Numerous prediction tools are available for estimating postoperative risk following spine surgery. External validation studies have shown mixed results. We present the development, validation, and comparative evaluation of novel tool (NZSpine) for modelling risk of complications within 30 days of spine surgery.

Data was gathered retrospectively from medical records of patients who underwent spine surgery at Waikato Hospital between January 2019 and December 2020 (n = 488). Variables were selected a priori based on previous evidence and clinical judgement. Postoperative adverse events were classified objectively using the Comprehensive Complication Index. Models were constructed for the occurrence of any complication and significant complications (based on CCI >26). Performance and clinical utility of the novel model was compared against SpineSage (https://depts.washington.edu/spinersk/), an extant online tool which we have shown in unpublished work to be valid in our local population.

Overall complication rate was 34%. In the multivariate model, higher age, increased surgical invasiveness and the presence of preoperative anemia were most strongly predictive of any postoperative complication (OR = 1.03, 1.09, 2.1 respectively, p <0.001), whereas the occurrence of a major postoperative complication (CCI >26) was most strongly associated with the presence of respiratory disease (OR = 2.82, p <0.001).

Internal validation using the bootstrapped models showed the model was robust, with an AUC of 0.73. Using sensitivity analysis, 80% of the model's predictions were correct. By comparison SpineSage had an AUC of 0.71, and in decision curve analysis the novel model showed greater expected benefit at all thresholds of risk.

NZSpine is a novel risk assessment tool for patients undergoing acute and elective spine surgery and may help inform clinicians and patients of their prognosis. Use of an objective tool may help to provide uniformity between DHBs when completing the “clinician assessment of risk” section of the national prioritization tool.

Aims. Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods. This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results. A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion. Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. Cite this article: Bone Jt Open 2023;4(6):447–456

Aims. The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. Methods. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial. Results. Eight retrospective studies involving 29,738 patients with IBD were included. Compared with non-IBD controls, patients with IBD were significantly more likely to have overall complications (OR 2.11 (95% CI 1.67 to 2.66), p < 0.001), medical complications (OR 2.15 (95% CI 1.73 to 2.68), p < 0.001), surgical complications (OR 1.43 (95% CI 1.21 to 1.70), p < 0.001), and 90-day readmissions (OR 1.42 (95% CI 1.23 to 1.65), p < 0.001). The presence of IBD was positively associated with the development of venous thromboembolism (OR 1.60 (95% CI 1.30 to 1.97), p < 0.001) and postoperative infection (OR 1.95 (95% CI 1.51 to 2.51), p < 0.001). In addition, patients with IBD tended to experience longer LOS and higher costs of care. Conclusion. The findings suggest that IBD is associated with an increased risk of postoperative complications and readmission after joint arthroplasty, resulting in longer hospital stay and greater financial burden. Surgeons should inform their patients of the possibility of adverse outcomes prior to surgery and make appropriate risk adjustments to minimize potential complications. Cite this article: Bone Joint Res 2023;12(6):362–371

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article: Bone Joint J 2023;105-B(5):471–473

Aims. Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data. Methods. We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS. Results. In the derivation cohort, five of the 27 variables were strongly predictive of the CFS (regression coefficient B = 6.383 (95% confidence interval 5.03 to 7.74), p < 0.001): age, Abbreviated Mental Test score, admission haemoglobin concentration (g/l), pre-admission mobility (needs assistance or not), and mechanism of injury (falls from standing height). In the validation cohort, there was strong agreement between the NTFI and the CFS (mean difference 0.02) with no apparent systematic bias. Conclusion. We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects. Cite this article: Bone Joint J 2024;106-B(4):412–418

Aims. The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. Methods. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. Results. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Conclusion. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus. Cite this article: Bone Jt Open 2024;5(9):785–792

