A comparison of distal femoral replacement versus fixation in treating periprosthetic supracondylar femur fractures: a systematic review and meta-analysis.

BACKGROUND: The treatment of periprosthetic femur fractures around a total knee replacement remains a technical challenge for the orthopedic surgeon. Management options include non-operative treatment, plate fixation, intramedullary nailing and distal femur replacement (DFR), with few studies comparing fixation with DFR. This is an up-to-date meta-analysis in the literature to directly compare clinical outcomes between fixation and distal femoral replacement in the treatment of supracondylar periprosthetic femur fractures. METHODS: A stratified literature search of the Medline, EMBASE and Cochrane databases was performed. All studies in English language were searched from inception to July 2022. The search was performed with the following MeSH terms: Periprosthetic fracture AND ORIF OR Internal Fixation AND Distal Femur Replacement. The search was conducted using a predesigned search strategy where all eligible literature was critically appraised for methodological quality using the Cochrane collaboration tool. We included Level I, II and III studies comparing fixation with DFR in the treatment of periprosthetic supracondylar femur fractures. Data from eligible studies were extracted by two authors (NP and AR) and a table created which included author, year, sample size, mean age, measured parameters, follow-up period, fracture classification, length of stay (days), mortality rate, revision rate and complication rate. RESULTS: The extracted data were pooled for meta-analysis using RevMan® v5.3.5 software (Nordic Cochrane Centre, Copenhagen, Denmark) and forest plots constructed. A p value < 0.05 was considered statistically significant and confidence intervals (CI) set to 95%. A total of six studies were included in the meta-analysis (n = 406). 153 patients underwent distal femur replacement and 253 patients underwent fixation with a mean follow-up time of 71.4 months. The results of this analysis suggest no statistically significant difference in measured outcomes. CONCLUSION: The results of this meta-analysis suggest no proven statistically significant difference between DFR and fixation in terms of length of hospital stay, mortality rate, revision rate and complication rate for the treatment of periprosthetic supracondylar femur fractures. Further prospective randomized research may help to define the specific indications for each treatment option which must include fracture configuration. Early functional outcome and cost-effectiveness have yet to be evaluated in the available literature.

Remnant preservation does not affect accuracy of tibial tunnel positioning in single-bundle ACL reconstruction.

PURPOSE: Remnant preservation, in anterior cruciate ligament (ACL) reconstruction, has potential biological advantages. However, graft positioning remains vital to functional outcome and the prevention of failure. The aim of this study was to investigate the accuracy and precision of tibial tunnel positioning in remnant preservation single-bundle hamstring reconstruction. METHODS: Fifty consecutive adult patients, with isolated ACL rupture, were recruited to a prospective study. Remnant preservation was performed in all cases where > 25% of the native ACL was present. Three-dimensional computer tomography was preformed 3-6 months post-operatively to assess tibial tunnel position (using a grid-based measurement). Accuracy and precision of this technique were assessed against published anatomical data in direct comparison with the group where remnant preservation could not be performed. RESULTS: Two patients withdrew following surgery. In the remaining groups (31 remnant preservation; 17 non-remnant preservation), no difference was demonstrated in tunnel position (40.4 ± 6.7% (anterior-to-posterior) and 47.4 ± 1.5% (medial-to-lateral) vs. 38.8 ± 4.9% and 46.7 ± 1.5%, respectively; n.s.), accuracy (6.1% vs. 4.8%; n.s.) or precision (3.9% vs. 2.8%; n.s.). CONCLUSIONS: Remnant preservation can be safely performed without compromising tunnel position. Therefore, the potential benefits of this technique can be utilised, in clinical practice, without sacrificing the ability to optimize tibial tunnel positioning. LEVEL OF EVIDENCE: III.

A comparison of femoral tunnel placement in ACL reconstruction using a 70° arthroscope through the anterolateral portal versus a 30° arthroscope through the anteromedial portal: a pilot 3D-CT study.

