to study the MRI findings of 

recurrent patellar instability in patients undergoing MPFL reconstruction. 

Methods: 

19 patients undergoing MPFL reconstruction between 2009 and 2014 who had 

MRI scan for preoperative evaluation of their patellar instability under the care of 

a specialist knee surgeon at a teaching hospital were randomly selected. The MRI 

scans were reviewed independently by 3 consultant radiologist with special interest 

in musculoskeletal radiology to assess the Medial patellofemoral ligament (MPFL), 

trochlear dysplasia, patellar tilt and patella alta. The inter-observer agreement for 

different findings on the MRI scan was assessed by using Kappa test. 

Results: 

The mean age for 10 female (53%) and 9 male (47%) patients was 21 years (range 

13-33). MPFL was identified in all patients by all three observers. MPFL was found 

to be intact in 12 patients (63%), lax in 1 patient (5%) and torn in 6 patients (32%). 

The kappa value for MPFL status was 0.57. MPFL rupture site was patella in 5 

patients (83%) and both patella and femur in 1 patient (17%) with a kappa value 

of 0.66. Trochlear dysplasia was noted in 16 patients (84%) with a kappa value of 

0.26. 6 patients (32%) had patellar tilt on MRI scan with a kappa value of 0.57 for 

inter-observer variability. The mean Insall-Salvati ratio was 1.3 (range 1.1-1.6). The 

patella alta was noted in 12/18 patients (67%) with a kappa value of 0.93. 

Conclusions: 

We studied the MRI findings after recurrent patellar instability. Trochlear dysplasia was 

present in 84% patients and patella alta was noted in 67% cases. There was poor 

inter-observer agreement for MRI findings for MPFL status (kappa 0.57), trochlear 

dysplasia (kappa 0.26) and patellar tilt (kappa 0.57). The highest inter-observer 

agreement was for patella alta with a kappa value of 0.93. We believe that MRI 

findings alone cannot be used as the definitive diagnostic test for patellar instability. 

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367 

NOTES

POSTER SESSIONS 

POSTERS 

POSTERS - ARTHROPLASTY 

Paper 16 


Authors: Wilson CJ, Watts A, Krishnan J. 


Abstract title: A DOUBLE BLINDED, RANDOMIZED, CONTROLLED PROOF 

OF CONCEPT STUDY TO COMPARE POST-OPERATIVE ANALGESIC AND 

MOBILIZATION OUTCOMES OF LOCAL INFILTRATION ANALGESIA, SINGLE SHOT 

FEMORAL NERVE BLOCK AND INTRATHECAL MORPHINE IN PRIMARY TOTAL 

KNEE ARTHROPLASTY. 

Introduction & Aims 

Total knee arthroplasty is associated with early postoperative pain. Appropriate 

pain management is important to facilitate postoperative rehabilitation and positive 

functional outcomes. This study compares outcomes in TKA with three techniques; 

local infiltration analgesia, single shot femoral nerve block and intrathecal morphine. 

Method 

Forty-five patients undergoing elective primary Total Knee Arthroplasty (TKA) with 

were randomized into one of three groups in a double blind proof of concept study. 

Study arm 1 received local infiltration analgesia ropivacaine intra-operatively, an 

elastomeric device of ropivacaine for 24 hours post-op. Study arm 2 received a 

femoral nerve block of ropivacaine with placebo local infiltration analgesia and 

placebo intrathecal morphine. Study arm 3 received intrathecal morphine, placebo 

femoral nerve block and placebo local infiltration analgesia. 

Participants were mobilized at 4 hrs, 24hrs and 48 hrs post operation. Range of 

Motion, Visual Analogue Scale (VAS) pain intensity scores and two minute walk test 

and Timed Up and Go test were performed. Postoperative use of analgesic drugs 

was recorded. 

Results – 

Preliminary results of 34 participants convey the positive outcomes after total knee 

replacement demonstrated by the improvement in Oxford Knee Score and Knee 

Osteoarthritis Outcome score. There are marked improvements in the metres walked 

in the 2-minute walk tests at the six week time-point. Interestingly at 4 hours postoperative 

7 out of 11 participants were able to stand up out of bed and complete 

a timed up and go test. At day one post-operative only 5 participants were unable 

to walk. Patient-controlled analgesia was used on 5 occasions on day one, 2 of 

which continued on day two. Sedation scores were recorded in six participants on 

day one and 2 on day two. Nausea was reported in 5 cases on day one and 9 

on day two. Urinary catheter was needed in 5 cases on day one. Importantly the 


368

study remains blinded, therefore an analysis of the three study arms is not available 

and is therefore currently difficult to report on the statistical significance. There will 

be further assessment of the efficacy of analgesia using VAS pain scores, analgesia 

consumption and side effects collected preoperatively, 0-24hrs and 24-48 hours 

postoperatively between the three randomized groups. 

Conclusions – 

Results from the study will provide important information for the management of TKA in 

the hospital setting. The comparison of the three commonly used analgesic techniques 

and mobilization outcomes are pertinent for physiotherapy and rehabilitation 

management, anaesthetic specialists, nursing staff, orthopaedic surgeons and 

patients. 

Paper 18 


Authors: Shunmugam M, Bowman A, Krishnan J & WILSON CJ 


Abstract title: Radiographic alignment analysis: Inter and intra observer variability 

pre and post total knee arthroplasty 


Long leg radiographs are used for assessment of mechanical alignment in total knee 

arthroplasty patients. We aim to establish if there is significant inter and Intraobserver 

variability in the alignment measured by observers of different experience. The study 

also explored whether monitor quality influences the accuracy of measurements of 

alignment. 

Method 

Long leg radiographs are used for assessment of mechanical alignment in total knee 

arthroplasty patients. We aim to establish if there is significant inter and Intraobserver 

variability in the alignment measured by observers of different experience. The study 

also explored whether monitor quality influences the accuracy of measurements of 

alignment. 

Results 

Interobserver correlation was high for pre-operative LLR’s with an intra-class correlation 

(ICC) of >0.9 at all experience levels. Post-operative ICC was lowest between the 

surgeon and the medical student at 0.7. Intraobserver correlation was high at all 

experience levels. Larger deformities were exaggerated for both pre and postoperative 

images. There appeared to be no effect of the monitor size and quality on 

the accuracy of measurement. 

Conclusions 

There is good correlation across different levels of experience with adequate training 

in measurement of alignment. This conclusion validates that current practice, where 

patient are assess by numerous different surgeons of differing levels of experience in 

the outpatient clinic setting, is adequate for review of long leg alignment for patients. 

369

Paper 29 


Authors: H.H. Wu, J. Silvestre, C.L. Nelson, C.L. Israelite, A.F. Kamath 


Abstract title: Patients Accurately Report Weight Prior to Total Joint Arthroplasty: 

No Disparity between Self-Reported and Measured BMI 

INTRODUCTION: The utility of accurate self-reported weight in the preoperative 

evaluation of patients undergoing total joint arthroplasty (TJA) has implications for 

perioperative care, patient understanding of medical risks, and targeted patient 

counseling. The purpose of this study is to examine the disparity between self-reported 

and measured weight and the patient factors that may influence it. 

METHODS: A retrospective review of patients undergoing TJA was performed and 

compared with a control group of consecutive arthroscopy patients. Self-reported 

weights were recorded from a preoperative questionnaire and compared to measured 

weights in the clinic. Self-reported weight was considered accurate within one pound 

of measured weight, but accuracy within five and ten pounds was also recorded. 

BMI class, age, gender, socioeconomic status and psychiatric comorbidity were 

compared with disparity between self-reported and measured weight. 

RESULTS: 400 patients undergoing TJA (200 total knee arthroplasty, 200 total 

hip arthroplasty) reported their weights within 0.4 +/- 8 kg of measured weight. 

There were no significant differences in reported accuracy within one, five and ten 

kilograms of measured weight, overestimation or underestimation among normal 

(BMI40) patients (p>0.05). There was no significant correlation between 

age, gender, socioeconomic status and psychiatric comorbidity with differences 

in weight disparity (p>0.05). TJA patients (mean age: 61.9) in comparison to 

arthroscopy patients (n=85; mean age: 31.5) were less likely to accurately report 

their weight (29%vs.48%, p=0.04). A higher proportion of TJA patients with a BMI 

Abstract title: Total Knee Arthroplasty in a haemophilia A patient with high titre of 

inhibitor using recombinant factor VIIa 

Hemophilia Asimply described as deficiency of factor VIII(FVIII) and patients with this 

disorder have bleeding complications in different organs. By using the recombinant 

factor VIII in these patients elective orthopedic surgeries have been done approximately 

in 40 last years .About 10-30 % of these patients have bleeding complications in 

their surgeries even by using recombinant factor VIII because of their inhibitor against 

FVIII molecule. Perioperative hemostatic management in these patients is challenging. 

We treated a 28-year-old male patient with hemophilia A with FVIII inhibitor which 

had been detected when he was14 years old (with the titer 54 Bethesda unit (BU)) 

scheduled for total knee arthroplasty (TKA). We use 90 µg/kg rFVIIa just before the 

surgery and every 2 hours during surgery. The patient did not have any significant 

hemorrhage during the surgery and after that. For the 2 days after surgery the rFVIIa 

repeated every 2 hours as the same as preoperative dosage(90 µg/kg) and for 

another 2 days of postoperative admission it continued every 4 hours. After 4 th day 

the rFVIIa continued every 6 hours with same dosage until the sixth day from the 

surgery, and finally the patient were discharged about two weeks after surgery. Seven 

days after the discharge, he came back for the follow up visit. On the follow up 

examination the site of the surgery had neither infection hemarthroses signs. 

Paper 141 

Presenter: A Beswick 

Authors: A.D. Beswick, N. Artz, P. Jepson, C.M. Sackley, V. Wylde, R. 

Gooberman-Hill, A.W. Blom 


Abstract title: How close are we to evidence-based comprehensive rehabilitation 

for patients receiving total hip and knee replacement? A programme of systematic 

reviews and feasibility studies 


To aid recovery, rehabilitation is an important adjunct to surgery. Acknowledging 

the MRC framework for complex interventions we assessed the evidence-base for 

components of comprehensive rehabilitation throughout total hip (THR) and knee 

replacement (TKR) pathways. 


We conducted systematic reviews and meta-analyses of randomised controlled trials 

(RCT) of pre-surgical exercise and education, occupational therapy and post-operative 

physiotherapy. In feasibility RCTs we explored acceptability of pain self-management 

and occupational therapy before THR, and physiotherapy after TKR. We searched 

trial registers for ongoing RCTs. 

371


Pre-surgical interventions 

Systematic review identified 38 interventions targeting physical function before 

THR and TKR. Interventions showed functional benefit compared with controls, 

standardised mean difference (SMD) 0.32 (95%CI 0.20, 0.44; p

Paper 161 

Presenter: KJ Saleh 

Authors: G. Barinaga, E. Wright, M.C. Chambers, A. Anoushiravani, Z.Sayeed, 

M. El-Othmani, P. Cagle, K.J. Saleh 


Abstract title: Predictive Factors for Economic Outcomes in Patients with Hip 

Fractures 

Introduction: Longer life-expectancy is associated with a higher incidence of hip 

fracture. The financial burden to the healthcare system motivates efforts to decrease 

costs without compromising quality. The identification of variables predictive of 

postoperative outcomes is essential to providing low-cost healthcare. This study 

assesses the predictive value of the American Society of Anesthesiologists (ASA), 

mortality risk level and severity level scores along with other variables such as patient 

characteristics and surgical timing as it relates to economic outcomes. 

Methods: We conducted a retrospective review of patients admitted to a level-1 

trauma center for treatment of hip fractures between 2011 and 2013. Gender, 

Age, BMI, ASA score, severity level, mortality risk, time to surgery and length of 

surgery were gathered and compared with length of stay, hospital cost, and charge. 

Means were used to compare continuous outcomes and statistical significance was 

determined (p

Paper 162 


Authors: G. Barinaga, E. Wright, M.C. Chambers, Z.Sayeed, A. Anoushiravani, 

M. El-Othmani, P. Cagle, K.J. Saleh 


Abstract title: Predictive Factors for Quality Measure Outcomes in Patients with 

Hip Fractures 

Introduction: With a rise in the aging population, there is a higher incidence 

of emergent orthopaedic injuries. Hip fractures are a common injury associated 

with poor morbidity and mortality. Provisions of the ACA have focused efforts to 

identify measures that can be used to bundle reimbursements based on quality of 

care. Hospitals and providers will depend more heavily on predictors to evaluate 

level of risk and potential outcomes based on patient co-morbidities. Identification 

of variables that are predictive of postoperative outcomes is essential to providing 

high-quality care without increasing the financial burden to healthcare institutions. 

This study assesses the predictive value of the American Society of Anesthesiologists 

(ASA), severity and mortality risk scores along with other variables as it relates to 

quality measure outcomes. 

Methods: This is a retrospective review of 508 consecutive patients, who met inclusion 

criteria treated for hip fractures at a level-1 trauma center between 2011 and 2013. 

Gender, Age, BMI, ASA score, severity level, mortality risk, time to surgery and length 

of surgery used as variable factors in relation to 30-day and 7-day readmission, 

mortality and complications. Odds ratios were used with 95% Confidence Interval. 

Results: The average age was 81.6 years. Definitive treatment included a 

cephalomedullary nail (216 patients), dynamic hip screw (64 patients), hemiarthroplasty 

(144 patients), and percutaneous pin (78 patients). ASA significantly 

correlates with 30-day readmission for those treated with percutaneous pin (OR 

=5.06, CI 1.12-22.91), 7-day readmission (OR=3.76, CI 1.02-13.87) and 

mortality (OR =7.64, CI 1.49-39.06) for patients treated with CMN, and time to 

surgery for all groups (p

etween co-morbid risk scores and suggests they can be used to predict quality 

measure outcomes. Risk stratification encourages providers to make medical decisions 

based on value and not volume. 

Paper 163 

Presenter: PJ Cagle 

Authors: J. Horberg, A. Kurdi, B. Voss, M. Chambers, A. Anoushiravani, Z.Sayeed, 

M. El-Othmani, K. Saleh 


Abstract title: Assessing Risk Factors for Thirty-day Readmission after Total Hip 

Arthroplasty: A Retrospective Analysis 

Introduction: The Affordable Care Act (ACA) outlines provisions that change healthcare 

reimbursements based on quality measures. Under new regulations, clinicians and 

hospital institutions are assessed by various parameters, such as rates of readmissions. 

As a result, it is necessary that clinicians understand contributory factors associated 

with increased hospital readmission rates. Identifying such risk factors will assist in 

efforts to reduce the financial burden on the healthcare system, while also improving 

patient outcomes. The goal of this study is to identify potential risk factors that may 

contribute to readmission within 30 days following a total hip arthroplasty (THA). 

Methods: Data collected revealed 1,251 patients who underwent THA at a level-1 trauma 

center from January 2010 to December 2013. Patient data was categorized into two 

groups based on postoperative 30-day readmission status. Group I consisted of 1,190 

patients who were not readmitted following surgery. Group II consisted of 61 patients 

with ≥1 readmission. Potential risk factors assessed were demographics, social factors, 

medical comorbidity, surgical indications, and postoperative interventions. Logistic 

regression using the Firth penalized likelihood was used to determine which variables 

best predict readmission. Statistical significance was considered with a p-value

also found to be a significant risk factor for readmission within 30 days following 

discharge. Further research is needed to determine how our results can be utilized to 

reduce 30-day readmission rates after THA. 

Paper 205 

Presenter: A King 

Authors: A. King, A Kassam, N. Talbot, I. Sharpe 


Abstract title: Early experiences of the Infinity fixed bearing Total Ankle 

Replacement 

We present early results and learning experiences using the Infinity total ankle 

replacement (TAR) at our institution since the implant’s launch in the UK in July 2014. 

This is the largest non-originator surgeon series currently present in the literature. The 

Infinity TAR is a low profile, fluoroscopically navigated, fixed bearing implant which 

requires less bone resection compared to other implants. 

20 Infinity TARs were performed and prospectively followed-up with a range of 3-20 

months. The indication for surgery was either osteoarthritis or inflammatory arthritis. 

Intra-operative fluoroscopic navigation has allowed excellent alignment of all 

prostheses and restored anatomical and mechanical alignment in all patients. No 

patients have undergone, or are awaiting, revision surgery and there is no evidence 

of radiographic loosening in any patient. 

Significant improvement has been shown in patient reported outcome with direct 

patient questioning and in Manchester-Oxford Foot Questionnaire (MOXFQ) and EQ- 

5D questionnaires. No complications have been encountered including periprosthetic 

fracture, infection, deep vein thrombosis (DVT) or pulmonary embolus (PE). 

In line with a learning curve for a new implant, surgical time for the procedure 

has reduced as has a significant reduction in radiation exposure from intra-operative 

image intensifier navigation. 

In the biggest non-originator series to date we present the early outcome data and 

the learning experience of our institution using this implant including relevant tips 

to shorten the learning curve for other surgeons utilising this implant. Early clinical 

results indicate that the Infinity fixed-bearing total ankle arthroplasty system provides 

significant improvement in pain, quality of life, and standard functional measures in 

patients with end-stage ankle arthritis. 

Whilst we are aware that these represent early results, patient outcomes are extremely 

encouraging and we will continue to follow up these patients and monitor results on 

the UK National Joint registry. 


376

Paper 219 


Authors: A. Riddell, M. Dodd, D. Woodnutt, M. Mullins 


Abstract title: Revision of Charnley Total Hip Arthroplasty to a Dual Mobility 

System – A Case Series using a Novel Technique 

The revision of failing acetabular components in the presence of a well-fixed monoblock 

Charnley stem is not an uncommon clinical scenario. In this predominantly elderly 

population a strategy to avoid revision of the femoral component would give the 

advantages of decreased anaesthetic time, decreased surgical insult and potential 

improved outcomes. Retaining the monoblock and using the 22.2mm stainless 

steel head as the central portion of a dual mobility (DM) prosthesis seems sensible. 

Unfortunately most DM prostheses use modular heads and are assembled on the 

scrub table before implantation, excluding their use in this patient cohort without 

revision of the entire femoral component. 

We have used a 22.2mm DM prosthesis with the advantage that the constrained 

polyethylene can be inserted and integrated with the monoblock in situ. The Charnley 

stem is converted to a bipolar head using a custom built applicator and the failing 

acetabular component is revised to a polished metal cup. To date we have undertaken 

10 of these procedures with no failures out to 3 years. Prospectively gathered Harris 

hip scores showed a mean of 72 at last follow up, in most cases limited by other 

co-morbidities. In our opinion this technique is a valid revision strategy in this patient 

cohort where increased anaesthetic and surgical insults should be minimised and 

other possible management options, such as an excision arthroplasty, would be 

unlikely to give a good result. 

Paper 238 


Authors: Anoushiravani AA, Sayeed Z, Chambers MC, Scaife SL, El-Othmani MM, 

Saleh KJ 


Abstract title: Comparative Analysis of Low and Normal BMI as it Relates to 

Nutritional Status and Postoperative Outcomes in TKA Patients 

Introduction: The importance of nutritional status as a factor for postoperative 

complications following Total Knee Arthroplasty (TKA) continues to be explored. 

The effect of this nutritional state on TKA have not been thoroughly examined. 

Being underweight is rarely an isolated diagnosis, and is usually associated with 

comorbidities that can possibly confound outcomes. It remains unknown whether 

being underweight independently increases risk of postoperative outcomes. We 

hypothesize that patients with low BMI (≤ 19 kg/m 2 ) in comparison to normal (19- 

24.9 kg/m 2 ) BMI will have poor postoperative TKA outcomes. 

377

Methods: Discharge data from 2006-2012 National Inpatient Sample (NIS) was 

used for this study. All patients received a primary TKA, were eligible for inclusion 

in this study. The included population was divided into groups determined by 

body mass index (BMI). The two groups included those with BMI scores suggesting 

underweight status and those with BMI scores suggesting normal weight. All groups 

were matched for 27 co-morbidities using the Elixhauser comorbidity index. Their 

in-hospital postoperative outcomes were then comparatively analyzed. Univariate 

analysis and logistic regression models with odds ratio (OR) and 95% confidence 

intervals (CI) were used for statistical analysis. 

Results: A total of 1,315 patients that received TKA met inclusion criteria. The patient 

population was statistically analyzed for both low and normal BMI groups relative 

to: demographics, comorbidities, postoperative outcomes, and resource utilization. In 

regards to postoperative outcomes, underweight patients had a higher risk of in-patient 

postoperative anemia (odds ratio [OR], 5.91; 95% CI, 4.45-7.85) compared with 

normal patients. Analysis of resource utilization demonstrated underweight patients 

had higher total hospital charge (USD 52082.0 versus 37085.5, p=

measures postoperative quality allowing for standardized reporting of TKA outcomes 

based on various radiographic views. 

Methods: Forty-four TKA patients were retrospectively enrolled following operation by 

the senior author. All patients received the VEGA PS knee prosthesis. Postoperative 

radiographs (weight-bearing anterior-posterior [AP], lateral, and skyline or Merchant 

views) were taken at each follow-up for a minimum of two years. One independent 

observer evaluated radiographs using KSRESS. Descriptive statistics were used to 

assess data. 

Results: The average age and BMI of patients enrolled was 68 years (51-89 

years) and 36.5 kg/m 2 (21.2-54 kg/m 2 ). Primary follow up visits were 1-4 weeks 

postoperatively. The AP femoral flexion and tibial angles were reordered at 93.34° 

and 88.40°, respectively. At two year follow up the average AP femoral and tibial 

angles were 94.94° and 88.03°, respectively; and the difference between the 1-4 

week and 2 year measurements was -1.59° for the femoral component and -.3687° 

for the tibial component. Lateral femoral flexion and tibial views were recorded. 

Lateral radiographs taken at 1-4 weeks indicated femoral flexion and tibial angles of 

20.93° and 92.48°, respectively. At two year follow-up the average lateral femoral 

flexion and tibial angle were measured at 20.63° and 92.74°, correspondingly; 

the resulting average difference between the two measurements was .30° and -.34°, 

respectively. Patellar width and thickness were measured pre and post operatively. 

The average difference was then reported (-2.59mm and 4.96mm, respectively). 

Difference in patellar tilt pre and post operatively was recorded at 24.05°. 

Conclusion: Assessment of the short-term survivorship of the VEGA PS prosthesis 

using radiographic findings was performed. Our study reports that radiolucency 

at the bone-prosthesis-interface remains relatively constant after two years of follow 

up; however, mid to long term studies assessing this junction are needed. A future 

prospective study using KSRESS in combination with clinical follow-up would assess 

the knee implant in comparison to other designs. 

Paper 241 


Authors: Z. Sayeed, A.A. Anoushiravani, M.C. Chambers, S. Scaife, M.M. El- 

Othmani, K.J. Saleh 


Abstract title: Comparing In-hospital Clinical Outcomes and Resource Consumption 

in Low and High BMI Patients Undergoing Primary Total Knee Arthroplasty 

Introduction: Total knee arthroplasty (TKA) is one of the most efficient procedures in 

terms of postoperative quality of life improvement. Body Mass Index (BMI) is a potential 

indicator of nutritional status that may be used to predict postoperative outcomes. 

Abnormal BMI scores are rarely isolated occurrences and are associated with many 

co-morbidities. As numbers of primary TKAs for patients with both high and low BMI 

379

scores continues to rise, interest on how BMI can serve as an objective measure 

to gauge TKA outcomes warrants exploration. This study compares postoperative 

outcomes following TKA between patients with low (≤ 19 kg/m 2 ) and high (≥40 kg/ 

m 2 ) BMI. 


used for this study. All patients who received a primary TKA, were eligible for 

inclusion in this study. The included population was divided into groups determined 

by BMI. The two groups included those with low BMI scores, suggesting underweight 

status, and those with high BMI scores, suggesting morbid obesity. All groups 

were matched for 27 co-morbidities using the Elixhauser comorbidity index. Their 

in-hospital postoperative outcomes were then comparatively analyzed. Using SAS 

9.3, multivariate analysis, logistic regression models, and chi squared results were 

generated. Data was analyzed using odds ratio with 95% confidence intervals and 

p-values. 

Results: A total of 956 patients were divided into the two cohorts. The patient 

population was analyzed for both low and high BMI groups relative to: demographics, 

comorbidities, postoperative outcomes, and resource utilization. In regards to 

postoperative outcomes, low BMI patients had a higher risk of postoperative anemia 

(odds ratio [OR], 3.1; 95% CI, 2.33-4.12) compared with high BMI patients. 

Analysis of resource utilization demonstrated patients with low BMI had higher total 

hospital charge (USD 51368.9 versus 40128.8, p=.0012), and higher hospital 

daily charge (USD 16252.6/day versus 12634.7/day, p


used for this study. All patients who received a primary TKA, were eligible for inclusion 

in this study. The included population was divided into groups determined by BMI, 

normal, obese, and morbidly obese. All groups were matched for 27 co-morbidities 

using the Elixhauser comorbidity index. Their in-hospital postoperative outcomes were 

then comparatively analyzed. Using SAS 9.3, multivariate analysis, logistic-regression 

models, and chi-squared results were generated. Data was analyzed using odds ratio 

(OR) with 95% confidence intervals (CI) and p-values. 

Results: Compared to normal BMI patients, morbidly obese patients displayed higher 

risk for wound dehiscence (OR, 2.54; 95% CI, 1.66-3.89) and postoperative anemia 

(OR, 1.77; 95% CI, 1.72-1.83). Normal BMI patients are at an increased risk for 

mortality (OR, .078; 95% CI, .03-.20), and all other postoperative complications. 

