Aims. The aim of this study was to investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies. We asked: is there a difference in APP-PT between young symptomatic patients being evaluated for joint preservation surgery and an asymptomatic control group? Does APP-PT vary among distinct acetabular and femoral pathomorphologies? And does APP-PT differ in symptomatic hips based on demographic factors?. Methods. This was an institutional review board-approved, single-centre, retrospective, case-control, comparative study, which included 388 symptomatic hips in 357 patients who presented to our tertiary centre for joint preservation between January 2011 and December 2015. Their mean age was 26 years (SD 2; 23 to 29) and 50% were female. They were allocated to 12 different morphological subgroups. The study group was compared with a control group of 20 asymptomatic hips in 20 patients. APP-PT was assessed in all patients based on supine anteroposterior pelvic radiographs using validated HipRecon software. Values in the two groups were compared using an independent-samples t-test. Multiple regression analysis was performed to examine the influences of diagnoses and demographic factors on APP-PT. The minimal clinically important difference (MCID) for APP-PT was defined as > 1 SD. Results. There were no significant differences in APP-PT between the control group and the overall group (1.1° (SD 3.0°; -4.9° to 5.9°) vs 1.8° (SD 3.4°; -6.9° to 13.2°); p = 0.323). Acetabular retroversion and overcoverage groups showed higher mean APP-PTs compared with the control group (p = 0.001 and p = 0.014) and were the only diagnoses with a significant influence on APP-PT in the stepwise multiple regression analysis. All differences were below the MCID. The age, sex, height, weight, and BMI showed no influence on APP-PT. Conclusion. APP-PT showed no radiologically significant variation across different pathomorphologies of the hip in patients being assessed for joint-preserving surgery. Cite this article: Bone Joint J 2024;106-B(5 Supple B):3–10

Aims. Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI. Methods. We reviewed 103 patients with DDH successfully treated by CR and spica casting in a single institution between January 2016 and December 2020. MRI was routinely performed immediately after CR and at the end of each cast. Using MRI, we described the labrum-acetabular cartilage complex (LACC) morphology, and measured the femoral head to triradiate cartilage distance (FTD) on the midcoronal section. A total of 13 hips with initial complete reduction (i.e. FTD < 1 mm) and ten hips with incomplete MRI follow-up were excluded. A total of 86 patients (92 hips) with a FTD > 1 mm were included in the analysis. Results. At the end of the first cast period, 73 hips (79.3%) had a FTD < 1 mm. Multiple regression analysis showed that FTD (p = 0.011) and immobilization duration (p = 0.028) were associated with complete reduction. At the end of the second cast period, all 92 hips achieved complete reduction. The LACC on initial MRI was inverted in 69 hips (75.0%), partly inverted in 16 hips (17.4%), and everted in seven hips (7.6%). The LACC became everted-congruent in 45 hips (48.9%) and 92 hips (100%) at the end of the first and second cast period, respectively. However, a residual inverted labrum was present in 50/85 hips (58.8%) with an initial inverted or partly inverted LACC. Conclusion. An eccentric reduction can become concentric after complete reduction and LACC remodelling following CR for DDH. Varying immobilization durations were required for achieving complete reduction. A residual inverted labrum was present in more than half of all hips after LACC remodelling. Cite this article: Bone Joint J 2023;105-B(2):140–147