BACKGROUND: Graft malposition is a risk factor for failure of anterior cruciate ligament reconstruction. A 70° arthroscope improves visualisation of the medial wall of the lateral femoral condyle without switching portals. We investigated whether the use of this arthroscope affected the accuracy and precision of femoral tunnel placement. METHODS: Fifty consecutive adult patients were recruited. Following one withdrawal and two exclusions, 47 patients (30 in group 1 (70° arthroscope), 17 in group 2 (30° arthroscope)) underwent three-dimensional computed tomography imaging using a grid-based system to measure tunnel position. RESULTS: No difference was found in the accuracy or precision of tunnels (mean position: group 1 = 33.3 ± 6.0% deep-shallow, 27.2 ± 5.2% high-low; group 2 = 31.7 ± 6.9% deep-shallow, 29.0 ± 6.2% high-low; not significant). A post-hoc power analysis suggests a study of 106 patients would be required. CONCLUSIONS: This pilot study suggests that tunnel position is not affected by the arthroscope used. An appropriately powered study could investigate this finding alongside other potential benefits of using a 70° arthroscope for this procedure. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02816606. Registered on 28 June 2016.

Bone Marrow Oedema in the Knees of Asymptomatic High-Level Athletes: Prevalence and Associated Factors.

BACKGROUND: Bone marrow oedema (BMO), seen on magnetic resonance imaging, can be associated with various injuries to the knee but may also occur in asymptomatic athletes. The prevalence and causal factors for these observations are not well understood. The aim of this study was to determine the prevalence of BMO in asymptomatic knees of athletes, competing at a high level, and to investigate the associated factors. MATERIALS AND METHODS: Twenty-five asymptomatic university athletes, competing at regional to international level, were recruited. Bilateral knee magnetic resonance imaging was performed in each athlete (total 50 knee scans) at the end of their competitive season. Imaging studies were reported independently by two experienced consultant musculoskeletal radiologists. RESULTS: There was almost perfect agreement between reporters for diagnosis of BMO (κ = 0.896). Seven participants (28%) were found to have BMO (six in one knee and one bilaterally). The amount of time spent training, during the season, was significantly associated with the appearance of BMO (p < 0.05). CONCLUSION: The occurrence of BMO in asymptomatic knees of athletes is common (occurring in over one-quarter of knees) and may be associated with training intensity. This should be considered when treating athletes and deciding upon appropriate treatment plans.

The use of GPS and inertial devices for player monitoring in team sports: A review of current and future applications.

Player-worn devices, combining global positioning system and inertial monitors, are being used increasingly by professional sports teams. Recent interest focusses on using the data generated to track trainingload and whether this may lead to more effective training prescription with better management of injury risk. The aim of this review is to summarize the development and current use of this technology alongside proposed future applications. PubMed and Medline searches (2000-2017) identified all relevant studies involving use in team sports or comparative studies with other accepted methods. Our review determined that the latest devices are valid and reliably track activity levels. This technology is both accurate and more efficient than previous methods. Furthermore, recent research has shown that measurable changes in trainingload (the acute-to-chronic load ratio) are related to injury risk. However, results remain very sport specific and generalization must be done with caution. Future uses may include injury-prevention strategies and return-to-play judgement.

Flexible reamers create comparable anterior cruciate ligament reconstruction femoral tunnels without the hyperflexion required with rigid reamers: 3D-CT analysis of tunnel morphology in a randomised clinical trial.

PURPOSE: The hyperflexion required for femoral tunnel drilling in anterior cruciate ligament reconstruction can be challenging in patients with increased body habitus or musculature. Whilst allowing femoral tunnel creation without hyperflexion, additional benefits of flexible reamers have been proposed in terms of tunnel dimensions. The purpose of this study was to examine whether these theoretical benefits are seen in a clinical study. METHODS: Fifty adult patients (with isolated anterior cruciate ligament rupture) were randomised to reconstruction with either flexible or rigid femoral reamers. Femoral tunnel drilling was performed at 100° flexion (flexible system) or maximal hyperflexion (rigid system). Otherwise, the procedure was standardised. Femoral tunnel measurements were performed by a consultant musculoskeletal radiologist who was blinded to the method of femoral drilling. Tunnel position, length and angles (axial and coronal) were measured alongside aperture shape and exit point using three-dimensional computed tomography 3-6 months post-operatively. RESULTS: With no difference in tunnel position, tunnel length was found to increase with the use of the flexible system (37.8 ± 3.7 vs 35.0 ± 4.4 mm; p = 0.024). In addition, the exit point and fixation device were more anterior on the lateral femur using the flexible reamers (p = 0.016). No difference was seen in either tunnel angles or aperture shape. One case of incomplete posterior blow-out was seen in each of the study groups. CONCLUSIONS: This comparative study shows that flexible reamers can reproduce a desired femoral tunnel position with only small improvements of no clinical relevance. As this can be achieved without hyperflexing the knee, these systems can be used for all patients (even when hyperflexion is a challenge). LEVEL OF EVIDENCE: I.