Analysis of resource utilization demonstrated normal BMI patients had longer length of 

stay (LOS) (3.71 vs. 3.30, p

Methods: Data from the National Inpatient Sample from 2006-2011 was extracted 

using the ICD-9 codes for patients that received a TKA or THA. Outcome measures 

included cardiovascular, cerebrovascular, pulmonary, mechanical wound, infection, 

and systemic complications. Inpatient and hospital demographics including primary 

diagnosis (RA vs. OA), payer type, Charlson score, hospital size, and median 

household income were assessed. 

The SAS 9.3 statistics software was used to Chi-square values and Cochran-Armitage 

trends. Results were weighted utilizing standard discharge weights from the NIS to 

ensure accurate comparison of data from different time points; p-values

age of 17, the patient had been drafted into the Boys Service of the armed forces 

and had no past medical history of relevance. During his initial gruelling assault 

course training he developed pain in his right hip. Radiographs were performed 

and he was diagnosed with Osteoarthritis secondary to old Perthes disease. He 

was subsequently discharged from the Navy on medical grounds and returned to 

working as a laboratory assistant. His hip symptoms deteriorated and in 1948 

he attended Manchester Royal Infirmary where he was reviewed by the newly 

appointed surgeon, Mr. John Charnley. The option of arthrodesis was discussed but 

on 6th October 1948 he underwent surgery and a metal cup had been inserted 

in preference to fusing the joint. He was then treated on bed rest in Thomas Splint 

traction for 6 weeks and was partially weight bearing on crutches for a period of 

three months. Following the operation there was noticable shortening of the right 

leg and restriction of movement of the hip, but it was pain-free and he continued 

to work in a wire-testing laboratory for the next 44 years, cycling to work with 

a wooden block secured to the right pedal to compensate for the leg length 

discrepancy. He first attended our department in 2004 having fallen from his 

bicycle sustaining a partial rupture of his left quadriceps. Radiographs confirmed the 

presence of a Smith-Petersen Mould Arthroplasty of the right hip. On examination 

there was a well-healed 9 inch long Y-shaped incision over the lateral aspect of 

the right hip, with wasting of the thigh and calf musculature. The right leg was 4cm 

short, with no fixed flexion deformity of the hp. Flexion was possible to 60 degrees, 

with only a few degrees in the other planes of motion, but the movements were 

pain free. The patient has remained under follow-up and has no complaints with 

regard to his right hip. Sequential radiographs have shown no changes and the hip 

continues to serve him well. The poster will be illustrated with radiographs, CT scans 

and the original records form the Military Medical Board. 

Paper 274 


Authors: A.D. Beswick, V. Wylde, E. Marques, E. Lenguerrand, R. Gooberman-Hill, 

S. Noble, M. Pyke, A.W. Blom 


Abstract title: The effect of local anaesthetic infiltration on chronic post-surgical 

pain after total hip replacement: Evidence from a systematic review, randomised 

controlled trial and health economic study 


Robust evidence is required on the effectiveness of perioperative local anaesthetic 

infiltration (LAI) in patients receiving total hip replacement (THR). We assessed LAI 

effectiveness using systematic review and meta-analysis, a fully powered randomised 

controlled trial (RCT), and economic evaluation. 

383


We searched bibliographic databases for RCTs of perioperative LAI in patients 

receiving THR. Two reviewers screened abstracts and extracted data. Outcomes 

were pain, opioid use, mobilisation, hospital stay and complications. 

In the APEX RCT, we randomised 322 patients awaiting THR to additional 

perioperative LAI (60mls 0.25% bupivacaine plus adrenaline) or standard anaesthesia 

alone. Postoperatively, all patients received patient-controlled morphine. The primary 

outcome was WOMAC-Pain at 12 months. Patients and assessors were blinded to 

allocation. 

Within APEX, cost-effectiveness was assessed from health and social-care perspectives 

in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. 

Resource use was collected from patients and hospital records. 


In 13 studies (909 patients), patients undergoing THR receiving LAI experienced 

greater pain reduction at 24 hours at rest, standardised mean difference (SMD) 

−0.61 (95%CI −1.05, −0.16; p=0.008) and at 48 hours during activity, SMD 

−0.43 (95%CI −0.78, −0.09; p=0.014). Patients receiving LAI spent fewer days in 

hospital, used less opioids and mobilised earlier. Complications were similar between 

groups. Long-term outcomes were not a focus of studies. 

In the APEX RCT, pain levels in hospital were broadly similar between groups, 

probably due to patient-controlled analgesia. Opioid use and complications were 

similar between groups. Time to mobilisation and discharge were largely dependent 

on local protocols and did not differ. Patients receiving LAI were less likely to report 

severe pain at 12 months than those receiving standard care, odds ratio 10.2 (95%CI 

2.1, 49.6; p=0.004). 

LAI was associated with lower costs and greater cost-effectiveness than standard 

care. Using a £20,000 per QALY threshold, the incremental net monetary benefit 

was £1,125 (95%CI £183, £2,067) and the probability of being cost-effective 

greater than 98%. 


Perioperative LAI may reduce pain immediately after THR. However this may not be 

seen if patient-controlled anaesthesia is provided. In the long-term, LAI may be an 

effective and cost-effective treatment for pain management in THR. 


384

Paper 276 


Authors: A.D. Beswick, V. Wylde, E. Marques, E. Lenguerrand, R. Gooberman-Hill, 

S. Noble, M. Pyke, A.W. Blom 



To assess the effectiveness of perioperative local anaesthetic infiltration (LAI) for pain 

management in patients receiving total knee replacement (TKR), we conducted a 

systematic review and meta-analysis, fully powered randomised controlled trial (RCT) 

and economic evaluation. 


We searched bibliographic databases for RCTs of perioperative LAI in TKR. Two 

reviewers screened abstracts and extracted data on pain, opioid use, mobilisation, 

hospital stay and complications. If femoral nerve block (FNB) was provided, studies 

were analysed separately. 

In the APEX RCT, we randomised 316 patients awaiting TKR to standard 

anaesthesia which included FNB, or the same regimen with additional perioperative 

LAI (60mls 0.25% bupivacaine plus adrenaline). Postoperatively, all patients 

received patient-controlled morphine. The primary outcome was WOMAC-Pain at 

12 months. Patients and assessors were blinded to allocation. 

Within APEX, cost-effectiveness was assessed from health and social-care 

perspectives relating to quality adjusted life years (QALYs) and WOMAC-Pain at 

12-months. Resource use was collected from patients and hospital records. 


Overall, 23 studies including 1,439 patients were identified. Compared with 

patients receiving no intervention, LAI reduced WOMAC-Pain by standardised 

mean difference (SMD) −0.40 (95%CI −0.58, −0.22; p

LAI was marginally associated with lower costs. Using the NICE £20,000 per 

QALY threshold, the incremental net monetary benefit was £264 (95%CI, −£710, 

£1,238) and the probability of being cost-effective was 62%. 


Although LAI appeared to have some benefit for reduced pain in hospital after TKR 

there was no evidence of pain control additional to that provided by FNB. However 

it was cost-effective at the current NICE threshold. 

Paper 319 

Presenter: S Hammouche 

Authors: S. Hammouche 


Abstract title: Can CFR-PEEK Materials Be Used As Hip Replacement Bearing 

Surfaces? The Most Comprehensive Tribological Assessment to Date. 

Purpose: 

The optimum hip replacement bearing surface should be non-wearing, low friction 

material with bio-inert wear debris. PEEK-based materials (particularly when carbonfibered 

reinforced CFR) are highly-wear resistant resins. 

The purpose of this study is to assess the wear factor, the friction co-efficient and 

the wear debris of PEEK-based materials under normal and extreme mechanical 

conditions in comparison with currently-used new generation crossed-linked (XL) 

polyethylene (PE). 

Methods: 

Unfilled (non-CFR), CFR-PEEK and XL PE were wear tested in simple geometry 

multidirectional wear machine against CoCr and Biolox Delta ceramics. The tests 

were conducted for one million cycles at wide range of contact pressures. 

CFR-PEEK acetabular cups were wear tested against Biolox Delta ceramic heads 

in hip simulator wear machine. Optimal optioning and edge loading conditions 

were applied subsequently (6 million cycles). 

Gravimetric, volumetric, profilometric, advanced microscopic and micro-CT scanning 

examinations were performed pre/post wear tests. 

The friction co-efficient were tested in a friction rig. Normal and high contact pressures 

were applied. 

Wear particles were isolated then assessed using electron microscopy. Particle size 

and area distributions were generated. Other particles characteristics were assessed 

per ASTM-1877. 

Results: 

Simple geometry: Unfilled PEEK resins exhibited the highest wear factor. It was 

deemed unviable and excluded from further studies. While CFP-PEEK vs. HC CoCr 


386

combination exhibited the lowest wear factor 8.6 x 10−⁸ mm³/ Nm (p=0.002), it 

scratched the metal counterface. CFR- PEEK vs. Biolox Delta showed similarly low 

wear factor (1.6 x 10−⁷mm³/ Nm) but this was not lower than XL PE. Carbon-fibres 

(CF) pull-out was noted. 

Hip simulator: volumetric wear analysis of CFR-PEEK cups showed 0.2 ± 0.1 mm³/ 

MC and 0.07 ± 0.04 mm³/MC wear in the optimum positioning and the edge 

loading phases subsequently. Wear was gravimetrically detected in the edge loading 

phase only. CF unplugging in the rim region was noted. There was no evidence of 

fatigue fractures on Micro-CT. 

Friction testing: PEEK-based bearing surfaces had four to five fold higher friction coefficient 

compared with XL PE materials (p

data is available for 61 patients: 40 (45 hips) in the Robot group and 21 (22 hips) in 

the Control group. Data collected included: Harris Hip Scale, HSQ-12, WOMAC, 

UCLA Activity Score, VAS Pain Score as well as radiographic analysis. Patients were 

implanted with the Depuy AML, Howmedica Osteoloc, or Zimmer VerSys FMT. The 

demographics at follow-up were: 

Robot (±SD) Control (±SD) 

Male/Female 35/10 12/10 

Index Age 59.1 ± 8.2 59.8 ± 9.4 

Age at Follow-up 72.8 ± 7.6 74.2 ± 8.2 

BMI (kg/m 2 ) 28.3 ± 4.7 29.4 ±6.5 

Follow-Up Length (years) 13.9 ± 2.7 14.2 ±4.7 

Results: 

There was one revision of the femoral component in each group for a post-op 

peri-prosthetic fracture. There were 3 reoperations in the Robot group and 5 in the 

Control group, all for head and liner change. Clinical results are given below: 

Robot Control P Value 

HHS Pain Score 41.81 ± 5.05 39.09 ± 7.37 0.025 * 

HHS Total 93.49 ± 8.77 89.50 ± 12.03 0.089 

HSQ-12 Pain 83.75 ± 20.40 72.65 ± 16.31 0.019 * 

HSQ-12 Total 683.52 ± 113.09 637.16 ± 104.53 0.087 

WOMAC 8.44 ± 11.48 11.32 ± 11.92 0.034 * 

UCLA Activity Score 6.09 ± 1.86 5.71 ± 1.45 0.417 

VAS Pain Score (0 – 100 mm) 4.69 ± 10.15 6.42 ± 10.89 0.112 

Radiographically, both groups had similar results for acetabular osteolysis (4% Robot, 

11% Control). Femoral osteolysis was limited to the proximal Gruen zones in both 

groups (4% Robot, 6% Control). Stress remodelling was seen in both groups receiving 

the Osteoloc implant. No components showed signs of radiographic loosening. 

Conclusions: 

Prior studies have demonstrated improved implant fit and alignment with the 

use of this active robot system. This long term study now shows no failures for stem 

loosening with superior clinical outcomes in the Robot Group for HSQ 12 Pain, Harris 

Pain and Total WOMAC scores at mean follow-up of 14 years. Long-term safety and 

efficacy has been shown for this technique of active robot-assisted THA. 

Paper 476 

Presenter: JRT Pietrzak 

Authors: JRT Pietrzak, L Mokete DR van der Jagt 


Abstract title: Survey of Total Hip Replacement bearing surface choices amongst 

South African orthopaedic surgeons: 


388

Introduction: 

Total Hip Replacement (THR) is a proven effective surgical procedure. The annual 

growth of THR use increases by 3,2% worldwide annually. One of the limiting factors 

of the longevity of THR is the performance of the bearing surface. The optimum 

bearing surface choice, however, remains controversial. 

Aims, material and methods: 

We attempted to understand what influenced the choice of bearing surfaces amongst 

South African orthopaedic surgeons and which they most likely would choose. As 

there is no epidemiological registry-based data available in South Africa we sent 

out a survey by SurveyMonkey® to all members of the South African Orthopaedic 

Association (SAOA). We used 4 parameters to elucidate which patient factors most 

impacted bearing surface selection: age, gender, level of activity and diagnosis. We 

used regressional and tree analysis to interpret results. 

Results: 

We received 133 responses. There were no differences in decision making and 

bearing surface choices according to the surgeons experience, type of practice or 

fellowship training. 

It was statistically significant that age was the first and most important factor when 

deciding upon a bearing surface. The patient’s activity level then played a secondary 

role in the final choice. We show that gender and clinical diagnosis played no 

significant part in decision-making. 

Ceramic-on-ceramic combinations were used most commonly in younger patients 

and metal-on-polyethylene in older patients. 72,7% of surgeons chose metal-onpolyethylene 

in patients older than 70 years. There were no surgeons who selected 

metal-on-metal or ceramic-on-metal combinations for any patients. 

Metal-on-polyethylene was first choice in 51,3% of all patients with a low-activity level 

and 22,6% of those patients with a high level of activity. Ceramic-on-ceramic and 

ceramic-on-polyethylene was first choice in patients with a high level of activity by 

32,2% and 34% of surgeons respectively. 

Conclusion: 

While each bearing surface combination has advantages and disadvantages we 

show the current trends in decision making and choices of bearing surfaces by South 

African orthopaedic surgeons. We also note the orthopaedic surgeon’s decision 

making process seems to have been influenced by the current adverse reports in 

respect of metal-on-metal bearings. 

389

Paper 480 

Presenter: D Ferguson 

Authors: D. Ferguson, C. Nolan, P Bachtiger, A. Hassan, H. Atkinson 


Abstract title: A new complication of hip arthroplasty and extreme weight loss 

post-bariatric surgery 


To describe a novel complication of concomitant hip arthroplasty and bariatric surgery. 


In-depth review of case notes to delineate chronology of and reasons for recurrent 

hip dislocation. 


An underweight 19.5 kg/m 2 54 year-old woman presented to the emergency 

department with three separate episodes of non-traumatic right total hip replacement 

dislocations. Previous morbid obese at 130kg with a BMI of 50.7 kg/m 2 was 

reserved with laparoscopic gastric banding aged 50. Development dysplasia of 

the hip (DDH) caused early osteoarthritis requiring bilateral total hip arthroplasty 

performed also when aged 50. 

The patient lost approximately 80 kilograms from ages 50 to 54 following her gastric 

band resulting in a significant reduction in BMI to 19.5 kg/m 2 . 

The patient’s significant weight loss allowed markedly increased range of hip 

movements as thigh habitus acted previously as a permanent abduction mechanism. 

Soft tissue laxity was noted on examination and following the reduction of the third 

dislocation the patient was revised with addition of captive cup liner and metal 

constraining ring within three weeks. 

Conclusion 

Obesity is a major public health concern commanding the highest financial 

expenditure, 1 with experts postulating the epidemic may reverse the millennia-long 

trend of increasing life expectancy. 2 

Laparoscopic gastric banding procedures are the most effective weight loss 

interventions, achieving 43.6kg (± 11.7) weight loss at one year, 3 with a reduction in 

musculoskeletal complaints from 100% pre-operatively to just 23% post-operatively. 4 

Bariatric surgery is not without complications - bowel perforation, conversion to 

open, and bleeding are common, 5 with pulmonary embolism and cardiac failure the 


390

leading causes for mortality. 6 To date no studies have demonstrated hip dislocation 

secondary to THR and weight loss. 

This rare presentation provides a useful learning point for upper GI and orthopaedic 

clinicians considering patients for surgery. With a DDH prevalence of 1.3 per 1000 

(range 0.84 to 1.50) in the developed world, 7 increased rates of hip arthroplasty 

and an expanding weight loss surgery industry creates a growing population of 

patients who will be at high risk of dislocation post arthroplasty. Healthcare providers 

should be mindful of this risk profile and ensure adequate patient education, follow-up 

and support from physiotherapists to ensure the risk of dislocation is minimised. 

Paper 495 

Presenter: S Tomescu 

Authors: S.S. Tomescu, J.C. Cameron 


Abstract title: Outcome of Combined Total Knee Arthroplasty and Tibial Rotational 

Osteotomy in Patients with Osteoarthritis and Excessive External Tibial Torsion 

Excessive tibial torsion (EETT) is an under recognized phenomenon that results in 

altered lower limb mechanics and patellar instability. Patients with knee osteoarthtis, 

EETT, and patella subluxation present a challenging surgical problem, with TKA 

alone often inadequate. Corrections of more than 30 degrees of rotation cannot 

be achieved without stretching the collateral ligaments and is an indication for a 

derotational osteotomy. 

We present a series of 16 patients (15 females, 1 male) with 19 knees that underwent 

concomitant TKA, derotational proximal tibial osteotomy, and tibial tubercle transfer. 

All patients were non-weight bearing for 6 weeks but allowed full range of motion. 

Outcomes were evaluated using the Knee Society Score, SF-12, and WOMAC 

questionnaire. 

The mean follow-up was 78 months (range 23-205). Fourteen patients (16 knees) 

had undergone previous tibial tubercle transfers or soft tissue procedures to stabilize 

the patella. The average pre-operative tibial torsion was 62 degrees (range 50-70) 

with a mean correction of 30 degrees (range 20-35). Compared to pre-operative 

scores, significant improvement was found in the Knees Society Score, SF-12, and 

WOMAC (p

POSTERS - FOOT AND ANKLE 

Paper 371 


Authors: N.S. Sandhu, L. Hodgson, T.P. Green, M.L. Newey, C.J. Kershaw, M. 

Girgis, E. Marshall, R.U. Ashford 


Abstract title: Plantar foot forces generated at the engagement of a rugby scrum: 

The front five 

Background 

The injury rates of rugby players have previously been reported as being the highest 

of recreational sports in the UK. There has been a large amount of attention on the 

medical staff within Rugby Union teams and the game as a whole to try and address 

and ultimately reduce injury rates. Collisions were 70% more likely to result in an 

injury than a tackle and scrums carried a 60% greater risk of injury than a tackle. 

Ankle, calf and lumbar injuries were shown to be most prominent across front five 

players in the scrum. There is paucity of research on the mechanics of the scrum and 

the link these may have to injury rates in the front five forwards. 

Methods 

Five professional rugby players from a championship rugby union team were used in 

the study (one in each position). One player was tested on each of the five scheduled 

testing days over a five week period. The WalkinSense® plantar pressure device 

was used to measure plantar pressures of the players. Each player was recorded on 

three engagements of the scrum with a full pack of forwards against a scrummaging 

machine. 

ANOVA tests and multiple linear regression models were used to assess statistical 

difference between players, between left and right feet of each player and plantar 

pressure differences within each foot. 

Results 

There were statistically significant differences of plantar pressures within each foot 

at point of engagement in the scrum. The fore foot was shown to have significantly 

higher forces than the mid and hind foot (p

generated at the scrum were through a very small area of the foot (medial side of the 

fore foot). 

The link between foot ankle and calf injuries is well understood, yet the link to lumbar 

injuries requires further research. Boot modifications and strength and conditioning 

of the lower limbs are areas that could be adapted to reduce non-traumatic injury 

prevalence. Further research on optimal joint angles at the rugby scrum could give 

improved performance and technique whilst reducing potential for injury. 

POSTERS - GENERAL 

Paper 23 

Presenter: C Kontoghiorghe 

Authors: C.N. Kontoghiorghe, H. Rowley, K. Bosch, L. Fletcher, B. Dala-Ali 


Abstract title: A Study To Determine Whether Vitamin D Deficiency Is A Risk Factor 

For Fractures In The Elderly 

Keywords: Vitamin D, Neck Of Femur, Fractures, Elderly, Deficiency, Risk Factors 

Introduction: Hip fractures alone cost the National Health Service (NHS) in the UK £2 

billion each year. Low bone mineral density is a risk factor for fractures in the elderly 

population, where fractures are a major cause of morbidity and mortality. Vitamin D, 

25-hydroxyvitamin D [25(OH)D], status has been proven to increase bone mineral 

density and bone turnover. Vitamin D supplementation may decrease bone turnover 

and increase bone mineral density. Vitamin D deficiency is associated with secondary 

hyperparathyroidism and bone loss, which can lead to osteoporosis and fractures. 

It is also related to mineralisation defects, which can contribute to osteomalacia 

and muscle weakness, which can then lead to falls and fractures. However, the 

relationship between vitamin D levels and fracture risk in the elderly population is still 

unclear. This study aims to discover whether Vitamin D deficiency is more prevalent 

in elderly patients presenting with a fracture compared with other elderly patients. 

Methods: A retrospective cohort study was carried out comparing the serum 

25-hydroxyvitamin D [25(OH)D] levels of 317 geriatric patients aged over 65 years 

who had been admitted to one London District General Hospital between 2011 and 

2014. Age, gender and reason for admission were all recorded, and patients were 

placed into two groups- those with fractures and those without. The vitamin D levels 

between the two groups were compared using statistical analysis on EXCEL and STATA. 

Results: A total of 317 patients were identified for the study. The study included 217 

geriatric patients who were admitted with a fracture and 100 patients without a 

fracture. The results showed the mean vitamin D levels of those admitted with a fracture 

393

was significantly lower than those admitted without a fracture (46.72 nmol/L vs 33.11 

nmol/L) using a paired t-test. The study discovered that 81% of geriatric patients 

admitted with a fracture had inadequate vitamin D levels (

CONCLUSION: The majority of orthopaedic residents matched into a program 

in the same region as their medical school. Close to one in every five orthopedic 

residents matched at their home institution. The proportion of residents matched at 

programs affiliated with or in the same region as their medical school was highest in 

the South and lowest in the West. While it is unclear why a significant regional bias 

was identified, both orthopedic surgery applicants and program directors should be 

cognizant of these data to optimize residency match outcome. Future investigation 

into the relative contribution of applicant and program preferences to this geographic 

bias is warranted. 

Paper 109 

Presenter: GL Foo 

Authors: G.L. Foo, E.B. Kwek 


Abstract title: Orthopaedic Residents Frequently Overestimate the Cost of 

Orthopaedic Implants 

Purpose 

With rising healthcare costs, it is important for orthopaedic surgeons to be aware of 

implant costs in order to better counsel patients and provide cost-effective surgical 

management. 

Our study explores the knowledge of implant costs amongst orthopaedic residents 

and also to assess if senior residents fare better. 

Methods 

We recruited all 33 orthopaedic residents within our institution. The survey was 

conducted electronically. The survey included the participant’s residency year, their 

perception of their knowledge of implant costs and an estimation of the cost of 13 

commonly used implants. The estimated implant cost was compared to the actual cost 

to determine the percentage error. 

We also compared the percentage error between senior residents (Year 4 and 5; R4 

and R5) and junior residents (R1, R2 and R3) to assess for any significant difference. 

Summary 

26 out of the 33 (78.8%) residents took part in the survey. The number of participants 

according to their residency year were R1 (2), R2 (6), R3 (9), R4 (4) and R5 (5). The 

participants’ perception of their knowledge of implant costs were mainly poor (11). 5 

felt their knowledge was very poor, 9 average and 1 good. 

The cost of the implants were all over-estimated by the residents, ranging from the 

395

most over-estimated 6-hole 1/3 tubular plate at 2834.5% to the most accurately 

estimated implant, the Synthes Proximal Femoral Nail Anti-Rotation at 11.6%. The 

combined average over-estimation was 404.9%. 

Senior residents have a lower mean over-estimation of 183% compared to junior 

residents who over-estimated by 523%. These might reflect on senior residents’ need 

for familiarity with the implants as they are the primary surgeons for some of the 

procedures whereas junior residents are usually the assistants. However, statistical 

analysis with an unpaired t-test did not show any significant difference in the estimation 

of implants costs amongst the senior and junior resident groups (p-value = 0.27). 

Conclusion 

The majority of orthopaedic residents feel that their knowledge of implant costs to be 

poor. They tend to over-estimate the costs of implants especially the more ‘basic’ ones. 

Senior residents have a mean better estimation of implant costs but no statistically 

significant difference compared to the junior residents. 

This study raises the issue of residents lacking in the knowledge of implant costs and 

the need to implement these into the residency curriculum. 

Paper 242 


Authors: M.A. Muderis, K. Tetsworth, A. Khemka, S.Wilmot, B. Bosley, V. Glatt 

Disclosure: Yes: Munjed Al Muderis is one of the designer’s of the implants and 

receives royalties 

Abstract title: The Osseointegration Group of Australia Accelerated Protocol 

(OGAAP-1) for Two-Stage Osseointegrated Reconstruction of Amputees 

This study introduces the Osseointegration Group of Australia Accelerated Protocol 

(OGAAP) using press-fit fixation for transcutaneous prostheses. The primary objective 

was to describe in detail this two-stage strategy (OGAAP-1) for the osseointegrated 

reconstruction of amputated limbs. Secondary objective to assess the clinical outcomes 

regarding efficacy of the OGAAP-1 program in unilateral transfemoral amputees. 