Aims. The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA). Methods. Patients waiting for a THA (n = 100) or KA (n = 100) for more than six months were prospectively recruited from the study centre. Overall,162 patients responded to the questionnaire (81 THA; 81 KA). Patient demographics, Oxford score, EuroQol five-dimension (EQ-5D) score, EuroQol visual analogue score (EQ-VAS), Rockwood Clinical Frailty Score (CFS), and time spent on the waiting list were collected. Results. There was a significant correlation between CFS and the Oxford score (THA r = −0.838; p < 0.001, KA r = −0.867; p < 0.001), EQ-5D index (THA r = −0.663, p =< 0.001; KA r = −0.681; p =< 0.001), and EQ-VAS (THA r = −0.414; p < 0.001, KA r = −0.386; p < 0.001). Confounding variables (demographics and waiting time) where adjusted for using multiple regression analysis. For each 8.5 (THA, 95% CI 7.1 to 10.0; p < 0.001) and 9.9 (KA, 95% CI 8.4 to 11.4; p < 0.001) point change in the Oxford score, there was an associated change in level of the CFS. For each 0.16 (THA, 95% CI 0.10 to 0.22; p < 0.001) and 0.20 (KA, 95% CI 0.12 to 0.27; p < 0.001) utility change in EQ-5D, there was an associated change in level of the CFS. EQ-VAS (THA, B = −11.5; p < 0.001, KA B = −7.9; p = 0.005) was also associated with CFS. Conclusion. JSF and HRQoL in patients awaiting THA or KA for more than six months, were independently associated with level of clinical frailty. With further prospective studies, clinical frailty may prove to be a useful metric to assist in the prioritization of arthroplasty waiting lists. Cite this article: Bone Jt Open 2023;4(4):241–249

To investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies, we asked: (1) Is there a difference in APP-PT between symptomatic young patients eligible for joint preservation surgery and an asymptomatic control group? (2) Does APP-PT vary between distinct acetabular and femoral pathomorphologies? (3) Does APP-PT differ in symptomatic hips based on demographic factors?. IRB-approved, single-center, retrospective, case-control, comparative study in 388 symptomatic hips (357) patients (mean age 26 ± 2 years [range 23 to 29], 50% females) that presented to our tertiary center for joint preservation over a five year-period. Patients were allocated to 12 different morphologic subgroups. The overall study group was compared to a control group of 20 asymptomatic hips (20 patients). APP-PT was assessed in all patients based on AP pelvis X-rays using the validated HipRecon software. Values between overall and control group were compared using an independent samples t-test. Multiple regression analysis was performed to examine the influences of diagnoses and demographic factors on APP-PT. Minimal clinically important difference (MCID) of APP-PT was defined as >1 standard deviation. No significant differences in APP-PT between the control group and overall group (1.1 ± 3.0° [−4.9 to 5.9] vs 1.8 ± 3.4° [−6.9 to 13.2], p = 0.323) were observed. Acetabular retroversion and overcoverage groups showed higher APP-PT compared to the control group (both p < 0.05) and were the only diagnoses with significant influence on APP-PT in the stepwise multiple regression analysis. However, all observed differences were below the MCID. Demographic factors age, gender, height, weight and BMI showed no influence on APP-PT. APP-PT across different hip pathomorphologies showed no clinically significant variation. It does not appear to be a relevant contributing factor in the evaluation of young patients eligible for hip preservation surgery

Abstract. Background. Autologous chondrocyte implantation is a NICE approved intervention however it involves the morbidity of two operations, a prolonged rehabilitation and substantial healthcare costs. This study describes a novel, one-step, bone marrow (BM) derived mesenchymal stem cell (MSC) transplantation technique for treating knee osteochondral lesions and presents our prospective clinical study investigating the success of this technique in 206 lesions over a 5 year period. Methodology. The surgical technique involves harvesting BM from patients’ anterior superior iliac spines, centrifugation to isolate MSCs and seeding into a type 1 collagen scaffold (SyngenitTM Biomatrix). Autologous fibrin glue is used to secure the scaffold into the defect. Inclusion criteria included patients aged 15 – 55 years old with symptomatic osteochondral lesions >1cm2. Exclusion criteria included patients with ligament instability, uncorrected alignment, inflammatory arthropathy and a Body Mass Index >35 kg/m2. Outcome measures included the Modified Cincinnati Knee Rating System (MCKRS), complications and reoperations. Results. Mean MCKR scores showed statistically significant improvements compared to pre-operative scores at 6 months 58.79 ± 3.5 and 1 year postoperatively 63.82 ± 3.93 with further improvements at 2 years and 5 years which did not reach statistical significance. Survival rates were 97.9%, 94% and 93.2% at 1, 2 and 5 years. Multiple regression analysis identified previous cartilage surgery, microfracture and age as factors affecting MCKRS scores (p < 0.029, 0.001 and 0.030, respectively). Conclusions. One-step BM derived stem cell transplantation demonstrates satisfactory outcomes over a 5 year period