Failure to Return to Preinjury Activity Level after Hamstring Anterior Cruciate Ligament Reconstruction: Factors Involved and Considerations in Goal Setting.

BACKGROUND: Recent interest in the return to sports, following anterior cruciate ligament reconstruction, has focused on the influence of psychological factors. However, many factors contribute to this endpoint. This study aimed to investigate the ability of nonprofessional athletes to return alongside the reasons for failure. MATERIALS AND METHODS: We retrospectively studied 101 postreconstruction patients with followup in excess of 12 months. All patients underwent hamstring autograft anterior cruciate reconstruction. The Cincinnati Sports Activity Scale was used to define activity level preinjury, postinjury, and postreconstruction. Structured questionnaires were used to identify factors in those who did not return to the same level. RESULTS: Seventy percent of patients returned to their preinjury activity score. Of the 30% of patients who failed, age, reconstruction type, and associated pathology were unrelated. However, reconstruction within 6 months of injury resulted in increased return to preinjury score (P < 0.05). Failure was associated with continued knee symptoms (57%), lifestyle changes (27%), anxiety (27%), fear (23%), and other musculoskeletal problems (10%). Considerable interplay was found between these factors. Failure to return was associated with increased further surgery, but this was successful in only one-third of patients. CONCLUSION: Psychological factors are important (and may require targeted input), but return-to-sport is multifactorial. Ongoing symptoms may prompt further surgery, but this is frequently unsuccessful in achieving return. Patient-specific goals should be sought and revisited throughout the rehabilitation program. Acknowledging psychological barriers, in those aiming to return to the same level, may help achieve this goal. In other patients, success may be return to a desired lower level. Understanding the patient's expectations is important in goal setting.

Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns.

PURPOSE: The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears, on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on preoperative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may aid detection. METHODS: Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of 188 multi-ligament injuries [median age 31 years (range 16-64)] was retrospectively reviewed by three musculoskeletal radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures. Assessment of injury pattern was solely made on this imaging. RESULTS: 38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%). The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury patterns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05). Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05). CONCLUSIONS: Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears and associated patterns of injury. LEVEL OF EVIDENCE: IV.

Complex Regional Pain Syndrome after Total Knee Arthroplasty is Rare and Misdiagnosis Potentially Hazardous-Prospective Study of the New Diagnostic Criteria in 100 Patients with No Cases Identified.

Previous studies suggest that complex regional pain syndrome (CRPS) occurs in up to 21% of patients following total knee arthroplasty (TKA). However, this diagnosis has a substantial impact on the patient's management if it is incorrect. We aimed to identify cases, using updated internationally accepted criteria, while investigating potential causes of misdiagnosis.We prospectively studied a consecutive series of 100 primary TKA patients. Each patient was assessed 6-week post-TKA. Pain levels were recorded with the presence of symptoms and signs of CRPS (Budapest Diagnostic Criteria) assessed in those with excessive pain. An alternative diagnosis was sought, in these patients, including the presence of neuropathic pain.We found no cases of CRPS (no patients had symptoms or signs in greater than two of four subgroups). Seventeen patients had excessive pain levels (nine had an alternative diagnosis explaining this). The commonest signs were sensory and sudomotor, whereas motor/trophic changes were not seen. Using a previous definition (Orlando Criteria), eight patients may have been diagnosed with CRPS. Over half of the patients with unexplained excessive pain had evidence of neuropathic pain.CRPS is a rare diagnosis following TKA using modern criteria. Isolated signs and symptoms may lead to the overdiagnosis of CRPS in the presence of unexplained pain following TKA. New diagnostic criteria, with strict definitions and treatment algorithms, are now accepted. Delays in managing more common causes (such as neuropathic pain) may negatively affect the patient's outcome.

Plain radiographs can be used for routine assessment of ACL reconstruction tunnel position with three-dimensional imaging reserved for research and revision surgery.