Prospective case series of 50 patients treated at a single centre included 34 males 

and 16 females, aged 24-73 (mean 49.4) years, with minimum one-year follow-up. 

Main outcome measures included Questionnaire for persons with a Trans-Femoral 

Amputation (Q-TFA), Short Form Health Survey 36 (SF-36), K levels, Six Minute Walk 

Test (6MWT) and Timed Up and Go (TUG) tests, pre- and post-operatively. Adverse 

events were recorded including infection, revision surgery, fractures, and implant 

failures. 

Clinical outcomes were obtained pre/post-operatively from 12-46 months (mean 


396

follow-up, 21 months). Compared to preoperative values with socket prostheses, 

the mean post-operative values for all five validated outcome measures were 

significantly improved. Post-operative Q-TFA global score (53.13±4.54 to 

85.81±2.46, p

draped per surgical routine. Patient temperature was recorded at 15 minute intervals 

throughout the surgery and throughout the recovery room stay. Intraoperative and 

recovery room temperatures between the two groups were compared using a student’s 

T-test. 

Results: No statistically significant difference in mean intra-operative temperatures was 

found between the two groups (FA 97.95 and CH 97.64, p=.063). No statistically 

significant difference in mean recovery room temperatures was found between the 

two groups (FA 97.68 and CH 97.53, p=.39). 

Conclusion: There was no difference between intra-operative and recovery room 

temperatures between patients using either a forced air device or a conductive heating 

device. Those involved in perioperative care should be familiar with conductive 

heating devices as a potential alternative to traditional forced air devices. 

Paper 325 

Presenter: JP Palencia 

Authors: J. Palencia, F. Serro, M. Khalid, A. León, J. Fakehaa 


Abstract title: OSTEOPOROSIS IN SAUDI ARABIA, IS IT A PROBLEM? 

Objectives 

• Analysis of the Saudi Arabia osteoporosis prevalence. 

• The future expectations of osteoporosis in Saudi Arabia. 

• Recommendations and advices. 

Material and Methods 

• General review about the prevalence of osteoporosis in Saudi Arabia. 

• Assuming the expectation of osteoporotic cases in the future. 

• Recommendations and guidelines for management of osteoporosis 

according to the population culture and food habits. 

We have don a retrospective study comparing the osteoporotic proximal femoral 

fracture number between two Hospitals. 

First Hospital is King Saud Medical City Hospital in Riyadh, Saudi Arabia. Second 

Hospital is University Clinic Hospital of Valladolid, Spain. Both are third level Hospitals. 

We have collected the number of patients, gender and age, who have had this type 

of fracture during 2014. 

Inclusion study was accepted by consecutive sampling, regarding n=number of 

patients 

Inclusion criteria were: 

• Osteoporotic proximal femoral fracture admitted in Ortho Department. 

• Age > 40 y.o. 

Exclusion criteria were: 

• Age < 40 y.o. 

Finally, we did a statistical study, comparing gender, number and range age 

distribution between both Hospitals. 


398

Results 

We have collected the number of patients with osteoporotic femoral neck fracture in 

two Hospitals during 2013: 

Gender Distribution 

Age Range Distribution 

The gender and age distribution of Spain shows a normal distribution for this type 

of fractures. However, in Saudi Hospital is different. If we remove the incidence of 

these fractures in


The patient presented to our orthopaedic service with a leg length discrepancy. There 

was 53mm shortening of the left lower limb, 39mm of the femoral and 14mm of 

the tibial segment. A trochanteric entry Precice 2 lengthening device was inserted 

uneventfully and lengthening commenced after observing a 6 day latent period. 

The patient presented 12 weeks after implantation with an angular deformity of the 

thigh following blunt trauma sustained in a motor vehicle accident. The regenerate 

measurement at time of injury was 19mm. The nail had a 30 degree apex 

anteriomedial angulation at the site of the regenerate but it remained intact. 

No further lengthening was attempted with the device. 

A cephalo-medullary nail was inserted after difficult retrieval of the original 

device. Further correction was attempted by acute lengthening at the time of secondary 

procedure. On table traction failed to produce any further lengthening. An Orthofix 

limb reconstruction system (LRS) external fixator was then applied. Lengthening with 

the LRS achieved 3mm of further distraction. 

Conclusion 

Blunt trauma lead to failure of a femoral lengthening nail before the desired correction 

had been achieved. The immediate priority is to obtain aseptic union while correcting 

residual shortening with a shoe raise. The option of another lengthening procedure 

will then be discussed with the patient. 

Paper 458 

Presenter: A Minnis 

Authors: A.A. Minnis, M. Tsama, M.T. Ramokgopa 


Abstract title: An Unusual Case of Glenohumeral Septic Arthritis associated with 

an infected Morel-Lavallee Lesion in an HIV Positive Patient 

Morel-Lavallee lesions are posttraumatic haemolymphatic subcutaneous fluid collections 

occurring as a consequence of a violent shearing force.This “closed degloving injury” 

occurs infrequently and may be missed at initial presentation, particularly if there 

is no associated fracture. This can set the stage for a delayed presentation and 

complicated sequelae making early diagnosis and management essential. 

Case Report: A 58-year-old male with blunt trauma to right shoulder was treated 

conservatively and discharged home. He presents to casualty two weeks later 

with increased swelling and pain in the right shoulder. Ultrasound and computed 

tomography imaging demonstrates a complex fluid collection extending from the 

shoulder to the mediastinum. Blood investigations were consistent with an infective 


400

process and serological studies confirmed he was HIV positive. He underwent an 

arthrotomy and surgical drainage with multiple debridements. The patient recovered 

completely after surgical and medical management. 

Morel-Lavallee lesions are rare and often missed or mistaken for tumours or 

haematomas. There have been no reports to date of a simultaneous glenohumeral 

septic arthritis in a HIV positive patient with a missed Morel-Lavallee lesion. This 

case illustrates that a missed Morel-Lavallee lesion can become infected and that a 

coexistent HIV infection may have also contributed to the development of a concurrent 

septic arthritis of the glenohumeral joint. Early diagnosis is essential to reducing the 

morbidity associated with missing this lesion. The impact of coexistent HIV infection as 

an event modifier or a confounding variable has yet to be determined. 

Paper 492 

Presenter: J van der Merwe 

Authors: NA 


Abstract title: TREATMENT OF DISPLACED CLAVICLE FRACTURES IN THE 

ADOLESCENT WITH TITANIUM ELASTIC NAILS 

Background: Displaced midshaft clavicle fractures unite well in children less than 12 

years old, owing to their inherent ability to remodel bone. In adolescents, remodeling 

occurs less and deformity or shortening can result. Recent literature in adults shows 

improved outcomes of these fractures with operative treatment. It has been suggested 

that these results may translate to adolescents. 

Study Objective: To assess the effectiveness of titanium elastic TEN nails in the 

treatment of displaced midshaft clavicle fractures in adolescents. 

Methods: Adolescent patients (age 12 to 18) with closed displaced midshaft clavicle 

fractures, sustained between 2008 and 2015, were treated operatively by a single 

surgeon, who inserted a TEN nail in an unreamed fashion from the sternal end of the 

clavicle. Post-operatively, patients were immobilised in a sling for 6 weeks. The nail 

was removed routinely at 12 weeks. All patients were assessed by the surgeon at 24 

weeks with regards to the radiological outcome, Constant shoulder score, scar quality 

and complications. 

Results: Sixteen patients, 12 males and 4 females (mean age 14,2 years) were 

assessed. 

fourteen patients had complete union by 6 weeks and the remaining two by 12 

weeks. 

The Constant score was graded below 11 for all patients by 12 weeks follow up and 

all patients were satisfied with their scars after 24 weeks. 

401

Two patients developed complications: in one, the nail perforated the posterior cortex 

of the lateral fragment and the other developed a haematoma. 

Conclusion: Operative treatment with a TEN nail is a safe, minimally invasive and 

reliable treatment method for displaced midshaft clavicle fractures in adolescents 

resulting in a satisfactory surgical outcome. 

POSTERS - HAND 

Paper 139 


Authors: J.S. Silvestre, H.H. Wu, J.M. Abbatamatteo, J.Z. Guzman, A.F. Kamath 


Abstract title: The Impact of Self-Citation on Scholarly Output in Orthopedics 

INTRODUCTION: Developed in 2005, the h-index is a widely utilized metric of an 

author’s scholarly output. Studies propose that self-citation may limit the utility of the 

h-index via artificial inflation. The purpose of this study was to evaluate the prevalence 

and impact of self-citation on the h-index in a cohort of orthopedic investigators. 

METHODS: The study cohort consisted of orthopedic faculty with NIH-funding, chairs, 

and program directors. The Scopus database was used to determine the h-index and 

number of citations with and without self-citations. Total number of peer-reviewed 

publications was correlated with change in h-index via self-citation. 

RESULTS: A total of 463 orthopedic investigators were included (198 NIH-funded, 

147 chairpersons, 118 program directors). 83.8% cited previous work at least once 

(mean 123.9 +/- 277.6 self-citations). These self-citations accounted for 5.8% of 

all citations. Including self-citations in bibliometric analyses increased h-indices from 

18.5 +/- 14.9 to 19.2 +/- 15.6. A minority of researchers (36.3%) increased their 

h-index via self-citation by at least one integer value (range, 0-8). At a threshold delta 

h-index of 1, authors had on average 88 articles and an h-index of 24. As authors 

achieved more publications, they were able to increase their h-index via self-citation 

to a greater degree. 

DISCUSSION AND CONCLUSION: The practice of self-citation is prevalent among 

orthopedic investigators, but its impact on the h-index is negligible for most authors. 

This finding suggests committees may disregard this factor for promotion. With 

more publications, researchers can increase h-indices via self-citation, but at a high 

threshold of published articles. 


402

POSTERS - HIPS 

Paper 32 

Presenter: S Nahas 

Authors: S Nahas, Patel A, Hislop S, Vedi V 

Disclosure: Yes: No conflict of interest. 

Abstract title: Independent assessment and Outcomes of 198 Short Tapered Stems 

with 72 Month Follow Up 

Introduction: Short tapered femoral stems for cementless total hip arthroplasty are 

now having longer-term outcome data becoming more readily available. The shorter 

stem has a metaphyseal fit, loading the bone in this area, leading to physiological 

bone remodelling 1 . Some quote the stem as bone preserving, as it is 35mm shorter, 

and thus gives greater bone stock distally if revision is required 2 . Due to the nature 

of the short stem, it may be easier to insert through a smaller incision and potentially 

reduce complication rates 3 . We present a prospective single surgeon case series 

of 197 patients (mean follow up 36 months). All patients had the cementless 

‘Microplasty Taperloc’ (Biomet). Primary outcome measures were femoral component 

revision rates. Secondary outcome measures included complications, patient reported 

outcome measures (Oxford Hip Score) and radiographic evidence of loosening 

(radiolucency/osteolysis, cortical hypertrophy, subsidence, stability/stress shielding 

– Engh’s criteria 4 ). 

Methods: Patients were identified using electronic software and all were routinely 

followed up and assessed in clinic since the introduction of the implant in 2009. 

Oxford hip scores were routinely obtained. A surgeon who had not carried out the 

procedure independently assessed radiographs. 

Results: 196 patients were identified. The revision rate was 1% due to an intraoperative 

peri-prosthetic fracture of the femur identified on postoperative radiograph, and 

a significant leg length discrepancy. Complication rate was 2%, attributable to: 

subsidence of the prosthesis (1 hip), postoperative dislocation (2 hips). Oxford hip 

score increased on average from 21 to 45 (pre to post operatively). There were no 

signs of radiographic loosening in any of the implants. 

Discussion and Conclusion: The results show that using the short tapered stem is 

proving so far to be a reliable and safe alternative to its longer counterpart and 

operative complication rates are lower. 

Paper 221 

Presenter: T McTighe 

Authors: E. McPherson, B. Vaughn, L. Keppler D. Brazil, and T. McTighe 

Disclosure: Yes: Disclosure Statement: One or more of our authors have disclosed 

information that may present potential for conflict of interest with this work. 

403

Abstract title: Dislocation Rate in Utilizing A Short-Curved Neck-Preserving Stem 

Design with the Posterior Surgical Approach. 

Purpose: 

Dislocation remains a significant complication of total hip arthroplasty. The increased 

trend of utilizing short neck-preserving stems potentially increases the risk of 

mechanical impingement. This can lead to residual pain, dysfunction, and possible 

hip dislocation. This study retrospectively reviews the clinical dislocation results for 

primary THA utilizing the posterior surgical approach at three different centers. 

Material and Methods: 

Between April 2010 and June 2014 338 short-curved neck-preserving stems (ARC 

Stem, Omni, E. Tauton, MA, USA) were implanted. All were performed utilizing the 

posterior surgical approach. All three surgeons along with the two additional coauthors 

were involved with the early development of both the stem and instrumentation. 

Preoperative training with cadaver workshops was a requirement prior to any clinical 

surgical evaluation of this device. Intra-operative x-rays were also required in the early 

stage of surgical implantation. 

The stem design features a short curved titanium alloy stem with a proximal conical 

flair for enhanced proximal compressive loading of the medial calcar. The proximal 

third of the stem has commercially pure titanium plasma spray coating with a surface 

layer of hydroxyapatite (HA) coating (25μm). The modular femoral neck is made of 

cobalt chromium alloy and allows for intra-operative adjustment of joint stability, leg 

length and offset. 

All acetabular components were a variety of hemispherical cementless titanium alloy 

porous coated designs and bearing surfaces. All head diameters were restricted 

to 32 mm or larger. In the smaller patient profile, a dual mobility style implant was 

chosen 77 times. Early in this series a limited number of large metal on metal (MoM) 

bearings were also used. 

Results: 

In our combined series 59% of patients were female and 41% were male. At an 

average follow-up of 38 months (range 12-56 months) there were three dislocations 

in this series (0.88%), all of which required revision surgery. In one case, the modular 

neck was exchanged to add 3.5mm in length and the polyethylene liner was also 

exchanged to add a 15º posterior hood. In the two other cases, the femoral stems 

were revised to conventional length stems, along with exchange of the polyethylene 

to add a posterior hood. 


404

Conclusion: 

The utilization of short-curved neck-preserving stems with the posterior approach did 

not result in a higher dislocation rate in this series. 

Paper 224 


Authors: D.R.van der Jagt, J,R.T.Pietrzak and L.Mokete 


Abstract title: Dissociation of ceramic liners from metal-backed acetabular cups. 

A report of two cases. 

We describe two cases where after significant trauma, a ceramic liner dissociated 

from a metal backed acetabular cup, and then relocated in an imperfect orientation. 

There was followed by an initial development of a squeaking noise, which later 

disappeared. Radiology at subsequent follow up revealed multiple ceramic fragments 

around the hip articulation. In both cases at revision, these ceramic fragments were 

found to have resulted from chip fractures of the edge of the ceramic liner. After 

removal of the ceramic liner, the cup morse taper was found to be undamaged, and 

a liner exchange was performed. 

We explore the combination of forces needed to allow the development of our 

documented clinical pictures. We calculated the suction effect of a distracting force 

in a ceramic coupling, leading to the dissociation of the ceramic liner from its metal 

backing. We calculated the theoretical advantage of different morse tapers, especially 

in respect of the taper angle and length. 

We also compare the relative advantages of different materials used with specific 

tapers. In the light of these findings we make recommendations in respect of the 

design of the morse taper couplings commonly found in un-cemented acetabular 

cups. We also suggest that ceramic liners bonded to metal may well offer certain 

advantages. 

Paper 227 

Presenter: T McTighe 

Authors: T. McTighe, S. D. Stulberg, J. Keggi, L. Keppler, D. Brazil, R. Kennon, E. 

McPherson 


Abstract title: A Classification System for Short Stem Total Hip Arthroplasty 

Purpose: 

The use of short stems is growing. Initial short and mid-term follow up studies of a 

number of these stems suggest that stable, durable fixation and excellent clinical 

405

outcomes can be achieved. As a result, a very large number of short stem designs 

are available. However, there does not exist a classification system for uncemented 

short stem implants that would allow comparisons of clinical and radiographic results. 

The purpose of this presentation is to propose a classification system based upon the 

length of the stem and the method by which the stem seeks to achieve stability. 

Methods: 

25 femoral components described as having “short stems” were evaluated. The range 

of lengths for each stem type and the method of achieving initial implant stability was 

determined. The optimum radiographic position of each of these implants and the 

proposed type of bone remodeling associated with this placement in the proximal 

femur was evaluated. 

Some of these devices are not available in the U. S. and some are new to their clinical 

experience. As a result this paper makes no assumption as to clinical performance 

or benefits to certain product feature. This is intended to point out certain trends for 

hip reconstruction and provide as base for development of the “JISRF Short Stem 

Classification System”. 

Results: 

1. Head Stabilization 

a. Hip Resurfacing 

b. Mid-Head Stem 

2. Neck Stabilized 

a. Short Curved Stem 

b. Short Lateral Flare Stem 

c. Neck Plugs 

3. Metaphyseal Stabilized 

a. Short Taper Stem 

b. Bulky or Fit & Fill Stem 

b+. Metaphyseal Lateral Flare Stem 

c. Metaphyseal Bolt/Cortex 

4. Conventional - Metaphyseal/Diaphyseal Stabilized 

Summary: 

Not all short stems generate the same radiographic findings and or clinical results. It 

is also important to appreciate the specific design and appropriate surgical technique 

for a given design. 

This classification will help differentiate and clarify when reporting on the design and 

clinical findings of short stem total hip arthroplasty. 

Paper 228 


Authors: D.R.van der Jagt, J.R.T.Pietrzak, L.Mokete K.Nwokeyi and A.Schepers 


Abstract title: Serum Metal Ion Levels. Do they mean anything? 


406

As part of a clinical trial a cohort of patients who had had total hip replacements done 

was followed up over a five-year period. Serial serum cobalt and chromium metal ion 

levels were performed. The patients included those with different bearing surfaces. 

The combinations were ceramic-onpolyethylene, ceramic-on-ceramic, metal-onmetal 

and ceramic-on-metal bearings. Serum metal ion levels were determined preoperatively, 

and at various points after their procedures. Standardized phlebotomy 

and analytical methods were employed. 

The general trend in this longitudinal analysis of serum metal ion levels followed 

expectations. An initial rise in metal ion levels was followed by a gradual decrease 

associated with the bedding in period in those patients with metal containing bearings. 

All groups though demonstrated outliers both within the group as well as within the 

individual longitudinal samples. Such aberrant results were generally followed by 

returns to expected levels. 

Various factors were entertained in trying to explain these metal ion level anomalies. 

These included both lapses in methodology as well as environmental factors. No 

consistent explanation could be found. We concluded that isolated serum chromium 

and cobalt metal ion levels need to be approached with extreme caution, especially 

when not correlating with clinical and radiological findings. In patients with a 

symptomatic hip replacement with a metal containing bearing using metal ion levels 

as a monitoring tool should be approached with caution. Serial levels with at least 

three specimens at three month intervals must be analyzed. Considering the high cost 

of such serum metal ion analysis, we would suggest that such metal ion level analysis 

should not be considered as an important part of the clinical work up. 

Paper 236 


Authors: Anoushiravani AA, Sayeed Z, Chambers MC, Scaife SL, El-Othmani MM, 

Saleh KJ 


Abstract title: Comparative Analysis of Low and Normal BMI as it Relates to 

Nutritional Status and Postoperative THA Outcomes 

Introduction: Total hip arthroplasty (THA) is one of the most common and successful 

procedures performed in the United States. Poor nutritional status is a preventable 

condition resulting from a diet low in nutrients, and commonly presents with low body 

mass index (BMI). A low BMI score may serve as an objective measure to assist 

surgeons in fully understanding the nutritional status of their patients. The purpose of 

this study is to comparatively analyze the effects of low (≤19 kg/m 2 ) and normal (19- 

24.9 kg/m 2 ) BMI and report the impact of both variables on postoperative outcomes 

and resource utilization. 


used for this study. All patients received a primary THA, were eligible for inclusion in 

407

this study. The included population was divided into low BMI and normal BMI. All 

groups were matched for 27 comorbidities using the Elixhauser comorbidity index. 

Their in-hospital postoperative outcomes were then comparatively analyzed. Using 

SAS 9.3 statistics software multivariate analysis, logistic regression models, and chisquared 

results were generated. Data was analyzed using odds ratio (OR), 95% 

confidence intervals (CI), and p-values. 

Results: A total of 3550 patient samples were split into two cohorts and matched. 

The patient population was statistically analyzed for both low and normal BMI groups 

relative to: demographics, comorbidities, postoperative outcomes, and resource 

utilization. In regards to postoperative outcomes, patients with lower BMI had a 

higher risk of postoperative anemia (OR 2.65; 95% CI, 2.30-3.07) compared with 

normal patients. Analysis of resource utilization demonstrated low BMI patients had 

longer lengths of stay (LOS) (5.30 days versus 4.40 days, p=.021), higher total 

hospital charge (USD 61346.8 versus 42990, p

The measurements were made for by a single operator, using a calipre and measuring 

tape. Head Volume (HV), Neck Length (NL), Neck Diameter (ND), Neck Volume 

(NV), Trochanteric Length (TL), Femoral Length (FL) and Neck Shaft Angle (NSA) were 

measured. 

The results were statistically analysed, comparing males and females, within the ethnic 

groups. HV (Head Volume), NL (Neck Length), ND (Neck Diameter), TL (Trochanteric 

Length) and FL (Femoral Length) were significantly larger in males. NSA (Neck Shaft 

Angle) was similar. Comparing between the ethnic group, all the HV (Head Volume), 

NL (Neck Length), ND (Neck Diameter), TL (Trochanteric Length) and FL (Femoral 

Length) were larger in the whites than the blacks. Black and coloured measurements 

were similar. NSA (Neck Shaft Angle) was similar in all groups. 

In conclusion, the geometric measurements differences between the groups, is in 

keeping with their different fracture rates which have been published. 

Paper 401 

Presenter: E SCHNAID 

Authors: A. Biscardi, E.Schnaid 


Abstract title: GEOMETRIC AND BONE MINERAL DENSITY IN BLACK AND WHITE 

SOUTH AFRICAN MALES - updated 

Geometry and Bone Mineral Density in Black and White South African Males. 

A. Biscardi, E.Schnaid, M.T. Ramokgopa 

Updated -Geometry measurements of the proximal femur, based on engineering 

and bio-mechanics of the skeletal framework should be related to femoral strength. 

Geometrical calculations should be used as the means to assess the population that 

might be at risk for fracture. Recent studies have shown that simple measurements of 

femoral geometry could be used to assess the fracture rate in different ethnic groups. 

Black females have been shown to have a shorter Hip Axis Length than white females. 

Males have less fracture incidences. 

The number of studies in a South African male population are not many, and in 

comparison between the two adult ethnic groups, geometrical measurement is as 

important as comparing their bone densities. This knowledge may define which 

conditions could predict fractures in a particular ethnic group within a diverse 

population. 

Methods: In this study we have compared geometry of the femur between 70 

black and 120 white male volunteers of comparative age, using dual energy x-ray 

absorptiometry (DXA) scans. We measured the Hip Axis Length (HAL), Neck Shaft 

Angle (NSA) and Femoral Neck Axis Length (FNAL). 

409

Comparisons were also done for the hip and lumbar regions calculated by DXA 

scans. Hip regions were Femoral Neck (FN), Trochanter, Bone Mineral Content 

(BMC/grams) and Bone Mineral Density (BMD/grams/cm 2 ) analysis for these 

regions. Lumbar region analysis were on L1-L4. 

Results showed there were statistical differences in most areas measured in the hip 

except for NSA. FNAL= 15.7mm for blacks and 20.10mm for whites. HAL was 

65.80mm for blacks and 73.76mm for whites. 

Bone density of the femur showed an Area of 40.63cm 2 and 46.20cm 2 and BMC 

of 39.94grams and 42.71grams black and white respectively. The value of BMC to 

Area in the blacks achieves equality in BMD with the whites 0.962 to 0.924. 

Bone density values for the lumbar were not significantly different: Blacks 0.9408 

grams/cm 2 and whites 0.9523grams/cm 2 . 

POSTERS - INFECTION 

Paper 347 


Authors: A.D. Beswick, S. Strange, E. Lenguerrand, A.J. Moore, S. Kunutsor, R. 

Gooberman-Hill, S. Noble, M.R. Whitehouse, A.W. Blom 


Abstract title: One- or two-stage revision of infected hip replacements: is a 

randomised controlled trial possible? 


Many patients with prosthetic hip infection receive revision surgery. Following 

prosthesis removal and debridement, prostheses are replaced in the same operation 

(one-stage) or delayed (two-stage). As the implications for patients and healthcare 

providers are substantial, we assessed the feasibility of a randomised controlled trial 

(RCT) to guide optimum treatment. 


We examined the National Joint Registry for England and Wales for use of one- and 

two-stage revision and variation between centres. 

In qualitative studies we interviewed 19 patients treated for prosthetic hip infection 

and 12 specialist surgeons to assess acceptability of randomisation. 

As there are no RCTs, we systematically searched bibliographic databases for case 

series of infection treated with one- or two-stage revision. Further infection rates were 

combined in random effects meta-analysis. 


410

We conducted a pilot RCT in seven major centres treating infected hip replacements. 

Consensus was reached on inclusion based on microbiology and health status. 