The musculoskeletal (MSK) profiles of water polo players and other overhead athletes has been shown to relate to injury and throwing performance (TP). There have been no robust studies conducted on the MSK profiles and the variables affecting TP amongst female, adolescent, elite water polo players. A prospective quantitative cohort design was conducted amongst eighty-three female adolescent, elite water polo players (range 14–19 years). All participants filled out the Kerlan-Jobe Orthopaedic Clinic questionnaire, followed by a battery of screening tests aimed to identify possible MSK factors affecting TP. Pain provocation tests, range of motion (ROM), upward scapula rotation (USR), strength and pectoralis minor length measurements were all included. Participants also performed throwing speed (TS) and throwing accuracy (TA) tests. All the data collected were grouped together and analysed using SPSS 28.0. The condition for statistical significance was set as p <0.05. Multi-collinearity was tested for among variables to find out inter-variable correlations. Finally, a multiple regression analysis was performed. The mean KJOC score was 82.55 ± 14.96. 26.5% tested positive for at least one of the impingement tests. The MSK profile revealed decreased internal rotation ROM, increased external rotation ROM, a downwardly rotated scapula, weak external rotators, weak serratus anterior strength, strong lower trapezius and gluteus medius strength and a shorter pectoralis minor length all on the dominant side. Age, pectoralis minor length, upper trapezius and serratus anterior strength as well as upward scapula rotation were all positively correlated with TS, while sitting height, upper trapezius and serratus anterior strength and glenohumeral internal rotation ROM were positively correlated with TA. Multiple MSK parameters were found to be related to TS and TA in elite, adolescent water polo players

The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA). Patients waiting for a THA (n=100) or KA (n=100) for more than six months were prospectively recruited from the study centre. Overall, 162 patients responded to the questionnaire (81 THA; 81 KA). Patient demographics, Oxford score, EuroQol five dimension (EQ-5D) score, EuroQol visual analogue score (EQ-VAS), Rockwood Clinical Frailty Score (CFS), and time spent on the waiting list were collected. There was a significant correlation between CFS and the Oxford score (THA r=ˆ’0.838; p<0.001, KA r=ˆ’0.867; p<0.001), EQ-5D index (THA r=ˆ’0.663, p<0.001; KA r=ˆ’0.681; p< 0.001), and EQ-VAS (THA r=ˆ’0.414; p<0.001, KA r=ˆ’0.386; p<0.001). Confounding variables (demographics and waiting time) where adjusted for using multiple regression analysis. For each 8.5 (THA, 95% CI 7.1 to 10.0; p<0.001) and 9.9 (KA, 95% CI 8.4 to 11.4; p<0.001) point change in the Oxford score, there was an associated change in level of the CFS. For each 0.16 (THA, 95% CI 0.10 to 0.22; p<0.001) and 0.20 (KA, 95% CI 0.12 to 0.27; p<0.001) utility change in EQ-5D, there was an associated change in level of the CFS. EQ-VAS (THA, B=ˆ’11.5; p<0.001, KA B=ˆ’7.9; p=0.005) was also associated with CFS. JSF and HRQoL in patients awaiting THA or KA for more than six months, were independently associated with level of clinical frailty. With further prospective studies, clinical frailty may prove to be a useful metric to assist in the prioritization of arthroplasty waiting lists