PURPOSE: The position of the osseous tunnels and graft during anterior cruciate ligament (ACL) reconstruction has been the subject of multiple studies aiming for either anatomical placement or an alternative. The assessment of these positions, using post-operative imaging, is therefore of interest to the surgeon in both the evaluation of surgical performance and surveillance of potential complications. The purpose of this review is to identify the optimal use of imaging in both the surveillance of clinical practice and in planning revision surgery. METHODS: A comprehensive systematic review was performed using Medline and Pubmed searches to identify radiological methods used to assess ACL reconstruction tunnel position. Commonly used methods were identified with correlation to either native anatomy or clinical results. RESULTS: The findings suggest that plain radiographs can be used to assess tunnel position and identify grafts that are positioned non-anatomically and may be at increased risk of complications. Computer tomography (CT) offers additional information about the tunnel aperture shape and size that is of importance for revision surgery and research projects whilst magnetic resonance imaging (MRI) provides further assessment of both graft integrity and associated soft tissue damage. CONCLUSION: In the surveillance of routine clinical practice, plain radiographs are sufficient to define tunnel position. The additional information provided by three-dimensional imaging is only required in revision surgery or research studies. LEVEL OF EVIDENCE: IV.

Anterior Cruciate Ligament Mechanoreceptors and their Potential Importance in Remnant-Preserving Reconstruction: A Review of Basic Science and Clinical Findings.

Mechanoreceptors, within the anterior cruciate ligament (ACL), are believed to have importance in proprioception, contributing to dynamic knee stability. The potential for reinnervation of the ACL graft is one of the proposed advantages of remnant-preserving reconstruction. The aim of this review is to summarize advances in the basic science underpinning this function, alongside recent clinical studies, to define the current role for remnant-preservation.A comprehensive systematic review was performed using PubMed and Medline searches. Studies were analyzed with particular focus placed on the methodology used to either identify mechanoreceptors or test proprioception.Contemporary work, using immunohistological staining, has shown mechanoreceptors primarily within proximity to the bony attachments of the ACL (peripherally in the subsynovial layer). The number of these receptors has been shown to decrease rapidly, following rupture, with adhesion to the posterior cruciate ligament slowing this decline. Recent studies have shown proprioceptive deficits, in both the injured and contralateral knees, with the clinical relevance of findings limited by testing methodology and the small differences found. The advantages of remnant-preservation, seen primarily in animal studies, have not been shown in systematic reviews or meta-analysis of clinical studies.The potential for reinnervation of the graft is likely time-dependent and reliant on continued loading of the remnant. Therefore, current clinical use and future research should focus on preserving remnants within 6 months of injury that remain loaded by adherence to the posterior cruciate ligament. Subsequent testing should account for central neurological changes and focus on clinically relevant outcomes.

The magnetic resonance imaging appearance of the anterolateral ligament of the knee in association with anterior cruciate rupture.

OBJECTIVE: The magnetic resonance imaging (MRI) appearance of the anterolateral ligament (ALL) has been described. However, the appearance of this structure and injury, in the presence of anterior cruciate ligament (ACL) injury, is less well defined. We studied the incidence of injury to the ALL and the pattern of this injury on MRI. MATERIALS AND METHODS: Following Institutional Review Board approval, a retrospective study of 375 consecutive MRI studies was performed. Cases were identified from a prospective database of ACL reconstruction patients. Following exclusions, 280 MRIs (277 patients; 197 males: 80 females; mean age 30.2 years, range, 16-54) were evaluated. Injury was defined as full thickness, partial thickness, or an avulsion fracture. Each study was independently assessed by two consultant musculoskeletal radiologists. RESULTS: Injury to the ALL was identified (by at least one observer) in only 10.7% of cases (2.50% full thickness, 7.50% partial thickness, and 0.71% avulsion fracture). There was an almost perfect level of interobserver agreement for both the identification of an injury (κ = 0.854) and grading of injury (κ = 0.858). The MRI incidence of ALL injury was significantly greater within 6 weeks of the knee injury (18.5 vs. 8.37%; p < 0.05). CONCLUSIONS: ALL injury was identified in only one-tenth of cases of ACL rupture. MRI changes can be reliably identified with strong agreement between observers. ALL injury is found more frequently on MRI within 6 weeks of the knee injury (compared to scans performed after this time period) suggesting that some injuries may resolve or become less visible.