Primary outcomes are patient-reported pain and function, and health service and 

patients costs. 


In 2014 in England and Wales, first revision for prosthetic hip infection was onestage 

in 38% and two-stage in 60% of patients. In the five largest centres, one-stage 

revision constituted 8% to 64% of revision strategies. 

Patients with prosthetic hip infection considered an RCT acceptable but struggled with 

the idea of randomisation due to prior experiences. Surgeons considered randomising 

patients acceptable depending on infecting organisms and health status. 

Two-year rates of further infection in 38 one-stage series (2,536 participants) and 

60 two-stage series (3,288 participants) were 8.2% (95%CI 6.0, 10.8) and 7.9% 

(95%CI 6.2, 9.7) respectively. 

In the pilot RCT coordinating centre, 10 patients were randomised, over 50% of those 

eligible. Seven major UK centres are now active with 26 patients randomised. 


Variation in rates of one- and two-stage revision between centres suggests that 

treatment choice is largely not protocol driven but surgeon preference. With defined 

inclusion criteria, specialist surgeons recognise the importance of an RCT. Patients 

considered an RCT acceptable but counselling on randomisation may be required. 

Evidence from case series suggest that infection rates subsequent to revision are 

similar between treatments. Randomising patients into an RCT is feasible but the low 

incidence of prosthetic hip infection indicates the importance of a multicentre study. 

Paper 425 

Presenter: J Page 

Authors: J.Page, A.Hassan 


Abstract title: The Use of Cerament G (Gentamicin Antibiotic Bone Eluting Bone 

Graft Substitute. Bone Solutions) in the immediate management of pin sites 

following the removal of fixation devices used in Ring Fixators. 

In a number of limb reconstruction/ fracture fixation procedures using a ring fixator, 

augmentation is often required with use of further hardware to protect the regenerate. 

This can either be in the form of intra/extramedullary fixation. In the authors view 

there is no such thing as a non-contaminated pin site. Implanting hardware into an 

already colonised field is taking a calculated risk regenerate fracture versus infection. 

411

Damage limitation surgery using spanning external-fixator is commonplace with 

secondary definitive fixation at a later stage. Again there is a very real concern with 

regards infection at time of secondary fixation. A medical device that delivers local 

antibiotics and allows the regeneration of bone stock is ideal in this situation. 

In certain limb reconstruction procedures there is the need for a frame holiday/ 

replacement of fixation pins/half wires. Bone stock is finite and reduces with each new 

pin/wire. Cerament G already has published success in the treatment of osteomyelitis 

and Cerament without gentamycin published data in bone regeneration. This would 

suggest an ideal use for it following the removal of pins/ wires of a ring fixator. 

Hypothesis: Cerament G would eradicate potential for post-operative infection, allow 

primary skin closure and allow the rapid regeneration of the bone stock. 

Null Hypothesis: No change with extra cost and possible morbidity. 

Method. 

12 Patients had frames removed and cerement G used to fill the void left. 

They were followed up both radiologically and clinically. 

Results 

1) Regeneration of bone stock in 8-16 weeks. 

2) Primary wound closure in 10 patients. 

3) Skin irritation in 5 patients, mimicking infection settled without antibiotics. 

4) No postoperative infection. 

Conclusion. 

1) In complex limb reconstruction patients there is a role for cerement G usage to 

allow primary closure of pin sites. 

2) Allows the rapid regeneration of bone stock allowing easier ‘part 2’ operations 

common in limb reconstruction. 

3) No postoperative wound infections noted however skin irritation. 

4) Role in complex limb reconstruction requiring secondary hardware implantation. 

5) Role in second stage procedures requiring implantation of hardware into a 

contaminated field. 

6) No role in surgery not requiring a further procedure after removal of frame. 

Paper 479 

Presenter: ZA Linda 

Authors: z. linda, k. sekhauli, p. swart and m. lukhele 


Abstract title: primary hydatid disease of thepelvis 

Human echinococcosis is a zoonotic infection. Musculoskeletal involvement presents 

in 1 -4% of cases. Primary hydatid disease is rare. In this poster we are reporting two 

female patients who presented with the disease two years apart and were treated 

in our institution. 


412

Both patients had severe destruction of the hemipelvis . One was treated surgically 

and medically and the other one only medically. In this poster we will be reviewing 

the literature and discussing challenges associated with this disease. 

POSTERS - KNEES 

Paper 110 

Presenter: GL Foo 

Authors: G.L. Foo, M.H. Lim 


Abstract title: Outcomes 1 Year After ACL Reconstruction With Focus on the 

Influence of Patient Age 

Purpose 

Our study aims to review the outcome of patients who have undergone ACL 

reconstruction analysing for a difference in outcome between different age cohorts. 

Methods 

72 patients who had an ACL reconstruction were identified from a surgical database. 

Inclusion criteria were primary ACL reconstruction with a minimum of a 1-year followup. 

Exclusion criteria were revision cases and concurrent pathologies (multi-ligament 

injuries, chondral injuries). The patients were divided into 3 cohorts: A (age 0 to 20), 

B (20 to 29) and C (30 to 39). Knee Injury and Osteoarthritis Outcome Score (KOOS) 

and International Knee Documentation Committee (IKDC) scores were conducted preoperatively, 

at 3 months, 6 months and 1 year. 

Results 

There were 14 patients in group A (mean age 17.8 years), 47 in group B (mean 

age 23.6) and 11 in group C (mean age 33.9). Group A’s IKDC mean scores were: 

62.0 (pre-op), 62.7 (3 months), 81.9 (6 months) and 90.9 (1 year), group B: 58.8 

(pre-op), 60.6 (3 months), 71.4 (6 months), 86.0 (1 year), and group C: 58.3 (preop), 

62.6(3 months), 66.7 (6 months) and 82.4 (1 year). There was no significant 

difference between the scores of group B and C. Group A had significantly better 

IKDC scores than group B and C at the 6 month mark and better than group B at the 

1 year mark. 

The KOOS scores were categorized into Symptoms, Pain, Activities of Daily Living 

(ADL), Sports and Quality of Life. For the KOOS score, group A had significantly 

better scores than group B in the pre-operative ADL, 3 month Sports and ADL, 6 

month ADL and 1 year Sports sub-scale. Group A also had better scores than group 

C at the 3 month Symptoms and 6 months Sports and ADL sub-scale. 

413

Conclusion 

There is good progression in outcome in patients who underwent ACL reconstruction 

in our cohort. However, our data suggests that younger patients have better outcome 

based on the IKDC score and also certain components of the KOOS scoring system 

at mid-term follow-up. Further analysis on muscular strength, pre-existing degeneration 

and rehabilitation program compliance would help identify possible factors for these 

differences. 

Paper 115 


Authors: RW Jordan, A Jones, A Pearse 


Abstract title: Defining The Role of Bisphosphonates for Osteonecrosis of The 

Knee: A Systematic Review 

Introduction 

Osteonecrosis of the knee encompasses three conditions; spontaneous, secondary 

and post-arthroscopic. Treatment options include non-operative treatment, joint 

preserving surgery and arthroplasty. Bisphosphonates have been shown to successfully 

prevent bone resorption in animal studies and hip osteonecrosis. This article aims to 

systematically review the available evidence that bisphosphonates reduce pain and 

improve function in patients with knee osteonecrosis. 

Methods 

A systematic review using the online databases Medline and EMBASE was 

conducted. All studies that assessed the use of bisphosphonates in the treatment 

of knee osteonecrosis were included. Critical appraisal using a validated quality 

assessment scale and the CONSORT statement was performed. 

Results 

Eight studies were eligible for inclusion, the total number of patients was 89 and the 

overall rate of side effects was 12%. Seven studies reported cases of spontaneous 

osteonecrosis; the mean time until MRI resolution ranged from 4 to 6 months but an 

RCT reported no improvement in clinical or radiological outcome when compared 

to placebo. Two studies reviewed post-arthroscopic cases with the largest study 

reporting an 80% improvement in pain and 67% radiological resolution. One study 

reported three cases of secondary knee osteonecrosis in children suffering from acute 

lymphoblastic leukaemia and only one case demonstrated improvement in pain or 

MRI findings. 


414

Conclusion 

Evidence from case series suggests bisphosphonates may have a role in knee 

osteonecrosis but this was not validated in the single published RCT which had 

several important limitations. The lack of high quality evidence necessitates further 

robust research to evaluate if bisphosphonates are an efficacious treatment modality. 

Paper 135 

Presenter: OK Muratoglu 

Authors: K.M. Varadarajan, T. Zumbrunn, M.P. Duffy, H.E. Rubash, H. Malchau, 

O.K. Muratoglu 

Disclosure: Yes: One or more co-authors are listed inventors on a patent application 

related to the technology discussed in this study. 

Abstract title: Is Retention of Native ACL the only Option for Addressing Abnormal 

Anteroposterior Kinematics of Cruciate Retaining TKA? 

Purpose: 

Sacrifice of the Anterior Cruciate Ligament (ACL) during Posterior Cruciate 

Ligament (PCL) retaining Total Knee Arthroplasty (TKA), leads to abnormal kinematics 

and joint stability. However, ACL retention poses several challenges including risk 

of tibial bone island fracture. Additionally, a sizable proportion of patients have 

an absent or non-functional ACL at surgery. We hypothesized that a novel ACL 

Substituting Cruciate Retaining (ASCR) implant that substitutes for the absent ACL, 

while preserving the native PCL, could be a viable alternative to ACL retention. The 

ASCR tibia includes an ACL substituting post that engages the intercondylar notch of 

the femoral component in low flexion to act for the missing ACL. Purpose of this study 

was to use biomechanical simulations to verify that the ASCR implant can address 

kinematic abnormalities of contemporary CR implants. 

Methods: 

Deep knee bend and chair-sit kinematics of the ACL substituting ASCR design 

were compared to that of a contemporary ACL sacrificing CR implant (NexGen-CR, 

Zimmer), an ACL retaining BCR-A implant (TKO BCR, Biopro), and an ACL retaining 

BCR-B implant (same articular surface as ASCR without a post but with an intact 

ACL).These kinematics were evaluated by using LifeModeler KneeSIM. The collateral 

ligaments, PCL, ACL (BCR implants only), and quadriceps were modeled using softtissue 

insertion data obtained from magnetic resonance imaging, and mechanical 

properties obtained from literature. 

Results: 

During deep knee bend, the CR implant showed posterior femoral subluxation in 

extension followed by anterior sliding until 90° flexion (~5.5 mm). Both ASCR and 

415

BCR-B implants showed nearly identical kinematics with femoral condyles located 

more anteriorly in extension than in the CR implant (~10mm), and no anterior femoral 

sliding. BCR-A also did not show anterior femoral sliding in low flexion. However, the 

femur was shifted posteriorly (~4 mm) compared to the ASCR and BCR-B implants. 

During chair-sit, the ASCR and BCR-B again showed near identical kinematics with 

net posterior femoral rollback of ~5-7mm. The femur in BCR-A was slightly shifted 

posteriorly in extension (~3 mm), and showed net rollback of 3 mm. The CR TKA 

again showed posterior subluxation in extension (~5 mm) followed by anterior femoral 

sliding. 

Conclusion: 

Similar to the ACL retaining designs, the ASCR implant improved the kinematic 

abnormalities of the contemporary CR implant across different activities, including 

posterior femoral shift in extension and paradoxical anterior sliding in early flexion. 

Thus ACL substitution may be an alternative to ACL retention for addressing kinematic 

abnormalities of CR implants. 

Paper 143 

Presenter: V Shetty 

Authors: S. Kulkarni , K. Alva , N. Shetty, V. Shetty 


Abstract title: Immediate post-operative pain relief after knee arthroscopy: 

Bupivacaine Vs Bupivacaine and morphine combination. A randomised control 

study 

Aim: To evaluate the analgesic effect of intra-articular injection of bupivacaine alone 

or a combination of bupivacaine and morphine following arthroscopy of the knee 

joint. 

Methods: In a prospective, randomized study, 34 (42 knees) patients who required 

elective knee arthroscopy were assigned to two groups: Group A consisted of 18 

patients (24 knees) who received bupivacaine (0.5%, 10cc) alone and Group B 

consisted of 16 patients (18 knees) who received a combination of bupivacaine 

(0.5%, 10cc) and morphine (1mg). Analgesic effect was evaluated by pain intensity 

(visual analogue scale) and analgesic requirements during the first four, eight, twelve 

and twenty-four hours post-operatively. 

Results: At 24 hours following the operation, the visual analogue scale score and the 

analgesic requirements were significantly higher in Group A compared to Group B 

(P

Paper 156 


Authors: A.D. Beswick, V. Wylde, J. Dennis, N. Howells, R. Gooberman-Hill 


Abstract title: Interventions for the management of long-term post-surgical pain 

after total knee replacement: a systematic review of randomised controlled trials 


For many people, total knee replacement (TKR) is a highly successful operation for 

pain relief. However, when optimal recovery should be achieved, around 10-34% 

of patients report moderate to severe post-surgical pain. We aimed to synthesise 

evidence on the effectiveness of pain management strategies for patients with 

long-term pain after TKR. As long-term pain is a known problem after other types of 

surgery it may be possible to apply evidence from other types of surgery to TKR and 

we sought evaluations of interventions for post-surgical pain after other surgeries. 


We conducted a systematic review of randomised controlled trials (RCT) that evaluated 

management interventions in patients with long-term pain after TKR. MEDLINE, Embase 

and The Cochrane Library were searched to September 2015. We also conducted 

a scoping search in other types of surgery. 


Searches identified one RCT evaluating an intervention in patients with long-term 

pain after TKR. Botulinum toxin A injection provided meaningful pain relief for about 

40 days. The authors described the need for a large trial of repeated injections. 

Regarding other types of surgery, over 13,000 articles were screened and 36 

evaluations of interventions were identified for pain management after back surgery 

(9 studies), amputation (12 studies), sternotomy (1 study), thoracotomy (1 study), 

cancer surgery (6 studies), hernia repair (3 studies), and spinal surgery (4 studies). 

Interventions focused on oral drug therapy (16 studies), injected drugs (3 studies), 

topical drugs (2 studies), acupuncture (1 study), exercise (1 study), epidural or spinal 

blocks (12 studies), or magnetic stimulation (1 study). 

No RCTs were identified investigating multidisciplinary interventions or individualised 

pain management strategies in TKR or other types of surgery. 


Our review highlights the lack of robust evidence about management strategies for 

long-term pain after TKR. While treatments identified in other surgeries may have 

relevance to long-term pain after TKR, no trials of multidisciplinary interventions or 

individualised treatments were identified. 

417

Future interventions for evaluation should consider the multifactorial nature of pain 

after TKR including: mechanical issues; the sensitising impact of long-term pain from 

osteoarthritis; complex regional pain syndrome; inflammation, infection and localised 

nerve injury; and psychological factors. 

As a large number of people are affected by long-term pain after TKR, there is a 

pressing need to develop the evidence base about care for these patients. 

Paper 179 

Presenter: E Pelser 

Authors: E. Pelser 


Abstract title: A Novel Surgical Approach For Valgus Knee Deformity Correction 

in Total Knee Arthroplasty: A Surgical / Cadaveric Correlation Study - Updated 

Total knee arthroplasty is a reliable and durable procedure in the treatment of valgus 

knee arthritis 

However, valgus-deformed knees present a unique set of problems and technical 

challenges to the arthroplasty surgeon in terms of the intraoperative balancing 

required to achieve correct alignment in order to maximize both the survivorship of 

the implants and patient satisfaction. 

Several different surgical techniques (via medial or lateral approaches) have been 

proposed to correct valgus deformities and these are well described in the peerreviewed 

literature. These include soft tissue releases of lateral supporting structures 

(e.g. “pie crusting” of the posterolateral corner by Ranawat and releases confined 

to the posterolateral capsule, Beverland) and / or bony procedures or sliding 

osteotomies (Keblish, Briad). 

We adopted the posterolateral capsule release technique, after witnessing a most 

spectacular demonstration of its application for correction of valgus deformity in 

Beverland’s institution, obtaining reproducible balance and correction of deformities 

resulting in very satisfied patients. 

However, with the insight of over 10 years’ experience and documenting all our 

valgus cases, we formulated the hypothesis that what is actually being resected is 

not the posterolateral capsule, but, a structure of ligamentous nature or origin. The 

objective, therefore, of this study was to test this hypothesis by using a cadaveric 

model. 

Two fresh cadavers were obtained by the Anatomy Department of the University of 

Pretoria and four dissections / investigations of the knee joints were undertaken using 

the “inside-out” and the “outside-in” techniques after exposing the ligaments and deep 

structures. 


418

The results confirmed our hypothesis and lead us to arrive to the, very surprising and 

interesting finding in valgus knee arthroplasty surgery: the posterolateral structure that 

we release is in fact the Lateral Collateral Ligament! 

Paper 282 

Presenter: M Boswell 

Authors: M. Boswell, B.L. Davis, M. Kelly, D. Filipkowski, J.J. Elias 


Abstract title: Determining a Relationship between Femoral Condyle Geometry 

and ACL Length 

Purpose of Study: A relationship between femoral condyle geometry and anterior 

cruciate ligament (ACL) length, although not currently quantified, would facilitate the 

design of ligament-sparing patient-specific knee implants for patients whose cartilage 

has been compromised due to osteoarthritis. 

Description of Methods: The relationships between the radii of the femoral lateral and 

medial condyles and the length of the ACL bundles were evaluated using five knee 

computational models. Ligaments and muscles were modeled as described previously 

[1]. For each condyle, anterior and posterior cylinders were used to represent the 

distal femoral anatomy. The models were run with the contact between the femur, or 

cylinders, and the tibia guiding the motion from 0° (extension) to 50°flexion. ACL 

force vs. flexion angle of the tibia for the two contact conditions was compared 

to confirm that the radii of the fitted cylinders matched those of the patients’ knees. 

The average root-mean-square error (RMSE) of the ACL forces between the original 

models and cylinder models was 5.1N with a normalized RMSE of 7.4%. Cylinder 

radii length was then compared to the ACL bundle lengths. 

Validation: To validate the results of the computational model, a cadaver study was 

performed on three human cadaver legs. A microscribe was used to digitize points 

and outline the geometry of the knee. Landmarks digitized included the origins and 

insertions of the ACL and PCL as well as the curvature of the femoral condyles. 

Summary of Results: After creating the models, comparisons were made between 

the length of each cylinder radii and the length of the anterior ACL and posterior 

ACL bundles. The strongest relationships were found between the ACL length and 

the medial posterior cylinder radii (R 2 =0.93, p=0.005) medial anterior cylinder radii 

(R 2 =0.89, p=0.009). Cadaver data was then compared to that of the computational 

model. Overall, the cadaver data had a wider range of ACL lengths than those used 

in the model but the linear trends for the computational model and cadaver specimens 

were very similar. 

Conclusion: The relationship observed between the ACL length and cylinder radii 

supported the hypothesis that there is a close synergy between condyle geometry and 

ACL length. This relationship can aid with patient-specific focused surgeries where 

there is a desire to spare the ACL and PCL ligaments. 

419

References: 

1. Purevsuren T, Elias JJ, Kim K, Kim YH. Dynamic simulation of tibial tuberosity 

realignment: model evaluation. Comput Methods Biomech Biomed Engin. 2014, 

(15)1-5. 

Paper 283 

Presenter: B Davis 

Authors: B.L. Davis, M.A. Boswell, J.J. Elias 


Abstract title: Femoral Condylar Radii Follow a Fibonacci Ratio 

Brian L. Davis, Ph.D. 1 , Melissa A. Boswell 1 , John J. Elias, Ph.D. 2 

1 

The University of Akron, Akron, OH, USA; 2 Akron General Medical Center, Akron, 

OH. USA 

Purpose of study: The purpose of this study was to examine the ratios of medial 

and lateral epicondyles radii and to test whether they follow a Fibonacci sequence. 

Fibonacci numbers (FN) describe numerous patterns in nature – from sunflower seed 

arrangements to anatomical dimensions of the human hand [1,2]. These numbers 

have never been associated with the human knee, despite applications to knee 

implant design. 

Description of methods: The relationships between the radii of the femoral lateral and 

medial condyles were evaluated using five cadaver knees and five computational 

models [3]. For each cadaver specimen, a microscribe was used to digitize points 

and outline the geometry of the knee. Landmarks digitized included the origin and 

insertion of the ACL and PCL, as well as the curvature of the femoral condyles. For 

the computational models, an anterior and posterior cylinder was used to represent 

the distal femoral anatomy for each condyle. The models were run with the contact 

between the femur, or cylinders, and the tibia guiding the motion from 0° (extension) to 

50°flexion. ACL force vs. flexion angle of the tibia for the two contact conditions was 

compared to confirm that the radii of the fitted cylinders matched those of the patients’ 

knees. The average root-mean-square error (RMSE) of the ACL forces between the 

original models and cylinder models was 5.1N with a normalized RMSE of 7.4%. 

Summary of results: For both the cadaver data and the computational models, ratios 

were obtained for anterior and posterior cylinder radii. For a Fibonacci sequence 

to be obtained, the ratios needed to either be 1.5 (for FN’s 3 and 2), or 1.6 (for 

FN’s 5 and 3). For the cadaver data, the 95% confidence interval was 1.47 to 1.7; 

whereas for the computational model data, the interval was 1.37 to 1.52. Overall, 

combining the data sets yielded a 95% confidence interval of 1.44 to 1.59. 

Conclusion: The relationship anterior and posterior femoral radii supported the 

concept that distal femoral anatomy is exceptionally close to a Fibonacci Number. 


420

This relationship can aid with both (i) understanding knee kinematics and (ii) knee 

implant design parameters. 

References: 

1. Dunlap, R. A. The Golden Ratio and Fibonacci Numbers. Singapore: 

World Scientific, 1997. 

2. Park, Andrew E., et al. “The Fibonacci sequence: relationship to the human 

hand.” The Journal of hand surgery 28.1 (2003): 157-160. 

3. Purevsuren T, Elias JJ, Kim K, Kim YH. Dynamic simulation of tibial tuberosity 

realignment: model evaluation. Comput Methods Biomech Biomed Engin. 

2014, (15)1-5. 

Paper 284 

Presenter: P Almela Matamoros 

Authors: P. Almela, J. Tadros, M. Sherafati 


Abstract title: Radiographic assessment of Total Knee Replacements 

Radiographic assessment of total knee replacements (TKR) remains an essential part 

of routine care and follow-up. Appreciation of the various measurements identified 

radiologically is important as part of the assessment of outcomes. The Knee Society 

total knee arthroplasty radiological evaluation and scoring system remains widely 

used. The purpose of our study was to determine the replicability of radiographic 

analysis and therefore the reliability of data obtained using this method as part of the 

assessment of outcomes in implants. 

100 AP and LAT radiographs of TKR that had been analysed by the research team 

using TraumaCad® version 2.4 Voyant Health Ltd, a Brainlab company (2015), 

were randomly selected from the recorded database. The results recorded on the 

database using the Roentgenographic evaluation and scoring system were reviewed. 

The X-rays were re-analysed and results were compared to those transcribed in the 

database. 

0.07% of results were transferred in the database using the wrong format when 

recording angle measurement, giving results ranging between 1-16° rather than 85- 

100°. 0.03% presented angles of over 1000° in one or more of the angles. 0.05% 

had incomplete assessment with no data being recorded by the examiner in one 

of the required sections. 85% were analysed completely and were consistent with 

the expected results according to current literature. 15% had to be re-analysed and 

corrected in the database. In terms of radiolucency; 8 knees had radiolucency reported 

in at least one zone at 3 years and 10 at 5 years post-surgery. No measurement of 

the radiolucency in mm was recorded and therefore it is uncertain if it was performed. 

421

2 radiographs, one at 3 years and one at 5 years had progressive radiolucency 

noted by the examiner, but given that no measurements were taken of the radiolucent 

lines it is impossible to state that there is a progressive radiolucency. 

4 issues were identified during this audit regarding radiograph analysis of TKR: errors 

in measurement reporting, errors in data entry, incomplete data and inconsistency 

with guidelines in radiolucency reporting. 

The majority of X-rays adhered to the standardised method of radiography analysis. 

Results are positive in terms of the reliability of the data representing the outcomes 

of surgery in TKR, however there are actions to be taken in order to improve the 

methodology. 

Paper 306 

Presenter: V Mehta 

Authors: A. Nayak, R. Shah, V. Mehta 


Abstract title: Does Testing Adjustable-Length ACL Fixation Devices with 

Stiff Constructs Inaccurately Represent their Performance? A Comparison of 

Biomechanical Testing Methods 

Background: Adjustable-length fixation devices are a popular option for graft fixation 

during Anterior Cruciate Ligament (ACL) reconstruction. Numerous studies have tested 

these devices to compare their displacement during cyclic loading with traditional 

closed loop fixation devices, but secured them to a metal rod instead of a soft-tissue 

graft. This increases the stiffness of the construct, potentially resulting in displacement 

that would not be seen in clinical use. 

Purpose: To determine whether the displacement and load-to-failure of an adjustablelength 

fixation device is affected by attachment to a metal rod versus a soft-tissue 

graft. 

Study Design: Controlled laboratory study. 

Methods: Cyclic loading (250 cycles from 50-250 N) and load-to-failure testing was 

performed on 20 Arthrex TightRope devices. The loop of the device was attached to 

either a tibialis anterior graft (TA, n=10) or a metal rod (MR, n=10). Gap formation 

after 1 and 250 cycles was measured. Load to failure (LTF) was also measured. 