The aim of this study was to determine the long term 20 year survival and outcomes of high tibial osteotomy (HTO). 100 consecutive subjects underwent HTO under the care of a single surgeon between 2000 and 2002, consented to participation in a prospective study and completed preoperative WOMAC scores. Subjects were reviewed at 10 years, and again at a minimum of 20 years after surgery. PROMS included further surgery, WOMAC scores, Oxford Knee Score (OHS), KOOS, and EQ-5D, and satisfaction with surgery. 20 year survival was assessed with Kaplan-Meir analysis, and failure defined as proceeding to subsequent knee arthroplasty. The mean age at HTO was 50 years (range 26-66), and 72% were males. The 5, 10, and 20 year survival of the HTO was 88%, 76%, 43% respectively. On multiple regression analysis HTO failure was associated with poor preoperative WOMAC score of 45 or less (HR 3.2, 95% CI 1.7-6.0, p=0.001), age at surgery of 55 or more (HR 2.3, 95% CI 1.3-4.0, p=0.004), and obesity (HR 1.9, 95% CI 1.1-3.4, p=0.023). In patients who met all criteria of preoperative WOMAC score of 45 or less, age <55 years and body mass index of <30 HTO survival was 100%, 94%, and 59% at 5, 10 and 20 years respectively. Of those who had not proceeded to TKA the mean Oxford Score was 40, KOOS Pain score was 91 and KOOS function score was 97. 97% reported they were satisfied with the surgery and 88% would have the same surgery again under the same circumstances. At 20 years after HTO 43% had not proceeded to knee arthroplasty, and were continuing to demonstrate high subjective scores and satisfaction with surgery. HTO survival was higher in those under 55 years, with BMI <30 and baseline WOMAC score of >45 at 59% HTO survival over 20 years. HTO may be considered a viable procedure to delay premature knee arthroplasty in carefully selected subjects

Objectives. Sagittal alignment of the lumbosacral spine, and specifically pelvic incidence (PI), has been implicated in the development of spine pathology, but generally ignored with regards to diseases of the hip. We aimed to determine if increased PI is correlated with higher rates of hip osteoarthritis (HOA). The effect of PI on the development of knee osteoarthritis (KOA) was used as a negative control. Methods. We studied 400 well-preserved cadaveric skeletons ranging from 50 to 79 years of age at death. Each specimen’s OA of the hip and knee were graded using a previously described method. PI was measured from standardised lateral photographs of reconstructed pelvises. Multiple regression analysis was performed to determine the relationship between age and PI with HOA and KOA. Results. The mean age was 60.2 years (standard deviation (. sd. ) 8.1), and the mean PI was 46.7° (. sd. 10.7°). Multiple regression analysis demonstrated a significant correlation between increased PI and HOA (standardised beta = 0.103, p = 0.017). There was no correlation between PI and KOA (standardised beta = 0.003, p = 0.912). Conclusion. Higher PI in the younger individual may contribute to the development of HOA in later life. Cite this article: Dr J. J. Gebhart. Relationship between pelvic incidence and osteoarthritis of the hip. Bone Joint Res 2016;5:66–72. DOI: 10.1302/2046-3758.52.2000552

Introduction and Objective. To estimate the prevalence of acetabular ossifications in the adult population with asymptomatic, morphologically normal hips at CT and to determine whether the presence of labral ossifications is associated with patient-related (sex, age, BMI), or hip-related parameters (joint space width, and cam- and pincer-type femoroacetabular impingement morphotype). Materials and Methods. We prospectively included all patients undergoing thoracoabdominal CT over a 3-month period. After exclusion of patients with a clinical history of hip pathology and/or with signs of osteoarthritis on CT, we included a total of 150 hips from 75 patients. We analyzed the presence and the size of labral ossifications around the acetabular rim. The relationships between the size of labral ossifications and patient- and hip-related parameters were tested using multiple regression analysis. Results. The prevalence of labral ossifications in this population of asymptomatic, non-OA hips was 96% (95%CI=[80.1; 100.0]). The presence of labral ossifications and their size were correlated between right and left hips (Spearman coefficient=0.64 (95%CI=[0.46; 0.79]), p<0.05)). The size of labral ossifications was significantly associated with age (p<0.0001) but not with BMI (p=0.35), gender (p=0.05), joint space width (p≥0.53 for all locations) or any of the qualitative or quantitative parameters associated with femoroacetabular morphotype (all p≥0.34). Conclusions. Labral ossifications are extremely common in asymptomatic, non-osteoarthritic hips. Their size is not correlated with any patient-, or hip-related parameters except for the age. These findings suggest that the diagnosis of osteoarthritis or femoroacetabular impingement morphotype should not be made based on the sole presence of acetabular labral ossifications