Systematic Arthroscopic Treatment of Diffuse Pigmented Villonodular Synovitis in the Knee.

Pigmented villonodular synovitis (PVNS) is a benign aggressive disease that presents in either a localized (LPVNS) or diffuse (DPVNS) form. Arthroscopic synovectomy is the standard operative treatment for LPVNS, and when used to treat DPVNS, it is usually combined with an open posterior procedure. The purpose of this Technical Note is to report the technique that we have refined to allow for arthroscopic synovectomy as the sole treatment for DPVNS. We describe our technique with the factors we have found to be important to ensure adequate arthroscopic synovectomy, while minimizing risks and complications. The combination of additional portals, the use of multiple different shavers and arthroscopes, and the use of a leg holder all maximize our ability to clear disease.

The anterolateral ligament of the knee: unwrapping the enigma. Anatomical study and comparison to previous reports.

BACKGROUND: It has been suggested that the anterolateral ligament (ALL) of the knee may have importance in limiting rotational instability, and reconstruction may prevent a continued pivot-shift following anterior cruciate ligament surgery. However, the anatomy of this ligament has not been consistently reported in recent publications. We describe our experience of cadaveric dissection with reference to other published work. MATERIALS AND METHODS: Eleven fresh-frozen cadaveric knees were dissected using a standard technique. The ALL tissue was identified with internal rotation of the tibia and varus stress. Measurements were made using a digital caliper and details of the origin and insertion were recorded. RESULTS: The ALL was identified in ten of the 11 cadavers. The only specimen in which it was not identified was found to also have an anterior cruciate ligament deficiency. The mean dimensions were: length 40.1 (± 5.53) mm, width 4.63 (± 1.39) mm, thickness 0.87 (± 0.18) mm. The femoral origin was posterior and proximal to the lateral collateral ligament attachment in six knees, anterior and distal in three knees, and at the same site in one knee. The tibial insertion was a mean 17.7 (± 2.95) mm from Gerdy's tubercle (GT) and 12.3 (± 3.55) mm from the fibula head (FH). This was 59.5 (± 5.44) % from GT to FH. CONCLUSIONS: This anatomical data adds to previous information about the ALL. Our results support the finding that the ALL is a capsular thickening with meniscal attachment. The findings will help to guide the further work required to define the indications for reconstruction and appropriate grafts.

Revisiting the Anterolateral Ligament of the Knee.

Recent research has suggested that the anterolateral ligament (ALL) of the knee may have an important role in preventing persistent rotatory instability following anterior cruciate ligament (ACL) reconstruction.For this review, we performed a thorough literature search and identified the significant steps in the improvement of our understanding. This has progressed from historical reports to accurate characterization of the attachments and dimensions of the ALL through anatomical and histological studies. Alongside this, biomechanical data have demonstrated the role of this structure throughout the range of movement of the knee. Furthermore, the appearance of the ALL on magnetic resonance imaging has been comprehensibly described and radiological markers have been defined as a basis for suggested reconstructive procedures using fluoroscopy.We present a comprehensive review of the evolution of our understanding about this structure. Key advances in our understanding of the dimensions and attachments will guide research into reconstructive options. Further work is needed to determine the biomechanical and clinical outcome of extra-articular reconstruction of the ALL alongside ACL reconstruction.

Characterization of the anatomy of the anterolateral ligament of the knee using magnetic resonance imaging.

OBJECTIVE: The anterolateral ligament (ALL) may limit tibial internal rotation and pivot-shift following anterior cruciate ligament reconstruction. Previous studies, using magnetic resonance imaging (MRI) to identify this structure, have been inconsistent. We aimed to further characterize the anatomy of this ligament with reference to previous work. MATERIALS AND METHODS: Institutional Review Board approval was gained and a retrospective study of 154 consecutive 1.5-T MRI studies was performed by a consultant musculoskeletal radiologist. Cases with a lateral compartment or cruciate injury and patients under 16 years were excluded. A total of 100 MRIs (98 patients; 63 males: 35 females; mean age, 45.3 years, range, 16-85 years) were included in the study. RESULTS: The ALL was visualized partially in 94 (94.0%) of the cases and fully with distinct femoral and tibial fibers in 57 (57.0%) of the cases. Although the femoral origin was discreet in only 57 (57.0%) of cases, the tibial insertion (7.64 ± 1.26 mm below the joint-line) and meniscal attachment were demonstrated in all cases where the ligament was seen. Where the femoral origin was not seen, a broad expansion of the ligament was noted. We identified four types of meniscal attachment (complete, central, bipolar, and inferior-only). The thickness of the ALL, at the level of the joint-line, was 1.75 ± 0.57 mm. CONCLUSIONS: The ALL is a consistent structure with meniscal and tibial portions identifiable in the majority of MRI studies of the uninjured knee. There is an attachment to the lateral meniscus with anatomical variation described by our subclassification.