Results: Displacement after 1 cycle was found to be higher in the Metal Rod (MR) group 

versus the Tibialis Anterior (TA) group (.86 mm vs .28 mm, p

Conclusion: Significant increases in both initial and total displacement during cyclic 

loading were observed when an adjustable-length fixation device was tested using a 

metal rod versus a soft tissue graft. 

Clinical Relevance: Testing biomechanical properties of adjustable-length cortical 

fixation devices with a rigid rod instead of a soft-tissue graft may lead to an inaccurate 

representation of their clinical performance. 

Paper 405 


Authors: A Chauhan, K Singisetti, S Maheswaran 


Abstract title: Patella Reconstruction in patellectomized candidate undergoing a 

Primary Total Knee Arthroplasty 

Purpose of study - The Patella increases the moment arm of extensor mechanism and 

improves the efficiency of quadriceps. Patellectomy is known to cause extensor lag 

and quadriceps weakness. Results of total knee arthroplasty in patients with previous 

patellectomy are less successful than in patients with patella intact. Restoration of knee 

biomechanics can be restored with patella reconstruction. Patella can be restored 

with either autografts or allografts. This reconstruction along with different techniques 

have been reported by very few authors. We report here a case of Cruciate Retaining 

Total Knee Arthroplasty in a patellectomised patient where patella was reconstructed 

with distal medial femoral resection autograft with excellent results during 12 month 

follow up with relevant review of literature. 

Description of Methods – A 66 year old male, with patellectomy done 10 years 

ago for communited fracture, complained of pain left knee for past two years. On 

examination, knee had anterior longitudinal scar, 5-10 degrees varus, quadriceps 

wasting, 10 degrees extensor lag, with significant anteroposterior instability. 

Quadriceps strength was 3/5 on Medical Research Council (MRC) Grading with 

range of motion from 5-110 degrees of flexion. Preoperative knee society score was 

50(poor) and function score was 45(poor). Radiographs revealed osteoarthritis of 

knee. Patient underwent a Cruciate Retaining Total Knee Arthroplasty. 

Utilising old scar, standard anterior medial parapatellar approach was employed. 

Standard femoral and tibial cuts were taken and cut sections were preserved. After 

implanting cemented femoral and tibial prosthesis, distal medial femoral condyle 

cut was kept over soft tissue scar of previous patella and shaped accordingly. Final 

measurement came out to be 28mm diameter and 10 mm thickness. A small 25 

mm incision was made and sharp dissection was done separating the synovium 

and quadriceps, forming a subsynovial sleeve. The graft was placed in the synovial 

sleeve in such a way that the chondral surface, with intervening synovium, was facing 

towards femoral component and cancellous surface towards patellar tendon for firm 

adherence. 

423

Summary of Results – Accelerated knee rehabilitation started with assisted ambulation 

on first postoperative day. Post operative recovery was uneventful. Radiographs 

revealed good position of patella. At 12 months, his quadriceps were 5/5 on MRC 

grade with range of motion from 0-130 degrees. His postoperative knee society 

score was 85(excellent) and function score was 90(excellent). 

Conclusion- This report with relevant review of literature is an attempt to include 

this important step in the preoperative planning of a total knee arthroplasty in a 

patellectomized patient. 

Paper 504 


Authors: Muhammad Adeel Akhtar, Brent Ascherl, Ian Curzon, Sheamus Fitzgerald, 

Anthony Hui 


Abstract title: Magnetic Resonance Imaging (MRI) Evaluation of Intermeniscal 

Ligament in Patients with Recurrent Patellar Instability 

Purpose: 

The intermeniscal ligament is present in 53% to 94% of knees and controls the relative 

position of the two menisci. Our aim was to study the presence of intermeniscal 

ligament on the MRI scan for patients with recurrent patellar instability undergoing 

MPFL reconstruction. 

Methods: 

19 patients undergoing MPFL reconstruction between 2009 and 2014 who had 

MRI scan for preoperative evaluation of patellar instability under the care of a 

specialist knee surgeon at a teaching hospital were randomly selected. The MRI 

scans were reviewed independently by 3 consultant radiologist with special interest 

in musculoskeletal radiology. The intermeniscal ligament was reviewed on the MRI 

scan images along with MFPL and trochlea dysplasia. The inter-observer agreement 

for the MRI scan findings was assessed by using Kappa test. 

Results: 

The mean age for 10 female (53%) and 9 male (47%) patients was 21 years (range 

13-33). MPFL was identified in all patients by all three observers. The intermeniscal 

ligament was identified in only 12 patients (63%) with a kappa value of 0.51 on the 

MRI scan. 

Conclusions: 

We suggest the use of a standardized reporting template for MRI scans to assess the 

intermeniscal ligament in cases of anterior knee pain without a known cause 


424

POSTERS - PAEDIATRICS 

Paper 111 

Presenter: FM Bischof 

Authors: F. Bischof, T. Aduc 


Abstract title: Botulinum Toxin A combined with casting and a home program for 

idiopathic toe walking: a case report 

Purpose of the study: Idiopathic toe walking (ITW) is the persistence of a tip toe gait 

in the absence of a neurological condition. The cause is unknown. The approach to 

the management of the condition is varied and includes observation, surgery, casting, 

Botulinum Toxin A and physiotherapy. The choice of management is controversial. 

The objective of this study was to evaluate the outcome of a combined intervention 

(Botulinum Toxin A, casting and a home exercise program) in an eight year old child 

with a habitual toe walking gait pattern. He had started walking on his toes at thirteen 

months when he began to walk independently. 

Methods: Botulinum Toxin A (total dosage 400u) was injected into his gastrocnemius 

and hamstrings bilaterally under anaesthesia. Below knee plaster casts were worn 

for two weeks. A home exercise program was demonstrated by the physiotherapist. 

Measurements were taken before the intervention, at seven weeks and again at 

six months after the intervention. Outcome measures included ankle dorsiflexion, 

popliteal angle, scoring of gait using the observational gait scale and parent report. 

Results: Passive ankle dorsiflexion improved from 90-15 degrees to 90 degrees 

bilaterally at six month follow up. The popliteal angle (30 degrees bilaterally) 

remained the same at follow up. The observational gait score improved from 16 on 

the right and 14 on the left to 20 on each side at final follow up (a perfect score is 

22 on each side). The parents reported that he walked on his toes only occasionally 

when he was tired. 

Conclusions: A combined regimen of Botulinum Toxin A, casting and a home exercise 

program was successful in correcting habitual toe walking in this child. 

Paper 215 

Presenter: P Reddy 

Authors: P Reddy, DM Thompson 


Abstract title: Vaccine Associated Paralytic Poliomyelitis presenting to an 

Orthopeadic Unit 

425

Vaccine Associated Paralytic Poliomyelitis presenting to an Orthopeadic Unit 


Vaccination against Poliomyelitis was heralded as a medical revolution when first 

introduced by Salk and Sabin in 1950. In a short span of time the oral polio vaccine 

(OPV) dramatically decreased the global burden of Polio from an estimated 58000 

in 1950 to 161 recorded cases in 1961. As of 2015, only 3 countries remain 

endemic to wild poliovirus - Nigeria, Pakistan, and Afghanistan with 41 confirmed 

cases reported. However the OPV is associated with a rare but well described 

adverse event - Vaccine-associated paralytic poliomyelitis (VAPP) accounting for 

13 reported cases in 2015. VAPP is not associated with the use of the injectable 

inactivated poliovirus vaccine (IPV). 

The purpose of this study is to suggest that VAPP is under reported in South Africa and 

to highlight the clinical features of polio, which may not be readily recognisable to 

younger clinicians due to the almost global eradication of this disease. 


We describe a series of patients between the ages of 3 and 8 who presented with 

lower limb deformities typical of poliomyelitis. One case had been documented with 

VAPP and presented to us years later with unilateral left lower limb monoparesis and 

deformity. The other cases presented with deformities typical of poliomyelitis years 

after receiving OPV but with no documented evidence of acute flaccid paralysis. 

These cases were fully investigated and no other apparent cause of deformity could 

be elucidated. 


Our findings suggest that VAPP may be under reported in South Africa with patients 

presenting with deformities typical of Poliomyelitis many years after completion of their 

OPV schedule. 

Conclusion 

In South Africa endemic Poliomyelitis has been eradicated and VAPP appears to be 

under reported. Due to the late presentation of deformities and the relative lack of 

clinical experience with this condition, many of these patients may go undiagnosed. 

The incidence of VAPP with its subsequent complications, although low, further 

supports the current drive to introduce the injectable inactivated poliovirus vaccine 

(IPV) as the form of vaccination in future. 


426

Paper 323 

Presenter: JP Palencia 

Authors: J. Palencia, J. Al Qathani, F. Serro, J. Fakeeha 


Abstract title: RARE CASE OF PROXIMAL FEMORAL EPIPHYSIOLYSIS WITH 

DISLOCATION OF THE FEMORAL HEAD AND ACETABULUM FRACTURE IN A 

CHILD. CASE REPORT 

INTRODUCTION 

Traumatic transphyseal hip fracture and hip dislocation are rare to present in daily 

practice especially when associated with acetabulum fracture. The goals of treatment 

are early anatomic reduction, maintenance of reduction until complete healing, and 

minimization of complications associated with the injury and treatment. 

OBJECTIVES 

The objective of our study is to present a rare case of proximal femoral epiphysiolysis 

with dislocation of the femoral head. This study presents the management and followup. 

MATERIAL AND METHODS 

Twelve-year-old boy, not known to have any chronic illnesses, presented to Emergency 

Department as a case of poly-trauma post traffic accident. Patient was unrestrained 

frontal passenger in an automobile when it rolled over. After resuscitation and 

assessment patient was conscious, alert and oriented. There was shortening, external 

rotation of left lower limb, with tenderness and painful decreased range of motion 

of left hip joint. The distal neurovascular status was intact. Radiological assessment 

showed complete transphyseal posterior dislocation and displaced fracture of left 

anterior column of acetabulum

In the literature, treatment choices are generally open reduction and internal fixation. 

However, some authors have presented closed reduction as the preferred treatment 

choice if possible. 

Avascular necrosis is the most common complication after these types of fracturedislocation 

injuries. In studies of traumatic transepiphyseal separation, the incidence 

of avascular necrosis is reported to be 80%–100%. 

Paper 435 

Presenter: M Liu 

Authors: M. Liu, H.H. Wu, K.R. Patel, W. Turner, L. Baltus, A.M. Caldwell, J. Hahn, 

R. Coughlin, S. Morshed, D. Shearer. 


Abstract title: Regional variation in pediatric orthopedic clinical research projects 

conducted in low-and-middle income countries 

Purpose of Study: Despite the high burden of pediatric orthopedic disease in lowand-middle 

income countries (LMICs), little is known about the research efforts to 

address this burden. The purpose of this scoping review is to (1) determine where 

research capacity is lacking the most and (2) identify the most commonly studied 

pediatric orthopedic disease processes. 

Description of Methods: In this scoping review, pediatric orthopedic clinical studies 

conducted in LMICs within the past ten years were evaluated. Studies that did not 

examine skeletally immature patients or patients

Conclusion: Our review identified wide regional variation in where pediatric 

orthopedic studies are being conducted with a disproportionate number being done 

in South Asia and Sub-Saharan Africa. Furthermore, the vast majority of studies 

focused on traumatic and congenital diseases. The low quality papers and the 

limited use of control groups highlight the need for improved research methodology 

in this literature. Thus, future studies are needed to determine the best method of 

improving the quality of pediatric orthopedic research in LMICs. 

POSTERS - SHOULDER & ELBOW 

Paper 21 

Presenter: W Yuan 

Authors: W. Yuan, R. Subramaniam 


Abstract title: Short term clinical outcomes of surgical repair for full-thickness 

rotator cuff tear 

Purpose: Efficacy of surgical repair for full-thickness rotator cuff tear has been well 

established. We conducted this retrospective study to evaluate the short-term clinical 

outcomes after surgery in the local setting. 

Methods: We reviewed 80 full-thickness rotator cuff tears in 77 patients with 1 year 

follow-up. Single-row repair (SR) was performed for 21 shoulders and Double-row 

(DR) for 53. The other 6 underwent transosseous repairs. Medium size tears were 

found in 38 shoulders, large in 27 and massive in 15. Constant score and UCLA 

score were employed to evaluate clinical outcomes. 

Results: Comparing to pre-op, Constant score and UCLA score showed significant 

improvement at 6 months and 1 year post-op in both SR and DR groups. There were 

no significant differences between the SR and DR groups at pre-op, 6 months and 1 

year post-op. Patients with different tear sizes didn’t show significant differences at 

these three points of time either. 

Conclusions: The short term clinical outcomes of rotator cuff repair for full-thickness 

tears are promising. Repair technique and tear size don’t affect clinical outcomes. 

Paper 26 


Authors: Sheps DM, Styles Tripp F, Beaupre L, Saraswat M, Luciak Corea C, Otto 

D, Lalani A, Balyk R 


Abstract title: Functional Outcome and Health-Related Quality of Life after 

Surgical Repair of Full-Thickness Rotator Cuff Tears Using a Mini-Open Technique: 

A Concise Follow-up, at Ten Years, of a Previous Report 

429

Background: 

Although good short- and mid-term outcomes are reported for mini-open 

rotator cuff (RC) repair, few prospective studies have investigated longterm 

results. The purpose of this study was to report the function and healthrelated 

quality of life (HRQL) at 10 years following mini-open RC repair. 

Methods: 

Subjects with a confirmed full-thickness RC tear who underwent a mini-open repair 

between April 1997 and July 2000 were evaluated preoperatively and one year 

and 10 years postoperatively for (1) pain, function and HRQL using the American 

Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff 

(WORC) Index; (2) active shoulder range of motion (ROM) using goniometry; 

and (3) satisfaction by an independent evaluator. Changes in function, HRQL and 

ROM over time were analyzed using repeated measures analysis of variance. 

Results: 

Eighty-four subjects were enrolled, of which 61 (73%) were men and the average 

age was 53 (±9.9) years. At 10 years, four (5%) subjects were deceased and four 

(5%) subjects had symptomatic re-tears. Fifty-nine (74%) subjects were evaluated, 

comprised of 43 (73%) males; 26 (44%) were less than 60 years old. Function and 

HRQL significantly improved over the course of follow-up (p

means that the quality, reliability and completeness of the information are unknown. 

The primary objective of this study was to assess the source, quality, and content 

accuracy of current Internet-based decision aids for shoulder arthritis. 

METHODS: The search term “shoulder arthritis” was entered into three Internet 

search engines and the first 50 websites from each search engine were selected. 

Of the 150 potential websites, 49 sites remained after all exclusion criteria were 

applied. A grading template was developed to evaluate the source, quality, and 

content accuracy of each website. Source was divided into one of six categories: 

academic, physician, commercial, personal, non-profit, and unidentified. Quality of 

information was measured by a previously-described 16-point scale used to assess 

the compliance of websites according to the Health On the Net (HON) Foundation 

principles. Content completeness was graded on a custom 49-point scale developed 

by two orthopaedic surgeons based on a previously-described algorithm. Three 

separate fellowship-trained orthopaedic surgeons evaluated the selected websites 

using the grading template. 

RESULTS: Of the 49 websites evaluated, 33% were physician-based, 33% 

commercial, 24% academic, and 10% non-profit groups. The HON reliability and 

quality score was 5.8±2.1 for academic sites, 6.6±2.7 for physician sites, 6.4±4.2 

for commercial sites, and 9.6±3.6 for non-profit sites on a maximum 16-point scale. 

The completeness score was 19.2±6.7 for academic sites, 16.6±6.3 for physician 

sites, 15.2±2.9 for commercial sites, and 18.7±6.8 for non-profit sites. Non-profit 

sites had significantly higher HON quality scores than other types of sites (p=0.0455). 

Commercial sites had more errors than other types of sites (p=0.002) while academic 

sites had fewer errors (p=0.021). The OrthoInfo site, created by the AAOS, scored 

among the top 3 websites for HON score and completeness. 

CONCLUSIONS: Patient information on the Internet regarding shoulder arthritis is 

of mixed quality and comprehensive sources are lacking. One-third of the websites 

were commercial in nature and were more likely to contain factual errors. Physicians 

should take the lead in directing patients to quality information sources on the Internet 

regarding shoulder arthritis. 

Paper 64 

Presenter: A Bois 

Authors: Y. Ono, J.M. Woodmass, A.A. Nelson, A.J. Bois, R.S. Boorman, G.M. 

Thornton, I.K.Y. Lo 

Disclosure: Yes: Communication Organization Affiliation - Associate Editor of The 

Shoulder textbook (Saunders Elsevier, USA). 

Abstract title: Arthroscopic repair of articular surface partial-thickness rotator cuff 

tears - transtendon technique versus repair after completion of the tear: A metaanalysis 

STUDY PURPOSE: Articular surface partial thickness rotator cuff tears (PTRCTs) 

are commonly repaired using one of two different surgical techniques including a 

431

transtendon repair technique or completion of the tear followed by formal repair. 

Although a number of studies have demonstrated excellent clinical outcomes, it is 

unclear which technique may provide superior clinical outcomes or tendon healing. 

The purpose of this study was therefore to evaluate and compare the clinical outcomes 

following arthroscopic repair of articular surface PTRCTs using a transtendon technique 

or completion of the tear. 

METHODS: A systematic review of the literature was performed using the PRISMA 

guidelines and checklist. The studies that fit the inclusion criteria were also assessed for 

quality by the Coleman Methodology Score (CMS). The objective outcome measures 

evaluated in this study were the Constant score, American Shoulder and Elbow 

Surgeons (ASES) score, and Visual Analogue Scale (VAS). In addition, shoulder range 

of motion, tendon healing as assessed using magnetic resonance imaging (MRI), and 

post-operative complications were recorded. Three reviewers evaluated the literature 

separately and any discrepancies were re-evaluated and resolved by consensus. 

RESULTS: Three recent studies met our inclusion criteria and were included in our 

analysis. All three studies, published during 2012 and 2013, were prospective 

randomized comparative studies with level II evidence. The mean CMS was 91.3 

indicating the quality of the studies was excellent. A total of 182 shoulder repairs were 

analyzed, with a weighted mean age of 53.7 years. The overall weighted mean 

follow-up was 40.5 months. Both procedures provided excellent clinical outcomes 

and there was no significant difference in clinical outcome measures between the 

two procedures. 

CONCLUSIONS: Both procedures demonstrated improved clinical outcomes 

following arthroscopic repair of PTRCTs. However, there were no significant 

differences between the techniques. Further studies are required to determine the 

long-term outcome of each surgical technique. 

Paper 69 

Presenter: C Poage 

Authors: C. Poage, S. Brotherton, T. MacCleod, C. Leddon, C. Roth 

Disclosure: Yes: Lockdown Medical Provided $5,000 in funding for our study to 

pay for cadavers and implants. 

Abstract title: Kinematic and Radiographic Analysis of a Synthetic Ligament 

Device for Acromioclavicular Reconstruction 

INTRODUCTION: The AC joint forms a bridge between the clavicle and the scapula, 

acting as a stabilizer during shoulder motion through ligamentous and muscular 

attachments. When the clavicular strut is disrupted, the acromion is destabilized, 

leading to excessive motion of the scapula, or scapular dyskinesis, which can lead 

to chronic pain and morbidity. The optimal surgical technique for unstable AC joint 

injuries remains unclear. This trial evaluated the kinematic and radiographic effect of 

the Lockdown device, a synthetic ligament for AC reconstruction. 


432

METHODS: We thawed 3 fresh frozed cadaver torsos (6 shoulders) and inserted 

bone pins with reflective motion markers. 3D kinematc data was then obtained on 

each shoulder throughout a range of motion in the native state, with AC and CC 

ligaments severed, and after reconstruction with the Lockdown. Standard and stress 

Zanca radiographs were obtained at each step as well. 

RESULTS: Motion analysis across 3 planes (flexion, scaption, abduction) showed 

excessive motion in the severed state compared to the native (p=0.004) and the 

reconstructed (p=0.092). Stress Zanca radiographs showed an increased CC 

interval in the severed state when compared with the reconstructed (p=0.001) and 

native (p=0.053). 

CONCLUSION: Reconstruction of the AC joint with the Lockdown synthetic ligament 

device appears to restore the motion of both the clavicle and the acromion to near 

native levels, thereby decreasing scapular dyskinesis and joint instability. It also 

appears to stabilize the joint on stress radiographs. 

Paper 106 


Authors: J. Chepeha, D. Magee, D.M. Sheps, M. Bouliane, L. Beaupre 


Abstract title: Effectiveness of a Posterior Shoulder Stretching Program on 

Collegiate-Level Overhead Athletes: A Randomized Controlled Trial 

Background: 

Athletes involved in repetitive overhead shoulder rotation demonstrate increased 

external rotation and decreased internal rotation range of motion. Deficits in internal 

rotation have been linked to the development of shoulder pathology. The purpose 

of this study is to determine if a posterior shoulder stretch program is effective in 

increasing dominant arm internal rotation and horizontal adduction range of motion 

in overhead athletes identified as having reduced mobility and posterior shoulder 

tightness. 

Methods: 

Thirty-seven overhead athletes in volleyball, swimming and tennis, with internal 

rotation range of motion deficits less than or equal to 15°, were randomized into 

intervention or control groups. The intervention group performed the “sleeper stretch” 

daily for eight weeks while the control group performed usual activities. Independent 

t-tests determined whether internal rotation and horizontal adduction range of motion 

differences between groups were significant and two-way repeated measures analysis 

of variance tests measured the rate of shoulder range of motion change. Reported 

shoulder pain and function were also obtained at each evaluation. 

433

Results: 

Significant differences were found between the intervention and control groups’ 

internal rotation and horizontal adduction range of motion at eight weeks (p

Conclusion: The technique described is an all arthroscopic technique that addresses 

reconstruction of both the coracoclavicular ligaments and the acromioclavicular 

ligaments. While follow up is at this stage short, the technique appears promising. 

Paper 187 


Authors: k Cutbush, N A Peter, K M Hirpara 


Abstract title: A Technique For All Arthroscopic Latissimus Dorsi Transfer 

Purpose of study: Massive irreparable rotator cuff tears are often associated with 

severe functional impairment and disabling pain. They, and present a significant 

challenge for shoulder surgeons. One viable treatment option is a latissimus dorsi 

tendon muscle transfer, which has become a well-established solution for massive 

posterosuperior rotator cuff tears. However, current established techniques for 

this procedure involve either an all open or an arthroscopic assisted technique. We 

propose a novel all arthroscopic technique that we believe avoids insult to the deltoid 

musculature, while reducing morbidity from open harvest of the tendon. 

Description of methods: The operation is performed with the patient in the lateral 

decubitus position, using a combination of viewing and working portals in the 

axilla. The initial viewing portal is placed along the anterior belly of the latissimus 

muscle and then along the posterior axillary line in the axilla. The latissimus and 

teres major are identified, as is the thoracodorsal neurovascular pedicle. 

The tendons are carefully separated and the inferior and superior borders of 

the latissimus are whipstitched using a suture passer. The interval deep to the 

deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for 

arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilised 

arthroscopically to the lateral aspect of the infraspinatus and supraspinatus footprints 

with multiple suture anchors. 

Summary of results: To date 6 cases have been performed. Follow up is still very 

early, but three month MRI assessment of the transfers has shown that all tendon 

transfers remain intact. 

Conclusion: Our preliminary data suggest that this surgical technique results in 

improvement in pain, range of motion, and function. We believe our technique 

offers a practical alternative to open or mini open techniques, and based on our 

initial results, further investigation of the technique is warranted. 

Paper 416 


Authors: R Dachs, P Naude, T De Wet, T Trevor, D Chiba, J-P Du Plessis, B Vrettos, 

S Roche 


435

Abstract title: Comparison of Coracoid and Glenoid Size between Males and 

Females: a CT Analysis with Reference to the Impact on Latarjet Outcomes 

Background: The literature supports the use of the Latarjet procedure for recurrent 

anterior instability of the shoulder in contact athletes. The great majority of 

reported outcomes are from male-predominant cohorts. A comparison of coracoid 

process and glenoid dimensions between males and females was therefore 

investigated, with specific reference to recommended graft size and orientation, 

and the possible implications for Latarjet procedure outcomes in female patients. 

Methods:: CT scans with 3D reconstructions of the scapulae of 31 females and 

30 males were reviewed. The coracoid process was measured from 2D cuts 

with reference to a predefined base point. Width, height, and length of the 

coracoid were measured at this point. The anterior-to-posterior (AP) and superiorto-inferior 

diameters of the glenoid were measured using 3D reconstructions. 

Ratios of coracoid width and height to glenoid AP diameter were calculated. 

Results: All coracoid and glenoid measurements were statistically significantly 

larger in males. The ratio of coracoid width to AP diameter in both 

groups was found to be similar, (p = 0.46), whereas the ratio of coracoid 

height to AP diameter was significantly lower in females (p = 0.0021). 

Conclusions: : Differences between South African male and female coracoid and 

glenoid sizes were found to be significant and may have an impact on surgical 

outcomes. 

Paper 421 


Authors: R Dachs, P Naude, M Zinn, JP Du Plessis, B Vrettos, S Roche 


Abstract title: Reliability of the classification and treatment of Acromioclavicular 

Joint Injuries: An Assessment of inter-observer reliability among South African 

Shoulder Surgeons 

Aim: To investigate the reliability of the Rockwood classification of acromioclavicular 

joint (ACJ) injuries. We evaluated interobserver reliability of the classification and 

treatment of dislocations amongst South African shoulder and elbow specialists. 