Until today it is unknown whether preservation of the joint capsule positively affects patient reported outcome (PROs) in DAA-THA. A recent RCT found no clinical difference at 1 year. Since 2015 we preserve the capsule suture it at the end. We here evaluate whether this change had any effect on PROs and revisions, 2 years post-operatively. Two subsequent cohorts operated by the senior author were compared. The capsule was resected in the first cohort (January 2012 – December 2014) and preserved in the second cohort (July 2015 – December 2017). No other technical changes have been introduced between the two cohorts. Patient demographics, Charlson Comorbidity Index (CCI), and surgical data were collected from our clinical information system. 2-years PROs questionnaires (OHS, COMI Hip) were obtained. Data was analyzed with generalized multiple regression analysis. 430 and 450 patients were included in the resected and preserved cohorts, respectively. Demographics, CCI surgical time and length of stay were equal in both groups. Blood loss was less in the preserved cohort (p<.05). Four patients had a revision (1 vs 3, n.s.). Once corrected for demographics, capsule preservation had significant worse PROs: +0.24 COMI (p<.001) and −1.6 OHS points (p<.05), however, effects were much smaller than the minimal clinically important difference (0.95 and 5 respectively). The date of surgery (i.e. surgeon's age) was not a significant factor. In this large retrospective study, we observed statistically significant, but probably clinically not relevant, worse PROs with capsule preservation. It might be speculated that the not resected hypertrophied capsule could have caused this difference

The aim of this study is the comparative assessment of long term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA. 122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford hip score (OHS), Short form-12 health survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, timed up and go test (TUG), Parker mobility, Lower extremity function score (LEFS) and UCLA scores. At a mean follow up of 14.4 years (10 to 20) a cumulative success rate of 96% (95% CI 96 to 99%) in Group A and 98% (95% CI 97 to 99%) in Group B with operation for any reason as an end point was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U test, p= 0.014), OHS (Mann-Whitney U test, p= 0.020) and physical component of SF-12 scores (Mann-Whitney U test, p= 0.029) only. In Group A, in multiple regression analysis, patients’ cognition (p=0.001), BMI (p=0.007) and pain (p=0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p=0.03) was found to influence quality of life (EQ-5D-5). In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes

Aims. Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO. Methods. In all, 202 consecutive patients who underwent PAO for developmental dysplasia of the hip (DDH) at our institution from 2015 to 2017 were included and followed up at 63 months (SD 10) postoperatively. Of these, 101 with complete data sets entered final analysis. Patients were assessed by questionnaire. Psychological status was measured by Brief Symptom Inventory (BSI-18), health-related quality of life was raised with 36-Item Short Form Survey (SF-36), hip functionality was measured by the short version 0f the International Hip Outcome Tool (iHOT-12), Subjective Hip Value (SHV), and Hip Disability and Outcome Score (HOS). Surgery satisfaction and pain were assessed. Dependent variables (endpoints) were postoperative quality of life (SF-36, HOS quality of life (QoL)), joint function (iHOT-12, SHV, HOS), patient satisfaction, and pain. Psychological distress was assessed by the Global Severity Index (GSI), somatization (BSI Soma), depression (BSI Depr), and anxiety (BSI Anx). Influence of psychological status was assessed by means of univariate and multiple multivariate regression analysis. Results. In multiple multivariate regression, postoperative GSI, BSI Soma, and BSI Depr had a negative effect on postoperative SF-36 (e -2.07, -3.05, and -2.67, respectively; p < 0.001), iHOT-12 (e -1.35 and -4.65, respectively; p < 0.001), SHV (e -1.20 and -2.71, respectively; p < 0.001), HOS QoL (e -2.09 and -4.79, respectively; p < 0.001), HOS Function (e -1.00 and -3.94, respectively; p < 0.001), and HOS Sport (e -1.44 and -5.29, respectively; p < 0.001), and had an effect on postoperative pain (e 0.13 and 0.37, respectively; p < 0.001). Conclusion. Psychological distress, depression, and somatization disorders affect health-related quality of life, perceived joint function, and sports ability. Pain perception is significantly increased by somatization. However, patient satisfaction with surgery is not affected. Cite this article: Bone Jt Open 2023;4(10):758–765