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807

Introduction. The association between preoperative opioid use and adverse outcomes after total hip arthroplasty (THA) has been reported. However, a quantitative assessment used to evaluate the combined effect of controlled substance use and define a threshold for adverse outcomes after THA has not been established. The current study aimed to identify the association between the NarxCare Score (NCS) (indicative of controlled substance use) and length of stay (LOS), discharge disposition, 90-day emergency department (ED) visits, readmission, and reoperation after primary THA, necessary to identify a preoperative NCS threshold for adverse outcomes. Methods. A total of 2,787 THAs (57.3% female; mean age: 64.3±11.14 years; NCS range: 0–800) were performed between November 2018-January 2020 at an integrated healthcare system with preoperative NCSs. Outcomes assessed included LOS, discharge disposition, 90-day ED visits, readmission (all-cause, procedure and non-procedure-related) and reoperation. The association between NCS category (in 100-point increments) and was analyzed through multivariate logistic regression accounting for risk factors. Results. NCS of zero, 1–99 and 100–199 were similar regarding all investigated outcomes (p>0.05 for all). Compared to a NCS of zero, NCS of 300–399 was independently associated with higher odds of a LOS >2 days (odds ratio [OR]:2.27; 95% confidence interval [CI][1.59–3.24]; p<0.001), non-home discharge (OR: 2.0; 95% CI [1.34–2.99]; p=0.001), 90-day all-cause readmission (OR: 2.0; 95% CI [1.16–3.36]; p=0.012). Furthermore, NCS of 300–399 exhibited higher odds of a procedure-related readmission (OR: 3.74; 95% CI [1.48–8.13]; p=0.004). There were no differences between the NCS strata in 90-day reoperation and non-procedure related readmission rates (p>0.05 for each). Conclusion. Higher NCS was associated with greater LOS and 90-day readmission, as well as lower odds of discharge to home. A NCS threshold of 300 can potentially designate high-risk patients for adverse outcomes after THA. This score may help stratify patients in the current alternative payment environment

Introduction. Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach. Materials & Methods. We compared clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, fracture classification, post-treatment alignment and presence of an open fracture. Results. The mean time in frame was 168 days for the 2-ring group and 200 days for the 3+ rings group (p=0.003). No significant difference was found in the rate of malunion (p=0.428) or the requirement for secondary surgical intervention to achieve union (p=0.363). No significant difference in time in frame was found between individual surgeons. Conclusions. This study finds that 2-ring frame constructs are a reliable option associated with significantly shorter duration of treatment and no increase in rates of adverse outcomes compared with larger, more complex frame configurations. Although this study cannot identify the underlying cause of the difference in treatment time between frame designs, it is possible that differences in mechanical stability lead to a more favourable strain environment for fracture healing in the 2-ring group

Abstract. High tibial osteotomy (HTO) is a well-recognised procedure to address medial compartment osteoarthritis (OA). There remains dispute on the impact of pre-operative patient factors on patient related outcome measures (PROMS). Does BMI and age affect > 2 year and > 5 year oxford knee scores (OKS) and Knee injury and osteoarthritis outcome scores (KOOS). A retrospective review of a prospectively collected database was performed. Timeframe was 26/6/2014 and 25/8/2022. BMI and age were recorded. OKS and KOOS were collected at > 2 years and > 5 years. There were 81 procedures included, of these 50 had OKS and KOOS scores at > 2 years and 35 at > 5 years. Median BMI was 28.5kg/m. 2. , range was 18.6–40.8kg/m. 2. Spearman's rank for >2 year OKS was p(df)=−0.210 p=0.157, > 5 year OKS p(df)=−0.215 p=0.230. For > 2 year and > 5 year KOOS subscales there were no statistically significant associations on Spearman's rank. For age, median age was 52.5, range 26–71 years old. OKS at >2 year p(df)=0.068 p=0.664, OKS >5 years p(df)=0.065 p= 0.709. For >2 year and > 5 year KOOS subscales there were no statistically significant associations on Spearman's rank. There were no adverse outcome in patients up-to the age of 71. There were no statistically significant Spearman's rank correlations between PROMS and OKS/KOOS scores. This supports recent KOG consensus statement highlighting physiological age importance vs chronological age. Of note there were more negative associations in the BMI group compared with age

The Cierny and Mader classification assists with decision-making in the management of osteomyelitis by strafying the host status and the pathoanatomy of disease. However the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08– 8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistical significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months)). This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time