Methods: Thirty South African orthopaedic surgeons who are members of the South 

African Shoulder and Elbow Society completed an online survey where they were 

presented with 11 cases of acute ACJ injuries. Plain radiographs and a clinical 

scenario for each case were provided. The surgeons were asked to classify the 

injuries using the Rockwood classification system and recommend treatment. Four 

unrelated questions were asked to gain insight into the individual clinical and surgical 

habits of the surgeons. 


436

Results: Inter-observer reliability for diagnosis had a correlation coefficient of 0.120 

and a treatment correlation coefficient of 0.130. 

Conclusion: This study suggests an overall lack of reliability of the Rockwood 

classification of ACJ dislocations and of decisions regarding their treatment. There is 

poor inter-observer agreement in both the diagnosis and treatment of acromioclavicular 

joint injuries amongst shoulder and elbow surgeons. A better classification system 

would remove ambiguity and improve consensus between specialists. 

Paper 459 

Presenter: J Charilaou 

Authors: J Charilaou,SL Roche, JP du Plessis, B Vrettos 


Abstract title: Suprascapular nerve injury during anatomical shoulder arthroplasty 

due to bone cement extravasation 

Purpose 

First documented case report of suprascapular nerve neuropathy due to bone cement 

extravasation 

Methods 

Retrospective case report 

Summary 

Suprascapular nerve (SSN) injury has been well described after open and arthroscopic 

shoulder surgery. The anatomic location of the nerve in the suprascapular- and 

spinoglenoid notch makes it vulnerable to iatrogenic injury. 

A 28-year-old female patient had septic arthritis of her glenohumeral joint during 

childhood. She underwent arthrotomy and debridement at the time. She developed 

secondary osteoarthritis. A difficult hemiarthroplasty was done at age 24. She 

underwent revision surgery 4 years later for increasing pain. The humeral component 

was retained and a cemented glenoid inserted. She noticed new onset lateral border 

scapular pain post operatively. The pain was conservatively treated and infection 

ruled out. She was globally weak with 4/5 muscle power. The modified axillary 

view X-ray revealed a suspicion of cement extravasation around the spinoglenoid 

notch. A CT scan was performed to exclude an iatrogenic or stress fracture. This 

confirmed cement extravasation at the posterior glenoid neck extending into the 

spinoglenoid notch. There were no fractures seen. An EMG demonstrated chronic 

denervation changes. 

Revision surgery consisting of an open decompression and neurolysis of the SSN was 

performed through a posterior approach. The extruded cement was removed. It 

was compressing the nerve through a small posterior glenoid fracture. A follow up 

EMG was done 4 months post surgery. It revealed the infraspinatus muscle had 

chronic neurogenic changes, with signs of re-innervation. There was no evidence of 

denervation. There has been a gradual resolution of the lateral scapular border pain. 

Her shoulder strength improved globally with a pain free range of motion. 

437

Conclusion 

Bone cement can damage surrounding tissues due to exothermic heat reaction or 

mechanical impingement or entrapment causing a neuropathy. Occult fractures 

or drill hole penetration during preparation or insertion of the glenoid component 

predisposes cement extravasation. 

Paper 460 

Presenter: J SINGH 

Authors: J. Singh, D. Stsekes, D. Rossouw 

Disclosure: Yes: No conflict of interests 

Abstract title: Early outcomes of a novel Bone preserving Total Resurfacing 

Arthroplasty of Shoulder. 

Introduction 

Uncemented Total Shoulder resurfacing arthroplasty is a viable treatment option for 

active patients. It offers the advantages of bone preservation and a reduction in the 

risk of peri prosthetic fractures. 

Previous high failure rates were attributed to poor technique, malposition, loosening, 

over stuffing and glenoid wear. Improved insertion techniques and design of the 

prosthesis have renewed the interests of shoulder surgeons in total resurfacing 

arthroplasty. 

Objectives 

We present our two-year follow up results with total shoulder surface arthroplasty. 

Functional outcomes were noted using Oxford Shoulder and Constant scores. VAS 

scores were noted for pain . All patients had regular radiographs to look for any 

radiological signs of loosening. 

Methods 

We prospectively followed up eleven patients with an average age of 79 

years (73-86 yrs.) who underwent total shoulder resurfacing arthroplasty (Arrow 

resurfacing, FH Orthopaedics), male to female ratio was 10:1.The humeral 

component consists of hydroxyapatite coated cup whose fixation relies on 3 

peripheral pegs and press fit rim fixation, whereas the glenoid is a cemented 

polyethylene component with 4 pegs . All had primary procedure for osteoarthritis 

accept one patient who had a conversion from a resurfacing hemiarthroplasty to 

total resurfacing arthroplasty. 

The minimum follow-up was two years. 

Results 

All patients were reviewed clinically and radiologically at regular intervals. The 

mean Pre operative oxford score was 16 (12-19) and postoperative mean score at 

two years was 43.7 (41-46). 

At two years the average Constant score post operatively was 57.3 (33-82), 

average external rotation was 38 degrees (15-70) and average forward flexion 


438

was 120 degrees post operatively. The average VAS score was 1.8. 

All the patients were able to do hand to head (H2H0, hand to mouth (H2B) and 

hand to back (H2B). There were no radiological signs of loosening. 

Conclusions 

Our two-year follow up shows improved functional outcome and pain relief along with 

a theoretical lower risk of periprosthetic fracture combined with ease of conversion to 

a standard arthroplasty in future. 

Paper 498 

Presenter: W. A. Wallace 

Authors: W.A. Wallace, M. Ravenscroft, Ben Young, B.B. Seedhom, D.J.Beevers 

R.Chivers 

Disclosure: Yes: Prof W Angus Wallace and Mr Matt Ravenscroft have Consultancy 

Agreements with Xiros Ltd. Ben Young, Bahaa B Seedhom, David J Beevers and 

Robin Chivers work for Xiros Ltd 

Abstract title: The mechanical properties & indications for a Single Loop Anchor 

Device (SLAD) for Ligament Augmentation 

Background: 

The benefit of using a polyester mesh device for ligament stabilisation at the Acromio- 

Clavicular Joint (ACJ) has been well described by Jeon (2007) and Kumar (2014). Its success 

depends, in part, on the soft tissue on-growth and in-growth partly re-creating the original 

biological ligament to support the non-biological structure as reported by Kocsis (2015). 

Methods: 

A Single Loop Anchor Device (SLAD) has been developed, with the single loop 

designed to be used as an anchor by passing the device through its looped end. 

One single sized device is used to provide different lengths of ligament reconstruction 

through a unique fixation device to be used at the non-looped, adjustable end. 

Results: 

Mechanical testing of the device in different test configurations has shown 

its ultimate tensile strength is 1886 +/- 38 Newtons; and its stiffness is 184 

+/- 52 Newtons/mm. The “pull-out” strength when secured with the fixation 

device, simulated in dense Sawbone bone substitute, is 1100 Newtons. 

These results should be compared with the native coraco-clavicular ligament 

which has a strength to failure of 500 +/- 134 Newtons and a comparable 

double looped device which has a strength to failure of 1730 Newtons 

in longitudinal distraction. However, the strength to failure of the implanted 

double looped device in cadaveric testing was 725 +/- 249 Newtons. 

439

Different surgical techniques have been developed to allow the SLAD to be used to 

reinforce the coraco-clavicular; acromio-clavicular and the sterno-clavicular ligaments 

at the shoulder and the collateral ligaments at the elbow as well as repairs of distal 

biceps tendon avulsion. These techniques will be described in detail. 

Conclusions: 

This SLAD device is more versatile than previous devices, more economical and can 

be used for more reconstructive work because of its unique design. A submission for 

FDA approval is currently in process. 

POSTERS - SPINE 

Paper 84 


Authors: Burger, E L , Sandoval, M 


Abstract title: Best practice to prevent Spine infections, literature review 

Background: Surgical site infections are the most prevalent healthcare associated 

infection among hospitalized patients in the United States. A surgical site infection 

after spinal surgery results in significant morbidity and mortality. 

A large body of literature has focused on patient-specific and surgery-specific factors 

that may increase or minimize an orthopedic surgical spinal patient’s risk of developing 

a post-operative infection. 

Purpose: The purpose of this systematic review was to identify and summarize the 

past ten years of literature focused on patient-specific and procedure-specific risk and 

protective factors associated with surgical site infections among patients undergoing 

orthopedic spine surgery. 

Study design: The study design included a systematic review using the PRISMA 

method. 

Methods: CINAHL, PubMed, Ovid, Medline, and EBSCO databases were searched 

for articles within the past ten years meeting the predetermined criteria. The PRISMA 

checklist and diagram were used to report the method and results of the review. 

Results: Conflicting evidence exists identifying patient-specific and procedure-specific 

factors significantly associated with risk of post-operative surgical site infections among 

patients undergoing orthopedic spine surgery. Gender (male), age, extremes in BMI, 

cigarette smoking, diabetes, a history of previous infection and alcohol abuse were 

identified as common patient-specific risk factors. The presence of blood transfusion, 

implantation, and steroid use was found to significantly increase surgical site infection 

rates in certain studies and associated with no significant difference in rates in other 


440

studies reviewed. Limitations: This study was limited only to studies within the past 

ten years and only included studies written in the English language. 

Paper 116 

Presenter: A Younus 

Authors: A Younus, T Nakale 


Abstract title: Evaluation of Efficacy of Percutaneous Screw Stabilization of 

Unstable Fractures for Thoraco-lumbar spine 

Introduction: 

The occurrence of thoracolumbar spine injuries has increased substantially over 

the past few decades as a result of due to high speed Motor Vehicle Accidents. 

Surgical management of these injuries has traditionally been by open means with 

instrumentation and fusion. Over the last few decades however, there has been a shift 

towards percutaneous pedicle fixation of thoracolumbar injuries in an attempt to cut 

down on complications associated with open surgery. Percutaneous pedicle fixation 

has been shown to be an effective and safe option. This study is therefore aimed at 

generating local data that will validate claims that the percutaneous technique is a 

safe and effective method of managing unstable thoracolumbar fractures. 

Material and methods: 

The aim of this study is to evaluate the efficacy and safety of minimally invasive 

percutaneous pedicle screw fixation for unstable burst thoracolumbar fractures with or 

without neurology. Over 18 months, we did 16 case of thoracic and lumber spine. 

There were 12 male and 4 female patients. The average age was 42.14 years. The 

causes of injury were as follows: 9 patients were involved in Motor vehicle accidents, 

4 fell from a height, 3 patients had a heavy object fall on their back. The most 

common level was found to L1 level and wedge compression type. Nine of these 

patients have no neurology and five of them had mild to moderate neurology. All of 

these patients were treated with closed reduction and percutaneous stabilization by 

screw and rod. These patients were follow-up for 6 to 12 months 

Results: 

All of these patients showed stable fixation and no loss of reduction of thoracic 

and lumber spine in follow-up at 12 months. Their blood loss was also found to be 

minimal. The average stay in hospital following this procedure was also decreased 

to 3 to 4 days. There was no case in which neurology was worsened. The duration 

of operation averaged 134.14 minutes. It was also found that the duration of x-ray 

radiation the patients were exposed to be more then the normal open fusion method. 

The average VAS Score was 4.3. We had three complications, one where the screw 

441

was found to be outside the body of the vertebra, in another patient the trocar bent 

during introduction due to excessive hammering against the hard bone. Our last 

complication was one where the patient develops deep wound infection 

Discussion: 

Percutaneous pedicle screw fixation for thoracic and lumbar vertebrae has been an 

attractive alternative to typical open techniques. This offers a safe, less invasive, less 

traumatic, more aesthetically acceptable method for performing fusion. The other 

advantage of the procedure is short hospital stay and less bleeding. Much of the 

literature has shown that the results of success of percutaneous fusion ranges from 92 

to 98 %. In our patients we achieve good results with this method. All of our patients 

had less pain post-operatively; therefore they could mobilize early and subsequently 

an early discharge. 

Paper 118 

Presenter: A Younus 

Authors: A Younus, W Greeff 


Abstract title: The Siliconoma of lumber spine from interspinous device in spine 

surgery 

Introduction: 

Interspinous devices have becoming very popular in recent years. A large number 

interspinous process devices (IDP) has been introduced to the lumber spine surgeons 

as an alternative to conventional decompression surgery in management of the 

symptomatic lumber spinal pathology especially in the older population. The main 

aims of these devices are: unload spine, restoring the foraminal height and stabilized 

the spine by distracting the spinous process. But there are various complications of 

these devices, which range from dislocation, infection, dural tear and fracture of 

the spinous process. We are presenting an unusual complication of the interspinous 

device i.e., DIAM (Medtronic) with silicon leakage and resulting silicon synovitis of 

the posterior longitudinal ligament of the lumber spine. 

Case Presentation: 

We are presenting 43 years old male who present to us with sever backache, 

weakness in the right leg and decrease sensation in the right leg from last 3 months. 

He has a history of previously getting spinal surgery about 10 years ago and there 

was loss of bladder and bowel. On examination of lumber spine showed that he 

had tenderness in the lower lumber spine. His power in the lower lumber spine was 

4/5 in the quads and dorsiflexor of the right foot. His sensation was also decrease 

in the anterolateral side of the right leg. X-ray of the lumber spine showed that he had 

decrease intervertebral disc space at L4/5 level. MRI Scan showed disc recurrent 


442

disc prolapse at L4/5 level with spinal stenosis at this level with an interspinous 

device. 

Patient was taken to theater, where laminectomy, discectomy L4/5 level was done 

with removal of interspinous device was done. Intra-operative we found that he 

had reactive synovitis of the lumber spine A specimen was sending for histology, 

which conform the diagnosis. Postoperatively, the patient did very well. His pain and 

sensation in the right leg improved. 

Discussion: 

DIAM (Device for intervertebral assisted motion by Medtonic ) is a H shape silicon 

bumper wrapped with a polyster sheath connected to artificial ligaments of the same 

material that is designed to support dynamically the vertebrae, restoring posterior 

column height and maintain distraction of the foramina stenosis. The DIAM act as 

shock absorber, thus relieving stresses in both anterior and posterior elements of the 

spine. This device was mainly used in various pathologies i.e., degenerative disc 

disease, spinal canal stenosis, disc herniation, black disc and facet joint syndrome. 

The literature review showed that dislocation and infection as main complication 

of this device. However in plastic surgery it has been described that the leakage 

of silicon from the breast implant and which cause inflammation of the surrounding 

tissue, pain, discomfort and deformity of the breast. This will lead to Siliconomas in 

the surrounding tissue. This could have happened in our case. Our patient symptom 

settles down once we remove the device and siliconoma. 

Paper 226 


Authors: D.R. van der Jagt, J.R.T. Pietrzak, L. Mokete and I. M. Dymond 


Abstract title: Spinal Stenosis due to Polyethylene Granulomatous Lesions after 

Lumbar Disc Replacement. A Report of Two Cases. 

Spinal disc replacements are a relatively recent innovation in the management of 

spondylosis, either cervical or lumbar. Their use has grown exponentially in the last 

few years, despite the absence of any significant long-term outcome studies. It is 

well known from the hip and knee arthroplasty literature that the generation of wear 

particles may lead to serious consequences, including prosthesis loosening as well as 

other extra-articular sequelae. Polyethylene granulomatous lesions can be large space 

occupying masses, and destructive in respect of both the bony integrity as well as the 

adjacent soft tissues. We describe two cases where after lumbar intervertebral disc 

replacement the development of such a polyethylene granuloma caused compression 

of the neurological structures adjacent to the lumbar prosthetic disc replacement. The 

consequences of such a lesion can be catastrophic if not timeously and appropriately 

managed. 

443

Recent developments in spinal disc replacement technology have resulted in a 

swing to metal-on-metal bearing articulations, possibly following similar, now nearly 

abandoned trends in hip arthroplasty surgery. The recent arthroplasty experience with 

metal-on-metal articulations has led to these bearing surfaces being all but abandoned 

in hip replacements. This has been due to the described biological reactions such as 

metallosis and ALVAL, often leading to extensive destruction of bony and soft tissues 

around the hip. Concerns have also been raised in respect of increased blood metal 

ion levels, but these have yet to be validated. The problems and concerns highlighted 

in hip arthroplasty surgery in respect of metal-on-metal articulations should be similarly 

relevant in the context of metal-on-metal articulations in lumbar and cervical spinal 

disc replacements. 

There has been a report in the literature of an ALVAL lesion related to a lumbar disc 

replacement, resulting in similar neurological sequelae to our case. This highlights our 

concerns and emphasises that the various disciplines should collaborate closely to 

ensure appropriate patient safety profiles. The wealth in scientific data available in 

one discipline should prevent the repetition of poor choices in another discipline, so 

improving patient safety outcomes. 

We would further recommend that all patients undergoing both cervical and lumbar 

spinal disc replacement surgery should be properly counselled in respect of their preoperative 

informed consent so that they are aware of these potentially catastrophic 

sequelae after disc replacement surgery. They should also be followed up closely, 

with regular neurological and radiological assessments, as well as blood metal ion 

level monitoring when indicated. 

POSTERS - TRAUMA 

Paper 81 

Presenter: MK Shaath 

Authors: M. K. Shaath, K. Koury, P. Gibson, M. Adams, M. Sirkin, M. Reilly 


Abstract title: Associated Injuries in Skeletally Immature Children With Pelvic 

Fractures 

Introduction 

Pediatric pelvic fractures are rare injuries with a reported incidence of 1 per 100,000 

children per year. Such injuries result from high-energy mechanisms that warrant an 

extensive workup for associated injuries. We performed a retrospective study to 

review concomitant injuries in children who suffered a pelvic fracture and have an 

open triradiate cartilage. 


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Using a trauma database, all pediatric pelvic fractures presenting to the authors’ 

institution were extracted. Radiographs and CT scans were reviewed to ensure 

that tri-radiate cartilages were not fused and the pelvic injuries were classified 

using the Modified Torode Classification. Epidemiologic data included age, race, 

gender time of presentation, mechanism of injury, Glasgow Coma Scale (GCS), 

Injury Severity Score(ISS), Abbreviated Injury Score (AIS), units of blood transfused, 

length of hospitalization, need for surgical orthopedic intervention, and disposition. 

Associated injuries were classified as injuries to the head/neck region, injuries to 

face, injuries to chest, injuries to abdomen, and injuries to extremities. 

Results 

Sixty patients met the inclusion criteria and their average age was 8.3 years. Eleven 

patients required transfusions. Hospital stays ranged from 1-27 days with an average 

of 10.6 days and there were no fatalities. The most common mechanism of injury 

was a vehicle striking a pedestrian. There were no significant correlations between 

GCS, ISS, and AIS. All 60 children (100%) suffered additional extremity injuries. 

Nineteen patients required surgical orthopedic intervention and six required operative 

stabilization of the pelvis. Patients who were struck by a motor vehicle were more 

likely to have multiple pelvic fractures (p

closed (TRC). We hypothesize that based on the patency of the triradiate cartilage; 

these injuries will differ, ultimately leading to a difference in management. 


Using a trauma database, we retrospectively reviewed all patients less than 18 years 

of age with pelvic fractures presenting to a level 1 trauma center during a 14 year 

period. Radiographs and CT scans were reviewed. Pelvic injuries were classified 

using the modified Torode classification. Epidemiologic data included age, race, 

gender time of presentation, mechanism of injury, Glasgow Coma Scale (GCS), Injury 

Severity Score(ISS), Abbreviated Injury Score (AIS), and need for surgical orthopedic 

intervention. Orthopaedic injuries were also independently extracted and classified. 

Results 

178 patients met inclusion criteria, 60 TRO and 118 TRC. The average age for the 

TRO and TRC groups was 8.3 and 16.3, respectively. The mortality rates were 0% 

(TRO) and 5.9% (TRC). There were no statistically significant relationships between 

the GCS, ISS, and AIS between groups. The most common mechanism of injury in the 

TRO group was a vehicle striking a pedestrian compared to a motor vehicle accident 

in the TRC group (p

This has allowed us to dispense with all types of plaster casting, and has allowed 

early motion, with an earlier return to weight-bearing and exercise . 

METHOD: 

The indications, surgical technique, post-operative management and 1 year functional 

results are described for augmented: 

- Achilles tendon repair 

- Quadriceps tendon repair 

- Patella tendon repair 

The important features of the technique are highlighted, and the rationale behind the 

approach is reviewed. 

RESULTS/DISCUSSION: 

This technique has been successfully implemented in 30 patients with good functional 

results at one year. There have been no complications. 

CONCLUSION 

This novel technique has been shown to be simple and effective for different ligament 

and tendon ruptures. The principles of the technique can be adapted for reinforcement 

in most repairs and reconstructions. This technique is particularly appropriate in 

patients wishing an early functional recovery. Fibretape© is safe, inert and cheap, 

and an ideal material for the role of internal bracing. 

Paper 166 


Authors: G. Barinaga, E. Wright, P. Cagle, A. Anoushiravani, Z. Sayeed, M.C. 

Chambers, M. El-Othmani, K.J. Saleh 


Abstract title: Effect of Time of Operation on Hip Fracture Outcomes— 

A Retrospective Analysis 

Introduction: Hip fractures are a common source of morbidity, mortality, and cost 

burden for elderly patients. Our study examines postoperative-outcomes following 

hip fracture fixation in patients operated on during the day and those performed at 

night. 

Methods: Patients >55years who underwent definitive surgical fixation from April 

2011 to April 2013 were included in this study. Those operated on between 7am- 

5pm were included in the ‘day’ cohort while patients operated on between 5pm-7am 

were included in the ‘night’ cohort. 

Results: A total of 508 patients met study inclusion criteria. The day and night 

cohorts had similar distributions of baseline characteristics. However, postoperativeoutcomes 

and resource-utilization did vary significantly amongst the cohorts. 

Conclusion: In our study, time of surgical intervention had no statistical correlation with 

blood-loss or length of stay (LOS). A statistically significant increase in procedural 

charge, cost, and LOS was demonstrated in patients who were treated prior to 5pm. 

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Paper 167 

Presenter: P Cagle 

Authors: G. Barinaga, E. Wright, A. Anoushiravani, M.C. Chambers, Z. Sayeed, 

P.Cagle, M. El-Othmani, K.J. Saleh 


Abstract title: RETROSPECTIVE ANALYSIS OF THE IMPACT OF DAY OF ADMISSION, 

PAYER TYPE, AND DISPOSITION ON OUTCOMES FOLLOWING HIP FRACTURE 

PROCEDURES 

Introduction: Proximal femur fractures are among the leading diagnoses for hospital 

admissions in the elderly. In 2013, CMS made provisions to combat unnecessary 

expenditures and shorter hospital stays were presumed to be medically unnecessary. 

Medicare reimbursements require patients to stay at least two midnights during 

admission. While efforts intend to eliminate economic waste associated with fraud, 

imposing a 3-day requirement may still have financial waste. Patients with proximal 

femur fractures, that could be discharged sooner, have hospital admissions with longer 

length of stay and higher costs. This study investigates the impact of insurance type, 

in combination with day of admission and place of discharge, on hospital length of 

stay and financial outcomes for patients admitted for a hip fracture. 

Methods: This is a retrospective review of patients treated for proximal femur fractures 

at a level-1 trauma center from April 2011 to April 2013. High Impact trauma 

patients were excluded. Groups were separated based on day of admission, type 

of insurance (Medicare vs other), and location following disposition (skilled nursing 

facility (SNF), home, home health). Regression analysis was used to assess length 

of stay (LOS), cost, and charge. Data is expressed as means to determine statistical 

significance (p < .05). 

Results: 508 patients met inclusion criteria. The average age was 81.6 years, with 

381 females and 127 males. There was no statistically significant independent 

correlation between outcome and day of admission. Type of insurance showed a 

statistically significant longer LOS for Medicare patients compared to other payers 

(mean of 5.71 vs 4.48 days, respectively; p= 0.0297). Medicare patients also had 

15% higher cost (p= 0.0486) and charge (percentage, p= 0.0585) associated 

with their admission. All outcomes were significantly higher for patients discharged 

to a SNF. There was also statistical significance for all outcomes with a combination 

of all three variables (p=0.0034). Disposition had the greatest impact on statistical 

significance. 

Conclusion: Hip fractures are an emergent injury with unplanned admission. 

Several factors impact the economic burden translated to hospitals. Our results 

show a correlation between LOS, cost and charge, with a combination-model of 

day of admission, type of insurance, and discharge destination. Medicare patients 

and patients discharged to a SNF have longer hospital stay, higher cost and 


448

charges. Efforts to decrease expenditures remain a concern as adjustments are 

made to reimbursements for the growing Medicare population. A closer look at 

the ’2-midnight benchmark’ for Medicare patients may help improve outcomes and 

decrease expenditures. 

Paper 171 

Presenter: DD Lee 

Authors: Lee D.D., Lau H.Y.F., Kamil M. K., Tan H.P. 