Abstract. Objectives. Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and patient information. This study aimed to ascertain if BMI, pre-operative scores, demographic data and concomitant injuries in patients undergoing ACLR affected patient-reported functional outcomes. Methods. A prospective review collected data from a single surgeon series of 278 patients who underwent arthroscopic ACLR. BMI, age, gender, graft choice, pre-op Lysholm score, meniscal and chondral injuries were recorded. The Lysholm score, hop test and KT1000 were used to measure post-op functional outcome at one year. Multiple regression analysis was used to determine factors that predicted Lysholm scores at one year. Results. The mean age was 29 years, with 58 female and 220 male patients. The mean pre-op Lysholm score was 53.8. One hunded and seventy-nine patients had meniscal injuries, of which 81 were medial, 60 lateral, and 38 bilateral. Eighteen patients also had chondral injury and 106 patients had no other associated injury. Age, gender, graft type and presence of meniscal or chondral injuries did not affect one-year post-operative Lysholm scores. A BMI greater than 30, physio compliance and preoperative Lysholm scores helped predict one-year post-operative Lysholm scores (p=0.02). Pearson's correlation found a direct link between BMI and post-operative Lysholm (p=0.03). Conclusions. BMI, physio compliance and pre-operative Lysholm scores are the most significant determinants of short-term functional outcome after ACLR. However, the effects of associated injuries may be apparent in the long-term as degenerative changes set in or the continued detriment resulting from the concomitant injury affect outcome. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. Methods. A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years’ follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. Results. A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). Conclusion. HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components. Cite this article: Bone Jt Open 2022;3(12):924–932

Introduction. Wound condition after primary total knee arthroplasty (TKA) is important for prevention of periprosthetic infection. Any delay in wound healing will cause deep infection, which leads to the arthroplasty failure. Prevention of soft tissue problems is thus essential to achieve excellent clinical results. However, it is unknown as to the important surgical factors affecting the wound healing using detailed wound score after primary TKA so far. It was hypothesized that operative technique would affect wound healing in primary TKA. The purpose of the present study was to investigate and to clarify the important surgical factors affecting wound score after primary TKA. Methods. A total of 139 knees in 128 patients (mean 73 years) were enrolled. All primary TKAs were done by single surgeon. All patients underwent unilateral or bilateral TKA using Balanced Knee System®, posterior stabilized (PS) design (Ortho Development, Draper, UT) or Legion®, PS design (Smith and Nephew, Memphis, TN) under general and/or epidural anesthesia. Patients with immunosuppressive therapy, hypokalemia, poor nutrition (albumin < 3.4 g/dL), diverticulosis, infection elsewhere, uncontrolled diabetes mellitus (HbA1C>7.0%), obesity (Body Mass Index > 35 kg/m2), smoking, renal failure, hypothyroidism, alcohol abuse, rheumatoid arthritis, posttraumatic arthritis, and previous knee surgery were excluded. Hollander Wound Evaluation Score (HWES) was assessed on postoperative day 14. We evaluated age, sex, body mass index, HbA1C (%), preoperative femorotibial angle (FTA) on plain radiograph. In addition, intraoperative patella eversion, intraoperative anterior translation of the tibia, patella resurfacing, surgical time, tourniquet time, unidirectional barbed suture and length of skin incision were also evaluated as surgical factors. Multiple regression analysis was done using stepwise method to identify the surgical factors affecting HWES. Results. Detailed demographic data was presented in Table 1. The average HWES was 5.0 ± 0.8 point. As to the distribution of the HWES, data was shown in Figure 1. Namely, HWES was 3 point in 5 cases, 4 in 29 cases, 5 in 63 cases, and 6 in 42 cases. As any adverse events were not found in each TKA, there were no cases requiring debridement and re-closure of the wound after primary TKA. According to stepwise forward regression test, intraoperative patella eversion and anterior translation of the tibia were entered in this model, while age, Sex, BMI, HbA1C, FTA, surgical time, tourniquet time, patella resurfacing, unidirectional barbed suture and length of skin incision were not entered in the model. The multiple regression analysis in the current study would show the appropriate results, as Durbin-Watson ratio was 1.762. Standardized partial regression coefficient was as follows; 0.57 in anterior translation of the tibia, 0.38 in patella eversion (Table 2). Discussion. The results of the present study would support out hypothesis that operative technique would affect wound healing in primary TKA. Specifically, intraoperative patella eversion and anterior translation of the tibia should be avoided for quality cosmesis of the wound healing in primary TKA. To view tables/figures, please contact authors directly