National Joint Registry data inaccuracy: a threat to proper reporting.

INTRODUCTION: The authors set out to investigate the accuracy of the information their unit was inputting onto the National Joint Registry. This is important both in relation to implant surveillance and also to the use of these data to monitor the performance of surgeons. METHOD: A single consultant's arthroplasty patients were audited over 12 months. Data taken from the National Joint Registry were compared to the operation notes and the hospital's computer system. RESULTS: Of 78 cases inputted, 27 (35%) were incorrect. Sixteen cases (21%) had the incorrect 'consultant in charge' recorded, eight cases (10%) had the incorrect 'operating surgeon' recorded and three cases (4%) had both errors. The most frequent inaccuracies resulted from listing by another consultant and incorrectly recorded trainee supervision. These errors were highlighted to the unit and a corrected process was designed. The intervention was to implement this process by presenting to the involved groups and displaying posters to prevent the error-producing process. The audit was repeated (after 6 months) showing eradication of the problem. DISCUSSION: It is the surgeon's duty to ensure data recorded under his/her name are accurate and justify any discrepancies when compared to other surgeons. Pooling of patients and supervision of trainees are sources of potential error.

Fractured neck of femur patient care improved by simulated fast-track system.

BACKGROUND: Fractured neck of femur patients represent a large demand on trauma services, and timely management results in improvements in morbidity and mortality. NICE guidance, advocating surgery on the day of admission or the following day, emphasises this. We set out to investigate whether a simulated fast-track management system could improve neck of femur fracture patient care. MATERIALS AND METHODS: This prospective study was performed in a district general hospital in South West England, following a change in practise. We studied 429 patients over a 1-year period. Patients were phoned through, by the ambulance crew, to a trauma coordinator who arranged prompt radiological assessment and review. Patients with confirmed fractures were transferred to an optimisation area for orthopaedic and anaesthetic assessment prior to surgery the same day or early the following day. Our primary outcome measures were time to theatre (h) and length of hospital stay (days/h). RESULTS: Time to theatre reduced from 44.95 (±27.42) to 29.28 (±21.23) h. Length of stay reduced from 10 days (245.92 (±131.02) h) to 9 days (225.30 (±128.75) h). Both of these improvements were statistically significant (P < 0.05). Despite operating on virtually all patients, no increase in adverse events was seen, there was no increase in 30-day mortality and there were no perioperative deaths. CONCLUSIONS: This coordinated management pathway improves the efficiency of the service and reduces inpatient length of stay. Increased productivity may lead to financial savings and improve our ability to meet guidelines.

Inter- and intra-observer reliability of a smartphone application for measuring hallux valgus angles.

BACKGROUND: Measurement of radiological angles can be useful in the planning of the management of patients with hallux valgus. A smartphone application offers an alternative way of measuring these angles in a clinic setting. We compared the reliability (inter- and intra-observer) of this method to the use of PACS. METHODS: Radiographs of 30 feet from new patients referred with hallux valgus were examined and angles (HVA, IMA, and DMAA) recorded using the smartphone application and PACS. RESULTS: The smartphone application provided good inter-observer reliability for HVA and IMA (r=0.93 and r=0.79 respectively). Intra-observer reliability for HVA and IMA was also found to be good (r=0.93-0.97 r=0.82-0.93 respectively). The inter- and intra-observer reliability for using this method to measure DMAA fell below useful levels (r<0.60 in each case). CONCLUSIONS: This smartphone application provides a reliable method to measure HVA and IMA but we would not recommend it to measure DMAA.