Abstract title: Anticoagulative Intravenous Heparin Infusion for Brachial Artery 

Thrombosis and Its Detriment for the Asian Patient 

A 35-year-old Asian male presented with post traumatic Right upper limb complete 

brachial plexus injury with associated Right acute ischaemic limb. An urgent CT 

Angiogram of the affected limb revealed non opacification of the middle 3rd of the 

right brachial artery suggestive of thrombosis. Plain CT Brain performed with the CT 

Angiogram showed no intracranial haemorrhage or fractures. Intravenous heparin 

infusion was initiated as per American College of Chest Physicians 2012 Guidelines 

for acute limb ischemia with an initial bolus of 5000 units and an hourly infusion 

of 1000 units. A target APTT of 60-90 seconds was sought with 4 hourly APTT 

monitoring. Eight hours following the commencement of heparin infusion, the patient 

deteriorated and was subsequently intubated. A repeated CT brain showed an 

obstructive hydrocephalus secondary to multiple subarachnoid hemorrhages. Heparin 

infusion was immediately halted and prothamine sulphate was administered. An 

emergent external ventricular drain was then inserted at a neurosurgical facility. The 

patient proceeded to recover with neither permanent neurological sequelae nor loss 

of limb. The purpose of anticoagulation therapy in an ischaemic limb is to prevent 

thrombus propagation, however surgical intervention has been advocated as the 

preferred intervention. This is to avoid the undesirable bleeding complications 

following anticoagulation therapy. In western populations, the prevalence of deep 

vein thrombosis (DVT) after total knee arthroplasty (TKA) has been reported to be 

46 to 84%, however in Asian populations it is lower 1–3 . This difference may be 

attributed to a lack of prothrombotic clotting factor polymorphisms (factor V Leiden 

and prothrombin G20210A) among the Asian population 4,5 .We propose that the 

Anticoagulation protocol by Western medical bodies with emphasis on Caucasian 

patients may be too potent for the Asian population. This may inherently cause higher 

bleeding complication rates in the Asian population. We suggest the usage of CT 

Angiogram brain prior to commencement of anticoagulation therapy for more sensitive 

detection of intracranial vascular malformations and hemorrhages. We also suggest 

the adoption of the anticoagulation regimes as per Blunt Vertebral Arterial Injury 

(BVAI) which omit the initial bolus of heparin and target a lower APTT, which reduced 

the incidence of anticoagulation related bleeding complications significantly, from 

54% 6 to 10% in BVAI patients, with favorable outcomes. These suggestions would 

require further investigations, which could improve anticoagulation hemorrhagic 

complication rates in the Asian population. 

449

Paper 201 


Authors: P.S. Schneider, M. Wall, E.L. Belzile, J.P. Brown, A.M. Cheung, E. Harvey, 

S.N. Morin 


Abstract title: Management of Atypical Femur Fractures: A Survey of Current 

Practices in Orthopaedic Surgery 

Purpose: Atypical femur fractures (AFF) are rare and there are currently no 

recommendations to guide treatment. We aimed to determine current practices in 

orthopaedic surgery and to identify knowledge gaps to inform the development of 

clinical guidelines. 

Methods: A 15-question self-administered online survey was developed and posted on 

the Orthopaedic Trauma Association (585 active members) website using LimeSurvey 

software. The survey, developed by a multidisciplinary panel, based on Dillman’s 

principles and the self-efficacy framework, was posted from July 1 to September 13, 

2015. Descriptive statistics were used for analysis. 

Results: A total of 100 complete responses were obtained from primarily trauma 

(59%) and arthroplasty (13%) surgeons. Surgeon experience ranged from ≤5 years 

(40%) to 5-10 years (21%) to 11-20 year (20%) to over 20 years (19%). Forty-six 

percent reported treating 1-2 AFFs in the last 6-months, 29% reported 3-5, and 8% 

treated 6 or more, 17% reported treating none and were not included for treatment 

preference analysis. 

Seventy-nine percent reported feeling Extremely or Very Confident, and 19% 

reported Moderate Confidence in diagnosing AFF. However, when asked regarding 

confidence in treating AFF, 69% reported feeling Extremely or Very Confident and 

27% Moderately Confident. Preferred management for complete and symptomatic 

incomplete AFFs was reported as surgical fixation with a cephalomedullary nail 

(CMN) by 90% and 84% respectively, while preferred management for asymptomatic 

incomplete AFFs was reported to be close follow-up, including serial imaging (67%). 

For bisphosphonate-associated AFF, most respondents would stop the drug and refer 

to an internist (77%) or a family physician (11%) for management, 5% would not stop 

the drug. 

In patients with unilateral AFF and no contralateral leg symptoms, 65% were Extremely 

Likely to obtain contralateral X-rays, however, if symptomatic, 98% were Extremely or 

Very Likely to obtain contralateral X-rays. In patients with bilateral AFFs, with one side 

surgically treated, 61% were Extremely Likely to surgically treat the contralateral side, 

if symtomatic, but only 16% were Extremely Likely if the patient was asymptomatic. 

The preferred timing for prophylactic fixation varied from same day to > 6 weeks. 

Most respondents felt treatment guidelines would be valuable (82%) and they would 

benefit from AFF educational resources (76%). 


450

Conclusion: Current orthopaedic treatment practices for AFFs are highly variable. 

These results will inform our ongoing multidisciplinary team that aims to develop 

evidence-based AFF practice guidelines and educational resources. 

Paper 237 


Authors: Z. Sayeed, A.A. Anoushiravani, G. Barinaga, Y. Sayeed, M.C. 

Chambers, M.M. El-Othmani, P. Cagle, KJ Saleh 


Abstract title: Implementation of a Hip Fracture Pathway Using Lean Six Sigma 

Methodology in a Level 1 Academic Trauma Center 

Background: The use of Lean Six Sigma (LSS) methodology in patient care represents a 

novel trend that is being adopted by academic institutions world-wide. This study aims 

to illustrate application of LSS principles via a hip fracture integrated care pathway 

(ICP) designed to reduce the amount of patients receiving operative management 48 

hours after admission. 

Methods: Crimsion database (Washington, D.C.) coupled with chart review allowed 

for a pre-implementation evaluation. A multidisciplinary team then created a hip 

fracture ICP at a level 1 trauma center. Implementation of an ICP aimed toward 

decreasing time-to surgery to less than 48 hours was implemented from April 2012- 

2013. Inclusion-criteria for cohorts included age ≥55 and radiographic evidence 

of hip fracture that indicated surgical intervention. Baseline characteristics were 

compared for pre- and post- implementation including age, gender, BMI, ASA score, 

fracture type, and instrumentation. Our performance metrics included time-to-surgery, 

percentage of patients operated beyond 48-hours, duration-of-surgery, detection-ofcomplication, 

transfusion-rate, length-of-stay (LOS), hospital charge and cost (USD), 

30-day readmission rate, and in-hospital mortality. Use of SAS 9.3 (SAS, Cary, NC, 

USA) for Windows software allowed for descriptive and multivariate comparative 

analysis of pre- and post-implementation. Chi-squared results were used for categorical 

data, and sample t-tests were used to assess continuous data. Significance was 

assigned to p-values

(p=.51), respectively. Thirty-day readmission rate decreased from 22.62% to 17.19% 

following implementation of ICP (p=.13). Finally, the post-implementation cohort 

demonstrated a lower postoperative transfusion rate that approached significance 

(58.37%versus 50.53%, p=.07) 

Conclusion: Our findings suggest that using LSS techniques in conjunction with an 

ICP at our institution resulted in significantly greater percentage of patients receiving 

operative care within 48 hours, and lower resource consumption. Interestingly, 

our detection of complication was significantly greater in the post-implementation 

cohort and may be due to more vigilant coding practices with adoption of a quality 

improvement protocols. 

Paper 244 


Authors: M. A. Muderis, K. Tetsworth, A. Khemka, S.Wilmot, B. Bosley, V. Glatt 

Disclosure: Yes: Munjed Al Muderis is one of the designer’s of the implants, receives 

royalties 

Abstract title: The Osseointegration Group of Australia Accelerated Protocol 

(OGAAP-2) for Single-Stage Osseointegrated Reconstruction of Amputees 

Osseointegration was developed to attempt to overcome persistent issues associated 

with socket-mounted prosthetics, by direct attachment of the prosthetic limb to the 

skeletal residuum. Until recently this has almost always been performed in two stages; 

however, since March 2014 this has been routinely performed as a single-stage 

under the Osseointegration Group of Australia Accelerated Protocol-2 (OGAAP-2). 

The primary objective here is to describe this single-stage strategy; the secondary 

objective is preliminary assessment of the safety and efficacy of the protocol. 

A prospective pilot study of 10 patients, compared to 10 similar two-stage cases. 

The study groups comprised 11 males, 9 females; aged 27-69 (mean 47.8) years; 

minimum one-year follow-up. Principle outcome measures included: Questionnaire for 

persons with a Trans-Femoral Amputation (Q-TFA); Short Form Health Survey 36 (SF- 

36); Six Minute Walk Test (6MWT); and Timed Up and Go (TUG). Adverse events 

were recorded including infection, revision surgery, fractures, and implant failures. 

Outcomes were obtained pre- and post-operatively from 12 to 36 months, with a 

mean follow-up of 20 months. Comparisons were made between protocols using the 

difference from the mean pre-operative values and the mean post-operative values 

in each group; the improvements observed for all four outcomes were comparable. 

The post-operative Q-TFA global score in the single-stage cohort (44.95±21.66 to 

71.30±18.22) was not significantly different from the two-stage cohort (52.50±28.88 

to 87.04±16.72) (mean diff 11.43, p=0.1204). The post-operative SF-36 physical 

component summary in the single-stage cohort (39.30±12.42 to 46.37±9.90) was 

not significantly different from the two-stage cohort (38.47±13.88 to 49.58±4.37) 

(mean diff 1.3, p=0.7216). The 6MWT in the single-stage cohort (164.8±178.4 


452

to 392.2±148.1) was not significantly different from the two-stage cohort 

(224.8±154.8 to 405.5±83.1) (mean diff 42.7, p=0.3659). The TUG in the 

single-stage cohort (10.48±8.67 to 6.21±6.84) was not significantly different from 

the two-stage cohort (11.94±9.28 to 8.63±2.13) (mean diff 2.05, p=0.3823). A 

total of 13 participants of 20 were adverse event-free; 7 patients had superficial 

infections that resolved with antibiotics, 2 of whom also underwent debridement of 

their stoma. Refashioning of soft tissue was performed on 3 patients; there were no 

periprosthetic fractures; no cases of implant fatigue failure; and no cases of aseptic 

loosening. 

These preliminary results suggest OGAAP-2 may be a comparably safe and effective 

alternative protocol for amputees experiencing socket-related discomfort, with the 

potential to dramatically reduce recovery time compared with two-stage treatment 

strategies. 

Paper 245 


Authors: Anoushiravani AA, Sayeed Z, Barinaga G, Wright E, Chambers MC, 

Scaife SL, El-Othmani MM, Cagle P, Saleh KJ 


Abstract title: Thromboprophylaxis in Hip Fracture Patients: A Study Assessing 

Outcomes and Resource Utilization Trends 

Background: As the incidence of hip fracture continue to rise, it is imperative that 

orthopaedic surgeons evaluate postoperative thromboprophylaxis modalities in an 

attempt improve patient outcomes while minimizing resource utilizations. The purpose 

of this study is to determine whether a specific method of thromboprophylaxis has an 

effect on postoperative outcomes and resource utilization in hip fracture patients. 

Methods: Hip fracture patients from our institution were separated into three cohorts 

depending on the type of thromboprophylaxis administered (aspirin, warfarin, and 

enoxaparin). Initially, all thromboprophylactic cohorts were assessed for baseline 

characteristics, postoperative outcomes, and resource utilization trends. Next, aspirin 

and enoxaparin cohorts were directly evaluated for baseline and outcome variables 

described in initial portion. Using SAS 9.3 descriptive statistics, multivariate analyses, 

chi-square, ANOVA, and sample t-test were generated. Significance was assigned 

at p-value

their hospital stay. However, total hospital cost was demonstrated to be 12.3% and 

16.9% (p=.01) greater within the enoxaparin and warfarin cohorts, when compared 

to the aspirin cohort. 

Three hundred and eighty-nine patients were administered aspirin or enoxaparin. 

Baseline characteristics between the cohorts revealed a significant difference in age 

(p=.03). Although, assessment of postoperative outcomes demonstrated no significant 

difference between the cohorts; LOS did trend towards statistical relevance ([aspirin] 

4.9 days versus [enoxaparin] 5.7 days [p=.07], respectively). Furthermore, hospital 

cost was 12.3% greater in patients administered enoxaparin than those receiving 

aspirin. 

Conclusion: Our study demonstrates postoperative administration of aspirin, 

warfarin, and enoxaparin are all practical methods of thromboprophylaxis. Analyses 

of postoperative outcomes indicated that hip fracture patients receiving warfarin 

were significantly more likely to require allogeneic transfusions than either patients 

administered aspirin or enoxaparin. Assessment of resource utilization trends 

also demonstrated a 16.9% and 12.3% increase in total hospital cost in patients 

receiving warfarin and enoxaparin, respectively. We conclude that when comparing 

enoxaparin and aspirin a significant difference in clinical outcomes does not exist; 

however, we did appreciate lower resource consumption within the aspirin cohort, 

suggesting it is a safe and cost-effective option. 

Paper 257 

Presenter: A Young 

Authors: Young, A. Engelke, E. Curwen, C. 


Abstract title: A PROSPECTIVE, MULTICENTER, UNCONTROLLED OBSERVATIONAL 

STUDY OF THE TRIGEN INTERTAN TROCHANTERIC NAIL IN PATIENTS WITH 

TROCHANTERIC FRACTURES 

Background 

The purpose of this study was to investigate outcomes associated with the Smith 

and Nephew InterTan Proximal Femoral Nail when treating intertrochanteric and 

subtrochanteric fractures of the femur. There is much controversy over the choice of 

implant a surgeon uses, specifically the use of intramedullary nails versus sliding 

hip screws for extracapsular hip fractures. The InterTan Nail uses two femoral head 

screws that interlock producing direct compression of intertrochanteric fractures. 

Methods 

202 subjects were enrolled into three study sites with the total length of enrollment 

1.69 year. Patients were assessed pre-operatively and at 3-months and then 1 year. 

Primary endpoints were HHS, Rand 36 Item Health Survey (RAND-36) and secondary 


454

endpoints were Time Up and Go Test (TUG), radiological Tip-Apex-Distance and 

medical and devices-related complications. 

Results 

The study population consisted of 157/202 (77.7%) females and 45/202 (22.3%) 

males. The mean subject age was 81.5 years (range 54-99) at surgery time 

23/202 (11.39%) subjects were lost to follow-up. 4/202 revisions occurred (1.98%) 

and 24/202 deaths (11.88%) occurred (within 1 year). 

The Harris Hip Score (HHS) improved from a mean of 71.1 at 3 months, to 78.0 at 

1 year. The paired t-test indicates that the HHS at 1 year is statistically significantly 

improved from the mean of HHS at 3 months (p < 0.0001). 

The total mean RAND-36 significantly improved (p

fracture. The initial management was done in the emergency room. Urologic surgery 

was necessary to withdraw the bone fragment. 

CASE PRESENTATION: 

Patient is a 45-year-old male, who presents after being struck by an automobile. 

Imaging studies: 

· X-ray and CT bone scan: bilateral nondisplacement sacral wing fracture, 

bilateral nondisplacement anterior column fracture, comminuted bilateral superior and 

inferior pubic ramies fracture, with a large displaced posterior fragment. The pelvis 

fracture was classified as a type 6.1 A2-3, according to AO/OTA Classification. 

The acetabulum fracture was classified as a type 6.2 A3-2, according to AO/OTA 

Classification. 

· CT cystogram: extravasation of contrast from urinary bladder through the anterior 

wall of acetabulum 

The management of the patient started in Emergency Room. Foley catheter was 

inserted, showing frank hematuria. 

Urologic Surgery Department took patient to Emergency Operative Room. Exploratory 

laparotomy was done, which found an anterior wall bladder injury, measuring 7 cm 

caused by a fragment of the pubic bone. A sharp-edge fragment measuring 4.5 x 

3.5 cm was discovered inside the bladder. Bladder was closed and insertion of 

suprapubic catheter was completed after surgery. 

The fractures did not require surgical treatment. 

Patient was monitored by Urology and Orthopedic Department with a series of x-rays 

for 2 weeks. The urine became clear and the patient was discharged to outpatient 

clinic for follow-up by Urology and Orthopedic Surgery Department. 

CONCLUSIONS: 

This case illustrates the potential risk of bladder injury after pelvic fracture. The fragment 

size seen in this case makes it a rare presentation. It is important to recognize the 

possibility of complications and be prepared to act immediately. The teamwork 

between orthopedic, urologist and vascular surgeons is mandatory. 

Paper 386 

Presenter: R Dhir 

Authors: Dhir R, Gee M, Arshad H, Culpan P, Bates P 


Abstract title: Early experiences of a new anatomic plating system for posterior 

acetabular fractures in a level 1 UK trauma centre 

Purpose of study The use of plates for the fixation of posterior column or wall fractures 

is well described. However, small posterior wall fragments can be difficult to secure 

and comminuted wall fragments may not be adequately captured by conventional 

plates. Our aim is to report early findings of an anatomical plating system for posterior 

wall and column acetabular fractures. Description of methods Over 12 months, 14 

consecutive fractures were treated with PRS (RX) posterior plates (ITS). Outcome 

measures included SF36, Merle D’Aubigne and VAS. X-rays were independently 

assessed for loss of reduction. Secondary outcomes included infection, VTE, nerve 


456

injury and reoperation. Summary of Results Mean age was 51.7 (range 24-84). 

Two patients were lost to follow-up. There were no cases of infection, VTE, iatrogenic 

nerve palsy or re-operation. Mean Merle D’Aubigne score was was 11.2/18. Mean 

VAS was 0.4/10 at rest (0-2) and 2.2 on mobilisation (3-5). There were no cases 

of loss of radiological reduction or early joint incongruence. Conclusion Our early 

results of anatomically contoured pelvic plates are promising, with no early failures. 

Perceived surgical benefits of the plates include the ease of application, the ability 

to put screws through the plate and posterior wall fragment, superior containment of 

both comminuted and very marginal posterior wall fragments and the multiple hole 

options anteriorly reduce the need for gluteal retraction. 

Paper 387 


Authors: Dhir R, Gee M, Arshad H, Culpan P, Bates P 


Abstract title: Early experiences of a new anatomic anterior plating system for 

acetabular fractures in a level-1 UK trauma centre 

Purpose of study Acetabular fracture patterns involving anterior and medial displacement 

can be technically challenging, particularly in older patients. Medial migration/loss 

of reduction is reported in 10-15% cases, which rises to 30-45% in patients over 65. 

Aims: To report the early findings of an anatomic plating system for anterior acetabular 

fractures and to describe our concept of injury to ‘the middle column’ in acetabular 

fractures in the elderly population. Description of methods Over 12 months, 16 

consecutive fractures were treated with PRS (RX) medial ‘bird-foot’ plates (ITS) through 

an anterior intra-pelvic (Stoppa) approach. Extent of middle column involvement was 

quantified pre-operatively. Outcome measures included SF36, Merle D’Aubigne and 

VAS. X-rays were independently assessed for loss of reduction. Secondary outcomes 

included infection, VTE, nerve injury and reoperation. Summary of results Mean age 

was 58.8 (28-91), two were lost to follow-up and mean follow-up was 29.9 weeks 

(6-52). Five of 16 (31.2%) were planned for fixation in two stages - anterior fixation, 

followed by THR within 1-2 weeks. Mean Merle D’Aubigne score was 12.6/18 (8- 

18); mean VAS was 0.3/10 at rest (0-2) and 2.0 on mobilisation (0-5). Conclusion 

Early results of anatomically contoured intra-pelvic plates are promising. Perceived 

surgical benefits of the plates include ease of application, broad foot-print over the 

quadrilateral surface and screw fixation within the sciatic buttress. We propose an 

algorithm for assessing middle column damage, as an indication for early THR. 

Paper 388 


Authors: Dhir R, Moore N, Konig T, Griffiths M, Barry M, Bates P 


Abstract title: Operative Plating For Traumatic Flail Chests In A Level 1 UK 

457

Trauma Centre 

Purpose of study Flail chest injuries can cause significant morbidity. Historically these 

injuries were treated with analgesia and positive pressure ventilation. Operative 

intervention is not a new phenomenon and was introduced in the 1960s. There were 

however problems implementing it due to technical and implant factors?. Newer 

randomised controlled trials showed improved outcomes in terms of ventilation 

duration, ICU stay, rates of pneumonia, mortality, residual chest wall deformity and 

total cost of care after operative fixation with rib plating. Managing these injuries 

with a multi-disciplinary approach (involving intensivists, trauma and orthopaedic 

surgeons) in selected patients has thus been shown in the literature to be a costeffective 

and safe approach to management. Description of methods We describe 

institution of a multidisciplinary rib plating service at a level 1 trauma centre and 

aim to evaluate its efficacy both clinically and as a financially superior option. 

Methods Inclusion criteria were any patients selected between June 2014 (when 

the service was instituted) and October 2015 with a flail segment rib fracture (2 

or more rib fractures in more than 1 place) who required operative intervention. A 

multidisciplinary approach to management was used for management of all traumatic 

flail chest injuries involving intensivists, orthopaedic and general trauma surgeons 

and patients selected appropriately for surgery. All patients with flail chests were 

presented at trauma meeting? and at risk patients identified (respiratory failure, slow 

wean, excessive pain)?. Criteria for selection and pathways to guide management 

were present. Patients were evaluated for clinical outcome and also cost effectiveness 

in terms of days of ventilation and intensive care stay saved. A standardised operative 

approach was used involving trauma surgeons (who carried out the throracotomy 

approach) and orthoapedic surgeons who performed the fixation. Synthes matrix 

rib implants were used. Summary of Results 15 patients had operative rib plating 

performed during the time period. We showed that patients were extubated more 

quickly with a mean of 1 day post-operatively. Days of ITU stay were reduced and 

this was found to be cost effective. There were no revisions or failure of reduction 

and no incidences of infections or iatroegnic pneumothorax. Conclusions: There is 

growing evidence showing substantial benefits for patients with flail chest injuries 

treated operatively. We have instituted a multi-disciplinary service at a level 1 trauma 

centre which has been shown to be clinically and financially effective. 

Paper 424 

Presenter: J. Du Plessis 

Authors: J. Du Plessis, M.T Ramokgopa, J.A Moolman, W.S Ndou 

Abstract title: Delayed pelvic reconstruction following complex pelvic fractures 

Introduction: Pelvic fractures occur as a result of high energy mechanisms. Hip 

dislocations are often associated with acetabular fractures in these high energy trauma 

situations.Complex pelvic injuries often warrant prolonged surgeries which are often 

delayed on our setting and can negatively impact on patients physiology and long 


458

term outcome. Objectives: To highlight the complexity and difficulties involved in 

delayed pelvic reconstructive surgery. Methods: We present a case of a 28 year old 

female involved in a motor vehicle accident. She sustained bilateral assymetrical hip 

dilocations with associated pelvic and acetabular fractures. We highlight challenges 

in delayed surgery and the importance of staged procedures in pelvic reconstruction. 

Conclusion: Complex pelvic injuries are associated with significant blood loss as well 

as life threatening injuries. Delayed surgery is often associated with poor outcomes 

and from our case we recommend early surgery and staged procedures in complex 

pelvic reconstructions. 

Objectives: To highlight the complexity and difficulties involved in delayed pelvic 

reconstructive surgery. 

Methods: We present a case of a 28 year old female involved in a motor vehicle 

accident. She sustained a combined anterior-posterior and lateral compression pelvic 

injuries. We highlight challenges in delayed surgery and the importance of staged 

procedures in pelvic reconstruction. 

Conclusion: Complex pelvic injuries are associated with significant blood loss as well 

as life threatening injuries. Delayed surgery is often associated with poor outcomes 

,from our case we recommend early surgery and staged procedures in complex 

pelvic reconstructions. 

Paper 444 

Presenter: B Ristevski 

Authors: B. Ristevski, S. Sprague, H. Chaudhry, J. Poon, T. Scott, M. Bhandari 


Abstract title: How Accurate are Distracted Driving Videos: An Analysis of the 

Evidence Quality Across 570 YouTube Videos 

(DRIVSAFE - Distractions on the Road: Injury eValuation in Surgery And FracturE Clinics) 

Purpose: 

Globally, distracted driving kills thousands of people each year. In addition, trauma 

occurring worldwide from road traffic collisions ranks in the top 10 causes of disability. 

According to statistics from the National Highway Traffic Safety Administration and 

Canadian governments, distracted driving is a factor in greater than 4 million road 

traffic collisions annually in North America alone. In addition to potentially sustaining 

serious musculoskeletal trauma, distracted drivers are 3 times more likely to be in a 

crash with a high risk of fatality. The purpose of this study is to characterize distracted 

driving videos available on YouTube in order to better understand the content, context, 

and gauge the popularity and quality of the messages portrayed by these videos. 

459

Methods: 

YouTube videos on distracted driving with greater than 3000 views were collected 

and screened for inclusion. Two authors independently collected a variety of both 

quantitative and qualitative data. Discrepancies in data were resolved by consensus 

via the coding authors. 

Results: 

A total of 570 videos met the inclusion criteria. The number of videos possessing 

greater than 3000 views on this topic were initially found in 2005 (1 video) with 

steady growth until 2012 (112 videos). A decline in the number of videos was 

seen in 2013 (93 videos) and 2014 (a projection of 51 videos, based on data 

for the first half of the year). This represents a 54.5% decline from the peak year 

of 2012. Viewers demonstrated a 16.2 “like” to “dislike” ratio for all the videos 

combined. Statistics were present in 34.5% of videos, with only 31.6% of these 

having a reference. Less than 1% of videos appeared to use peer reviewed data. In 

addition, only 10.0% of videos actually depicted or mentioned an orthopaedic injury. 