It is undetermined which factors predict return to work following arthroscopic rotator cuff repair. We aimed to identify which factors predicted return to work at any level, and return to pre-injury levels of work 6 months post-arthroscopic rotator cuff repair. Multiple logistic regression analysis of prospectively collected demographic, pre-injury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work, and return to pre-injury levels of work respectively, 6 months post-surgery. Six months post-rotator cuff repair, 76% of patients returned to work (RTW), and 40% returned to pre-injury levels of work (Full-RTW). RTW at 6 months was likely if patients were still working after their injuries, but prior to surgery (Wald statistic [W]=55, p<0.0001), were stronger in internal rotation preoperatively (W=8, p=0.004), had full-thickness tears (W=9, p=0.002), and were female (W=5, p=0.030). Patients who achieved Full-RTW were likely to have worked less strenuously pre-injury (W=173, p<0.0001), worked more strenuously post-injury but pre-surgery (W=22, p<0.0001), had greater behind-the-back lift-off strength preoperatively (W=8, p=0.004), and had less passive external rotation range of motion preoperatively (W=5, p=0.034). Patients who were still working post-injury, but pre-surgery were 1.6-times more likely to RTW than patients who were not (p<0.0001). Patients who nominated their pre-injury level of work as “light” were 11-times more likely to achieve Full-RTW than those who nominated “strenuous” (p<0.0001). Six months post-rotator cuff repair, a higher patient-rated post-injury, but pre-surgery level of work was the strongest predictor of RTW. A lower patient-rated pre-injury level of work was the strongest predictor of Full-RTW. Greater preoperative subscapularis strength independently predicted both RTW, and Full-RTW

Purpose. The correction obtained in the coronal plane knee deformity using guided growth was assessed in children with sick physes (Height<1SD of the normal children) to define the limits of this technique in sick physis. Methods. We retrospectively assessed deformity correction following guided growth using 8 plates in children with coronal plane deformity and metabolically abnormal physis- renal rickets in 6 and bone dysplasias (multiple epiphyseal dyspasia, spondyloepiphyseal dysplasia, metaphyseal dysplasia, mesomelic dysplasia, chondrodysplasia punctata) in 10 children aged 2 to 14 years. Lateral distal femoral angle(LDFA) and medial proximal tibia(MPTA) angles were serially assessed after eight plate application as a day care procedure. We noted correction achieved rate of correction, complications and additional surgical procedures. Fischer's exact test and multiple regression analysis was done to assess the effect of modifiers. Results. Sixteen children mean aged 7.8 years (2–14 years) with 9 boys and seven girls were followed for a mean of 16.125 months. Deviations from normal MPTA(n=6) were a mean of 11.82(range 8.4–16.9) and from normal LDFA(n=15) a mean of 13.96 (range 5.7–35.1). Mean rate of correction was 0.8°(range 0.1–2.65) per month in dysplasia group and 1.09°(range 0.5–1.6)per month. Complete correction was achieved in 2 out of 6 in renal and 4 out of 10 in dysplasia group. Complication included backing out of screw (1), suboptimal screw placement (2) in dysplasia group and stiffness of the knee (1). Multiple regression analysis found sex, severity of deformity >15° and duration of follow up to be not significant, however, age less than 6 years had a significantly higher chance of deformity correction(P=0.001). Conclusion. The rate of deformity correction with eight plates for guided growth is very variable even within the same patient in dysplasia group, chondrodyspalsia and SED having very slow correction rates. The deformities however correct completely before the age of 6 years irrespective of etiology. Bone dysplasias and metabolic causes require further study to understand their growth pattern and possibilities of relapse