Ceramic bearing fractures are rare events, but mandate revision and implantation of new bearings. Revisions using metal heads have been reported to lead to gross volumetric head wear (due to abrasive retained ceramic micro-debris), cobalt toxicity, multi-organ failure and death. Such complications are widely published (50+ reports), yet we know that patients continue to be put at risk. Using data from the NJR and AOANJRR, this study seeks to compare the risk of re-revision and death by revision bearing combination following a ceramic bearing fracture. Data were extracted from the NJR and AOANJRR, identifying revisions for ceramic bearing fracture. Subsequent outcomes of survival, re-revision and death were compared between revision bearing combinations (ceramic-on-ceramic, ceramic-on-polyethylene, and metal-on-polyethylene). 366 cases were available for analysis from the NJR dataset (MoP=34, CoP=112, CoC=221) and 174 from the AOANJRR dataset (MoP=17, CoP=44, CoC=113). The overall incidence rate of adverse outcome (revision or death) was 0.65 for metal heads and 0.23 for ceramic head articulations (p=0.0012) across the whole time period (NJR). Kaplan-Meir survival estimates demonstrate an increased risk of both re-revision and death where a metal head has been used vs a ceramic head following revision for ceramic fracture. There are few decisions in arthroplasty surgery that can lead to serious harm or death for our patients, but revision using a metal head following ceramic bearing fracture is one of them. This study enhances the signal of what is already known but previously only reported as inherently low-level evidence (case reports and small series) due to event rarity. Use of a metal head in revision for ceramic fracture represents an avoidable patient safety issue, which revision guidelines should seek to address

Introduction. The Cierny and Mader classification assists with decision-making by stratifying host status and the pathoanatomy of the disease. However, the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. Materials & Methods. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Results. Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08–8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistically significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months)). Conclusions. This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty. The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort. 939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements

Aim. To report outcomes of soft tissue reconstruction using free tissue transfer for the treatment of tibial osteomyelitis as part of a single-stage, ortho-plastic procedure. Method. Patients who underwent ortho-plastic reconstructive surgery to excise tibial osteomyelitis in combination with free tissue transfer in one stage were included. Patients underwent surgery between 2015 and 2024 in a single specialist centre within the UK. Baseline patient information, demographics, and infection information was recorded. Adverse outcomes were defined as (i) flap salvage required, (ii) flap failure and (iii) recurrence of infection. Patient reported quality of life was measured using the EuroQol EQ-5D-5L index score. Pre-operative QoL was compared to QoL at 1 year with a control group of 53 similar patients who underwent surgical treatment for tibial osteomyelitis without a free flap (local flap or primary closure). Results. Ninety-three patients were eligible for inclusion, with a mean age of 52 years (range 18–90). 77/93 (82.8%) had a free muscle flap with the remainder (17.2%) receiving a fasciocutaneous flap. The donor tissue was defined as 57 gracilis, 6 latissimus dorsi, 14 hemi-latissimus dorsi, and 16 anterolateral thigh. The recipient area of the tibia was distal 1/3 in 52 cases, middle 1/3 in 27 cases and proximal 1/3 in 12 cases. The average flap ischaemic time was 70 minutes (range 28 to 125). Seven patients (7.5%) required urgent flap salvage at a median time of 1.0 day (range 0.5 – 4.0). Of these, 4 (4.3%) went on to have total flap failure, of which 2 patients underwent below knee amputation subsequently. Flap failure was due to either arterial (n=2) or venous (n=2) anastomotic thrombus. There were 3 (3.2%) episodes of confirmed infection recurrence within the first year after the index procedure. EQ-index scores at 1-year post-operatively were significantly improved when compared to pre-operative scores (p=0.008). At 1-year post-operatively, EQ-index scores in patients who underwent free flap was similar compared to local flaps (p=0.410) and in those who underwent primary closure for tibial osteomyelitis (p=0.070). Conclusions. Microsurgical single stage surgery can achieve high flap survival rate (95.7%). Free flaps fail early due to anastomotic thrombus with no late failures seen. Free tissue transfer does not appear to give inferior QoL compared to matched patients with local flaps or direct closure in tibial osteomyelitis