Conclusion: 

This study demonstrates that the popularity of viewing videos focused on distracted 

driving appears to be declining on a forum that fluxes based on the current opinion 

of its users. The overall quality of evidence presented in these videos can be 

regarded as poor, with a significant paucity of peer reviewed data being presented. 

Surprisingly, orthopaedic injuries, a massive source of long-term disability, are vastly 

under-represented. This indicates a major need for public education to elucidate the 

true dangers such risky behaviour can lead to. 

Paper 445 


Authors: A. Chauhan, S. Anand, S. Maheswaran 


Abstract title: Locked knee - Keep intraarticular dislocation of patella in 

consideration! 

Purpose of study - DislocatIon of patella is a known orthopedic emergency. Its annual 

incidence is 5.8 per 1,00,000 in general population. It is common in adolescents 

in 10-17 year age group with an average incidence of 29 per 1,00,000. Out of 

many etiologies of locked knee, intraarticlular dislocation of patella is very rare. It 

has been Subclassified by Ofluoglu as horizontal and very rarely vertical dislocation 

of patella depending on the axis of its rotation. Purpose of this report is to keep this 

rare entity into differential diagnosis of a locked knee. 


460

Description of Methods - A 16 year old male attended accident and Emergency 

department with severe pain, deformity and inability to stand on right knee. He 

reported a twisting injury while playing football few hours before. No previous history 

of knee laxity or knee problems were informed. On examination, there was a visible 

skin tenting anteriorly in the patellar region without significant joint effusion. One of 

the borders of patella was felt anteriorly. Quadriceps tendon was found to be taut and 

intact. The distal neurovascular examination was completely normal. Resident doctor 

attempted to book an early MRI scan thinking of common meniscal and cartilage 

conditions as a cause of locked knee. While waiting for the MRI scan, radiographs 

were done in order to rule out any fracture and to look at the patellofemoral position. 

Description of results - Radiographs revealed vertical dislocation of patella. 

Reduction was achieved with intraarticular local anaesthetic and saline injection with 

manouvering of the patella. Post-reduction radiographs confirmed normal positon and 

alignment of patella without any fracture. 

Conclusion - Vertical dislocation of patella is a rare condition causing locked knee. 

Radiographs should always be a routine before any further investigations like MRI. 

Closed reduction can be achieved successfully in a young patient, as in our case, 

though open reduction may be required in elderly with osteophytes. 

POSTERS - TUMOURS 

Paper 138 


Authors: J Silvestre, J.M. Abbatamatteo, J.Z. Guzman, H.H. Wu, L.S. Levin 


Abstract title: Social Networking: An Emerging Tool for Communication in 

Orthopedics 

INTRODUCTION: Since its inception in 1997, social media has expanded from 

virtual non-existence to an estimated 1.43 billion users. However, the use of social 

media within the field of orthopedics remains largely unknown. We sought to quantify 

the social media presence of orthopedic journals and professional societies. 

METHODS: A comprehensive list of high impact journals in orthopedics was 

generated from SCImago and Google Scholar Metrics. Professional and patientcentered 

organizations were identified via a systematic search of Google, Facebook, 

Twitter, and LinkedIn. Social media activity was quantified by the number of Facebook 

“likes,” Twitter “followers,” and LinkedIn “members.” Correlations between social 

media venues were performed via chi square goodness of fit. 

RESULTS: As of January 1, 2015, only 19.2% of orthopedic journals were present 

on Facebook (30/156) and 19.9% on Twitter (31/156). The American Journal of 

Sports Medicine (4,632) and British Journal of Sports Medicine (4,276) had the most 

461

likes on Facebook. There was a strong correlation between use of Facebook and 

Twitter. Among professional societies the American Academy of Orthopaedic Surgery 

(16,209 likes, 17,890 followers) had the greatest social media presence by a wide 

margin. A strong correlation existed between use of Facebook, Twitter, and LinkedIn. 

DISCUSSION AND CONCLUSION: A large number of orthopedic societies utilize 

social media to connect members, but academic journals lag behind. Although 

some orthopedic journals are active in social media, most do not utilize online social 

networks 

Paper 372 


Authors: N.C. Eastley, R. Silk, K. Rao, T.A. McCulloch, M.S. Tamimy, A. Raurell, 

A.G.B. Perks, R.U. Ashford 


Abstract title: Outcome of Patients with Lymph Node Metastases from Soft Tissue 

Sarcoma 

Background: 

Soft tissue sarcomas (STS), unlike other solid tumours, rarely give rise to regional 

lymph node metastases, with an estimated incidence in the literature of between 

2.6% and 14.9%. We aim to evaluate the incidence, patient demographics, primary 

tumour characteristics and survival of patients with lymph node metastasis from soft 

tissue sarcomas presenting to the East Midlands Sarcoma Service (EMSS). 

Methods: 

Retrospective case note analysis of patients identified with lymph node metastasis 

from STS managed by EMSS over a 17 year period from 1998 to 2014. 

Results: 

15 patients were identified, of which one was excluded due to incomplete available 

Histopathological data. Mean age was 45.8 years (range 13-86yr), with a maleto-female 

ratio of 1:1. 

Groin was the site of metastasis in 8 patients, axilla in 5 and neck in 1 patient. In 

11 out of the 14 cases, metastases occurred from a primary within the lymph node 

basin, while 2 were distant lymph node metastases, and an unknown primary in 1 

case. 

With the exception of one patient who had synchronous metastasis, the mean time 

to development of the metastases was 52.9 months. Eleven patients underwent 

lymphadenectomy, following which the 1-year survival rates were 80% and 5-year 

was 50%. Those patients that did not under go lymphadenectomy had a mean 


462

survival of only 9 months from time of diagnosis of lymph node metastasis. Overall, 

7 of the 14 patients died, of which 3 deaths were from unrelated causes, and of the 

other 7 patients 4 remain disease free, with a mean follow-up period in the surviving 

patients of 59 months. 

Discussion: Lymph node metastasis from STS only occurs in a small number of 

patients. Our data shows higher rates of lymph node metastasis in extremity STS 

with a broad range of sarcoma sub-types involved. However, previous data has 

suggested that angiosarcoma, clear cell, and rhabdomyosarcoma sub-types may 

have a higher rate of regional nodal metastasis. Our data supports the current 

literature that patients with regional lymph node metastases can have good survival 

rates of around 50% at 5 years. 

Conclusions: Although rare, lymph node metastases from soft tissue sarcoma represent 

a heterogeneous group of patients. These complex patients often present with lymph 

node metastasis a long period after primary diagnosis and following resection of 

involved nodes can have good long-term survival rates. 

Paper 481 


Authors: Z Linda, K.Sikhauli and M. Lukhele 


Abstract title: Osteofibrous dysplasia of the ulna; a case report 

Osteofibrous dysplasia is a rare benign condition with an unkown cause. The 

disease has been under debate with other authers suggesting it may be manifestation 

of neurofibromatosis. The tibia is the mostly affected bone and presents as a firm 

swelling of the bone. In this poster we are presenting a 13 years old female who 

presented with a 3 year history of a painless mass on the right forearm. 

We will be discussing management and reviewal of the literature of this condition. 

463

Paper 483 


Authors: Z. Linda, K. Sikhauli, P. Swart and M . Lukhele 


Abstract title: Myoepithelial carcinoma of the forearm: an agressive neoplasm 

Primary myoepithelial carcinoma of the soft tissues are rare . It commonly affect 

salivary gland and composed of myoepithelial cells that exhibit dual epithelial and 

smooth muscle phenotype. This tumours have been reported in other soft tissue and 

criteria for diagnoses has recently been established. When the tumour is affecting 

children, the prognosis is poor and has high recurrency rate. 

In this poster we are presenting a 2 years old girl who presented with a recurrence 

after few months the tumour was resected in a peripheral hospital. Literature review 

and management will be discussed. 

NOTES 


464

465 

NOTES

INDEX OF PRESENTERS 

Number Surname Name 

496 Abbas Ghulam 





413 Akhtar Muhammad 

Adeel 


Adeel 


Adeel 


Adeel 


Adeel 


Adeel 


Adeel 

380 Al Muderis Munjed 

381 Al Muderis Munjed 

212 Alfahad Nawaf 

ICHAS04 Andrade T. 



ICAOR01 Argenson Jean-Noel 

258 Ashford Robert 

406 Ashton Fiona 

ICTU07 Aston W. 

ML08 Atkinson Denis 

ICH07 Atzei A. 



ICH02 Bain Greg 





ICI06 Bain Greg 

ICSE09 Bain Greg 



ICI17 Bain Greg 

ICK08 Barrow Michael 

ICHAS07 Bataillie F. 

ICHAS14 Bataillie F. 

379 Bates Peter 

ICAOF04 Bernstein Brian 

ICTR01 Bernstein Brian 

374 Bertie Julia Diana 

273 Bhandari Mohit 

322 Bhandari Mohit 

S24 Bhandari Mohit 

95 Biant Leela 

96 Biant Leela 

ICAOF07 Birkholtz Franz 

ICLL02 Birkholtz Franz 

375 Bismilla Muhammad 

Naadir 

S23 Black Kevin 

152 Blom Ashley 



104 Bois Aaron 

430 Bourke Gerard 

S03 Bozic Kevin 

S04 Bozic Kevin 

ICSE08 Breckon Charles 

S21 Briggs Tim 

277 Brousil James 

97 Buckley Richard 


466


ICTR05 Buckley Richard 

S16 Bucknill A. 

ICHAS15 Buly Robert 

85 Burger Evalina Levina 





151 Burn Peter James 

169 Burnand Henry 



289 burnett Stephen 

209 Cakic Josip Nenad 

211 Cakic Josip Nenad 

214 Calder Peter 

S04 Callaghan John 

391 Campi Stefano 

ER01 Cannon Stephen 

453 Carpenter James 

455 Carpenter James 

376 Chauhan Amit 



ICTU01 Choong Peter 

S21 Choong Peter 

S15 Choong Peter 

ICFA 05 Coetzee Chris 

ICS02 Coetzee Ettienne 

157 Coetzee J Chris 




ICSE10 Cutbush Kenneth 

(P182) 


ICSE29 Cutbush Kenneth 

(P183) 

184 Cutbush Kenneth 


ICL01 D’Ambrosia Robert 

418 Dachs Robert Paul 


463 Daly Karen 

ICS01 Davis Johan 

S25 Davis Johan 

ICSE02 de Beer J. 

10 de Beer Justin 

125 de Beer Justin 

ICLL01 de Lange Phillip 

57 De Muelenaere Phillip 

Francois 

S13 de Steiger R. 

S16 de Steiger R. 

ICK03 De Vlieg A. 

S21 de Vos Jan 

ICTR07 Della Rocca Gregory J. 

462 Della Rocca Gregory John 

ICSE23 Desai S. 

ICSE24 Desai S. 

30 Devane Peter 

31 Devane Peter 

ML06 Dickinson Ian 

296 Di Mascio L 

ICSE 18 Dix-Peek Stewart 

ICP03 Dobbs Matthew 

ICP05 Dobbs Matthew 

S17 Donnelley William 

487 du Plessis JP 

ICS01 Dunn Robert 

ICS02 Dunn Robert 

467


S23 Dunn Robert 

S25 Dunn Robert 

ER02 Eastwood Deborah 

ICP 02 Eastwood Deborah 

(P332) 

ML01 Edeling Herman 

155 Edwards Elton 

409 El-Daly Ibraheim 

Plenary Eltringham Mark Anthony 

99 Emery Sanford 

ICI15 Erasmus S. 

144 Espag Marius 

360 Favorito Paul 

377 Favorito Paul 

ICSE06 Favorito Paul 



(P361) 

ICI18 Favorito Paul 

ICI11 Ferguson M. 

ICSE03 Ferguson M. 

207 Ferrao Paulo 

251 Ferrao Paulo 

51 Ferreira Nando 

54 Ferreira Nando 

ICLL03 Ferreira Nando 

ICLL05 Ferriera Nando 

ICHAS02 Field Richard 

ICHAS06 Field Richard 

365 Finsen Vilhjalmur 

473 Firth Gregory 

Bodley 


Bodley 


Bodley 


S26 Firth Gregory 

Bodley 

231 Fowler Andy 

ML04 Foy Michael 

ICAOF10 Frey 

Chris 

ICAOF12 Frey 

Chris 

ICI02 Fu F. 

ICK09 Fu F. 

ICI04 Fu F. 

ICI09 Fu F. 

ICK13 Gelbart Brade 

149 Geraghty Liam 

260 Goni Vijay 

ICSE28 Gooding B. 

S08 Graves Stephen 



ICSE05 Greeff G. 

ICHAS05 Griffin Damian 



ICAOF08 Haas N. 

79 Haber Mark 

80 Haber Mark 

ICAOF09 Haddad 

Fares S 

ICAORO3 Haddad Fares S 

ER02 Haddad Fares S 

ICHAP04 Haddad Fares S 

(P508) 

ICHAP13 Haddad Fares S 

(P509) 

S22 Haddad Fares S 

S23 Hadlaw Simon 

ICSE01 Hardy Philip 


468




137 Hasenkam Christopher 

482 Hassan Abdul 

Rahman 

S03 Hawker Gillian 

ICTU04 Haydon R. 

65 Held Michael 

S25 Held Michael 

368 Helmy Naeder 

384 Helmy Naeder 

108 Hiddema Willem 

ICK05 Hirner M 

(P58) 

ICK04 Hobbs Hayden 

300 Hoerner Pierre 

ICFA09 Hogan V. 

ICFA11 Hogan V. 

389 Holland Philip 

390 Holland Philip 

120 Hooper Gary 



ICHAP03 Hooper Gary 

(P121) 

ICHAP08 Hooper Gary 

(P122) 

230 Horn Anria 

ICTU06 Hosking K. 

ICTU05 Hosking K. 

ICK 11 Howie Colin 

(P264) 

S22 Howie Colin 

ICAOF11 Huo 

Michael 

467 Ikram Ajmal 


469 Ikram Ajmal 

217 Ilg Ansgar 

ICHAS12 Ilizaliturri V. 

Plenary Incoll Ian 

S23 Incoll Ian 

98 Ingoe Helen 

427 Ingoe Helen 

33 Isaacs Samuel 

S22 Jackson W 

S21 Jacobs Josh 

186 Jain N 

83 Jameson Leslie 

327 Jerry Shao Ting 

329 Jerry Shao Ting 

ICTU08 Jeys L. 

ICTU14 Jeys L. 

102 Johal Herman 

305 Jordaan Pieter Willem 

402 Joubert Jan 

ICFA 06 Judet T. 

448 Karpe P 

449 Karpe P 

471 Karpe Prasad 

472 Karpe Prasad 

ICSE15 Kastanos Dinos 

499 Keays Susan 

S19 Keddell R. 

ICFA08 Kennedy J. 

34 Khan Shah Alam 




101 King Paul Reginald 

469


87 Kleck Christopher 







100 Koch Odette 

S20 Krause Brett 

14 Kretzer Jan Philippe 

107 Kretzer Jan Philippe 

ICS01 Kruger Neil 

6 Kruger Neil 

S04 Kwon YM 

263 Lamberts Robert P 

ICI05 Landrau P. 

ICI10 Landrau P. 

318 Laubscher Maritz 

8 laurent Obert 

39 Laurent Obert 




ICHAP12 Learmonth Ian 

(P512) 

ICHAP15 Learmonth Ian 

ICFA04 Lee T. 

357 Leighton Ross 



ICTR04 Leighton Ross 

ICTU12 Leighton Ross 

ICTU13 Leighton Ross 

S02 Leighton Ross 


S24 Leighton Ross 

S07 Lewis Peter 

S06 Lewis Peter 

ICTU02 Lindeque B. 

ICTU10 Lindeque B. 

67 Lisowski Andrzej 

134 Little David 

ICP07 Little 

David 

(P333) 

S05 Loefler Andreas 

Plenary Lukhele Mkhululi 

ICTU03 Luu H. 

431 Macnair Rory 

193 Malchau Henrik 




280 Mansouri Pejman 



ICAOF02 Maqungo Sithombo 

ICAOF06 Maqungo Sithombo 

S26 Maqungo Sithombo 

S26 Marais Len 

ICLL04 Marais Leonard 

ICTU09 Marais Leonard 

62 Marais Leonard 

393 Maré Pieter Herman 



178 Marsh Andrew 

S02 Marsh J.L. 

ICTR03 Marsh Larry 


470


S25 Marshall Mike 

ICA0R02 Masri Bas 

ICHAP02 

(P506) 

ICHAP05 

(P507) 

ICK 16 

(P150) 

Masri 

Masri 

Maxwell 

Bas 

Bas 

Rod 

150 Maxwell Rod 

213 Mayet Ziyaad 

S26 McCollum Graham 

ICI14 McCollum G. 

ICAOF03 McFadyn Iain 

ICTR02 McFadyn Iain 

ICHAP01 McGrory Brian 

ICHAP07 McGrory Brian 

ICAOR04 McLennan- 

Smith 

ICHAP11 

(P513) 

McLennan- 

Smith 

Robert 

Robert 

188 Middleton Scott 

202 Middleton Scott 

419 Mogale Nkhensani 

399 Mohideen Moosa 

Ahmed Farouk 

412 Mokete Lipalo 

9 Moldovan Radu 

373 Morton Neil 

197 Moses Peter 

235 Muderis Munjed Al 

ICFA02 Muir D. 


ICHAP06 Munting Thane 

(P514) 

S01 Murray Peter 

396 Myburgh Johannes 

Gerhardus 

378 Naidoo Arushka 

370 Nasar Ali 

432 Naude Jaco 

297 Naude Petrus Hendrik 

S04 Nelson C.L 

S25 Ngcelwane Mthunzi 

129 North David Martin 

S23 Nousiainen Markku 

249 O'Donnell John 

250 O'Donnell John 

ICHAS01 O'Donnell John 



308 Oosthuizen Christiaan 

Rudolf 


Rudolf 


Rudolf 


Rudolf 


Rudolf 

385 Orpen Neil 

ICSE04 Osman S. 

ICSE25 Osman S. 

(P404) 

488 Osman Humza 

461 Osmani Humza 

195 Outerleys Jereme 

471


ICK07 P. Landreau P. 

ICH01 Packard G 

ICH04 Packard G. 




429 Page Jonathan 

S09 Page Richard 

270 Pandit Hemant 



S19 Panting A. 

470 Parker Asifh 

216 Parkinson Richard 

103 Parkinson Richard 

S22 Parkinson Richard 

326 Parr Adam 

ICTU11 Peabody Terrence 

Plenary Peabody Terrence 

S01 Peabody Terrence 

ICFA10 Pearce C. 

ICFA12 Pearce C. 

S01 Perdekis Galen 

ICAOF13 Perka 

Carsten 

72 Petheram Timothy 

75 Petheram Timothy 

S24 Petrisor Brad 

123 Pienaar Gerhard 

474 Pietrzak Jurek Rafal 

Tomasz 

317 Pikor Tim Daniel 

316 Pikor Tim Pikor 

ICS01 Polley P. 

ICS01 Puddu Alberto 


489 Puddu Alberto 

ICP04 Ramachandran Manoj 

(P331) 

ICP09 Ramachandran Manoj 

(P330) 

ICS02 Ramlakan R.J. 

363 Rasool Mahomed 

Noor 

364 Rasool Mahomed 

Noor 

210 Ray Robbie 

254 Ray Robbie 

ML05 Richards Robin 

132 Riddell Alexander 



275 Rocca Greg Della 

415 Roche S 

ICI12 Roche Stephen 

ICSE19 Roche Stephen 

S26 Roche Stephen 

ICTR06 Rossiter Nigel 

ICSE26 Roth C. 

426 Roussot Mark Anthony 

S19 Rowan R. 

66 Russell Robert 

S04 Saleh K J 

ML07 Saleh K.J 

206 Saragas Nick 

S18 Saravanja Davor 

484 Schneider Prism 


ICP08 Schoenecker Jonathan 

(P334) 

68 Shahi Utkarths 

24 Sheps David 


472


25 Sheps David 

ICSE27 Sheps David 

(P105) 

142 Shetty Vijay 

407 Simmons Dina 

ER02 Simpson Hamish 

298 Sluis-Cremer Timothy 

Richard 

ICSE12 Smit A. 

434 Smit Adriaan 

ICAOF05 Smith 

Kevin 

ICAOF01 Smith 

Kevin 

203 Smith Stephen 

David 


David 


David 

128 Sochart David 


S22 Sochart David 

ICH05 Solomons Michael 

ICK01 Sonnery-Cottet B. 

ICK06 Sonnery-Cottet B. 

352 Spengler Dan 

S14 Stoney James 

383 Stoney James 

Plenary Stott Sue 

177 Strauss Karl 

ICK12 Street Matthew 

189 Streicher Robert 



200 Strydom Andrew 


ICSE 17 Suter J. 

ML02 Sutherland Romany 

199 Swiontkowski Marc 

ER03 Swiontkowski Marc 

(P515) 

60 Tennant Sally 

74 Tennant Sally 

S03 Teuscher David 

ICHAP09 Theis JC 

ICHAP14 Theis JC 

S19 Theis JC 

S20 Theis JC 

130 Thomas Mike 

76 Thornley Patrick 

Thornley 

290 Tucker John Keith 

293 Tucker John Keith 

S23 Turner Philip 

168 Uglow Michael 

222 Uglow Uglow Mike 

ML03 van den Bout Anton 

223 Van Der Jagt Dick Ronald 


ICHAP10 Van Der Jagt Dick Ronald 

(P229) 

491 van der Merwe Johan 

464 Van Der 

Merwe 

Johan 

Francois 

ICI08 van der Merwe W 

ICK02 van der Merwe W. 

ICK15 van der Merwe W. 

(P494) 

493 van der Merwe Werner 

473


ICI16 van der Merwe Werner 

ICI01 van der Merwe Willem 

ICI03 van Dijk N 



ICFA07 van Dijk N. 

ICI20 Van Dijk N. 

ICI19 van Dijk N. 

422 Van Niekerk Andries 

Hendrik 

423 Van Niekerk Andries 

Hendrik 

433 van Niekerk Michael 

340 Van Zyl Allan Aubrey 

ICK14 von Bormann Richard 

73 Vosloo Martie 

417 Vrettos Basil 

ICSE13 Vrettos Basil 

353 Waddell James 



ICK10 Waddell James 

(P355) 

Plenary Waddell James 

465 Wallace W Angus 

1 Walmsley Phil 



ICFA03 Wapner K. 

ICSE11 Webster Philip 

ICSE22 Webster Philip 

Plenary Weinstein Stuart 

S02 Weinstein Stuart 


S21 Weinstein Stuart 

232 Wells Martin Carr 

ICS02 Welsh David 

451 Weusten Axel 

112 Wilding C 

113 Wilding C 

114 Wilding C 

117 Wilding C 

119 Wilding C 

ICP01 Willis Baxter 

(P336) 

ICP06 Willis Baxter 

(P335) 

ICFA01 Willis Nigel 

13 Wilson Chris 




Plenary Wilton Tim 

S22 Wilton Tim 

291 Wood Gavin 

124 Wood Thomas J. 

174 Wu Hao-Hua 


28 Wu Hao-Hua 




337 Zheng Ming Hao 

338 Zheng Ming Hao 


474

475 

NOTES

www.comoc2016.org 

INDEX OF POSTER PRESENTERS 



Adeel 

284 Almela Patricia 

Matamoros 



446 Bargar William 

141 Beswick Andrew 





111 Bischof Faith Millicent 

63 Bois Aaron 

64 Bois Aaron 

282 Boswell Melissa 


167 Cagle Paul J 





456 Charilaou Johan 

459 Charilaou Johan 








160 Dala-Ali Benan 

283 Davis Brian 

386 Dhir Rishi 



480 Ferguson David 

109 Foo Gen Lin 

110 Foo Gen Lin 

319 Hammouche Salah 

205 King Andrew 

23 Kontoghiorghe Christina 

171 Lee Denis Dian 

479 Linda Zwelithini Alfred 



435 Liu Max 


221 McTighe Timothy 

227 McTighe Timothy 

306 Mehta Vishal 

307 Mehta Vishal 

458 Minnis Vishal 

242 Muderis Vishal 


476 

476


244 Muderis Munjed Al 

424 Ndou Wofhatwa 

425 Page Jonathan 

323 Palencia Jesus Palencia 



179 Pelser Eugene 

476 Pietrzak JRT 

69 Poage Chad 

215 Reddy Praven 


444 Ristevski Bill 

161 Saleh Khaled J 








400 Schnaid Edward 

401 Schnaid Edward 


81 Shaath M. Kareem 

82 Shaath M. Kareem 


26 Scheps David 

106 Scheps David 

143 Shetty Vijay 

460 Singh Jagwant 


495 Tomescu Sebastian 




492 van der Johan 

Merwe 

498 Wallace Angus 

115 Wilding C 



27 Wu Hao-Hua 

29 Wu Hao-Hua 



257 Young Alexander 

116 Younus Aftab 

118 Younus Aftab 

21 Yuan Wei 

477

NOTES 


478

Disclaimer: 

Please note that the material presented at the COMOC 

congress is not specifically endorsed or approved by the 

COMOC committee. 

All speakers have the right to express their views in an 

open forum and any delegate may comment on these 

views in an orderly and courteous manner. 

Any further correspondence regarding difference 

of opinions of expressed views must be addressed 

to the specific speakers and no correspondence on 

these matters will be entered into by the SAOA or the 

COMOC committee.

www.comoc2016.org

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