Aims. Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error. Methods. A total of 356 patients undergoing primary THA were prospectively enrolled from November 2016 to March 2018. Clinically relevant error using the CAS system was defined as a difference of > 5° between CAS and 3D radiological reconstruction measurements for acetabular component inclination and anteversion. Univariate and multiple logistic regression analyses were conducted to determine whether hypermobile (. Δ. sacral slope(SS). stand-sit. > 30°), or stiff (. ∆. SS. stand-sit. < 10°) spinopelvic mobility contributed to increased error rates. Results. The paired absolute difference between CAS and postoperative imaging measurements was 2.3° (standard deviation (SD) 2.6°) for inclination and 3.1° (SD 4.2°) for anteversion. Using a target zone of 40° (± 10°) (inclination) and 20° (± 10°) (anteversion), postoperative standing radiographs measured 96% of acetabular components within the target zone for both inclination and anteversion. Multiple logistic regression analysis controlling for BMI and sex revealed that hypermobile spinopelvic mobility significantly increased error rates for anteversion (odds ratio (OR) 2.48, p = 0.009) and inclination (OR 2.44, p = 0.016), whereas stiff spinopelvic mobility increased error rates for anteversion (OR 1.97, p = 0.028). There were no dislocations at a minimum three-year follow-up. Conclusion. Despite high reliability in acetabular positioning for inclination in a large patient cohort using an optical CAS system, hypermobile and stiff spinopelvic mobility significantly increased the risk of clinically relevant errors. In patients with abnormal spinopelvic mobility, CAS systems should be adjusted for use to avoid acetabular component misalignment and subsequent risk for long-term dislocation. Cite this article: Bone Jt Open 2022;3(6):475–484

Introduction. Hip and knee replacements are being performed at increasing rates and currently account for one of the largest procedure expenditures in the Medicare budget. Outcomes of total knee replacement (TKR) depend on surgeon, patient and implant factors. The impact that the specific implants might have on patient-reported outcomes is unknown. The primary purpose of this study was to evaluate the patient-reported functional outcomes and satisfaction after primary total knee arthroplasty in patients with osteoarthritis who underwent TKR using five different brands of posterior-stabilized implants. Specifically, the aim was to evaluate for any difference in patient-reported outcomes based on implant brand used. The hypothesis was that there would be no difference in functional outcome that could be attributed to the implant used in primary TKR. Methods. Using our institution's total joint arthroplasty registry, we identified 4,135 patients who underwent total knee replacement (TKR) using one of the five most common implant brands used at our institution. These included Biomet Vanguard (N=211 patients), Depuy/Johnson&Johnson Sigma (N=221), Exactech OptetrakLogic (N=1,507), Smith & Nephew Genesis II (N=1,414), and Zimmer NexGen (N=779). Only posterior-stabilized primary TKRs in patients with osteoarthritis were included. Patients were evaluated preoperatively using the Knee Osteoarthritis Outcomes Score (KOOS), Lower Extremity Activity Scale (LEAS), and Short Form-12 (SF-12). Demographics including age, body mass index (BMI), Charleston Comorbidity Index (CCI), ASA physical status classification, sex, and smoking status were collected. Postoperatively, 2-year KOOS, LEAS, SF-12, and satisfaction scores were compared between implant groups. Results. At 2-year follow-up, patient-reported outcome scores were available for a total of 4,069 patients. In multiple regression analysis which separately compared each implant group to the aggregate of all others, after accounting for age, BMI, CCI, ASA status, and sex, there were no clinically significant differences in KOOS score changes from baseline to 2-year follow-up between any of the implants. In 2-year satisfaction, >80% of patients in each implant group were satisfied in all domains measured. In the multivariate regression model, patients in the NexGen group had the highest likelihood of being satisfied (OR 1.63, p=0.006) and OptetrakLogic patients had the lowest likelihood of being satisfied (OR 0.60, P<0.001) although these differences were below the minimal clinically important thresholds. Conclusion. TKR provides patient satisfaction and improvement in function regardless of implant type. While some implant systems had higher outcome scores than others, these differences were all below clinically significant thresholds. Whether these differences are a function of surgeon expertise or implant design is unknown. Future research should focus on identifying specific design elements that contribute to improved patient outcomes. Healthcare administrators may find the similarities in clinical outcomes to be a useful consideration when negotiating implant purchasing contracts