Abstract. Introduction. The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision and compare these with primary knee arthroplasty. Methodology. Primary and revision arthroplasty procedures were identified in the national Hospital Episode Statistics and were linked by patient and side. A logistic regression model was used to investigate factors associated with 90-day mortality (primary outcome) and secondary serious adverse outcomes. Urgent indications for revision arthroplasty were defined as infection or fracture; other indications (e.g. loosening, instability, wear) were included in the elective cohort. Results. 939,021 primary knee arthroplasty and 40,584 revision cases were included. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of PE, MI, and stroke were observed in the infection and fracture cohort. Conclusion. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency with an anticipation for increased care requirements

Aims. We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture. Methods. Of 1,577 consecutive patients aged > 65 years with a fragility hip fracture admitted to one institution, for whom there were complete data, 1,255 (72%) were studied. Clinicians assigned CFS scores on admission. Audit personnel routinely prospectively completed the Standardised Audit of Hip Fracture in Europe form, including the following outcomes: 30-day survival; in-hospital complications; length of acute hospital stay; and new institutionalization. The relationship between the CFS scores and outcomes was examined graphically and the visual interpretations were tested statistically. The predictive values of the CFS and Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality were compared using receiver operating characteristic area under the curve (AUC) analysis. Results. Significant non-linear associations between CFS and outcomes were observed. Risk of death within 30 days rose linearly for CFS 1 to 5, but plateaued for CFS > 5. The incidence of complications and length of stay rose linearly for CFS 1 to 4, but plateaued for CFS > 4. In contrast, the risk of new institutionalization rose linearly for CFS 1 to 8. The AUCs for 30-day mortality for the CFS and NHFS were very similar: CFS AUC 0.63 (95% CI 0.57 to 0.69) and NHFS AUC 0.63 (95% CI 0.57 to 0.69). Conclusion. Use of the CFS may provide useful information on outcomes for fitter patients presenting with hip fracture, but completion of the CFS by the admitting orthopaedic team does not appear successful in distinguishing between higher CFS categories, which define patients with frailty. This makes a strong case for the role of the orthogeriatrician in the early assessment of these patients. Further work is needed to understand why patients assessed as being of mild, moderate, and severe frailty do not result in different outcomes. Cite this article: Bone Joint J 2022;104-B(8):980–986

Background. There is minimal published data regarding the long-term functional outcome in pyogenic spinal infection. Previous studies have used heterogeneous, unreliable and non-validated measure instruments, or neurological outcome alone, yielding data that is difficult to interpret. We aim to assess long-term adverse outcome using standardised measures, Oswestry disability index (ODI) and MOS short form-36 (SF-36). Methods. All cases of pyogenic spinal infection presenting to a single institution managed operatively and non-operatively from 1994-2004 were retrospectively identified. Follow-up was by clinical review and standardised questionnaires. Inclusion in each case was on the basis of consistent clinical, imaging and microbiology criteria. Results. Twenty-nine cases of pyogenic spinal infection were identified. Twenty-eight percent were managed operatively and 72% with antibiotic therapy alone. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) having persistent neurological deficit. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and patients who recovered (p=0.003). SF-36 scores of all patients, regardless of management or outcome, failed to reach those of a normative population. A strong correlation was observed between ODI and SF-36 PF scores (rho=0.61, p<0.05). Seventeen percent (n=5) of admissions resulted in acute sepsis-related death. Subgroup analysis revealed delay in diagnosis of spinal infection (p=0.025) and neurological impairment at diagnosis (p<0.001) to be significant predictors of neurological deficit at follow-up. Previous spinal surgery was associated with adverse outcome in patients requiring readmission within 1 year of hospital discharge following first spinal infection (p=0.018). No independent predictors of adverse outcome, persistent neurological impairment, readmission within 1 year or acute death were identified by logistical regression analysis. Conclusions. High rates of adverse outcome detected using SF-36 and ODI suggest under-reporting of poor outcome when ASIA score alone is used to qualify outcome