We determined the 10 year life expectancy of 5,831 patients who had undergone 6,653 elective primary total hip replacements (THR) at a regional orthopaedic centre between April 1993 and October 2004. Using Hospital, General Practitioner (GP) and the local health authority’s records, we determined dates of deaths for all those who had undergone surgery during this period. The mean age at operation was 73 (13–96) with a male to female ratio of 2:3. Of those with 10 year follow up 29.5% had died a mean of 5.6 (0–11.1) years after surgery. Using Kaplan Meier curves, 10-year survivorship was 89% in patients under 65 years at surgery, 75% in patients aged between 65 – 74 years and 51% in patients over 75. The standardised mortality rates (SMR) were significantly higher than expected for patients under 45 years, 20% higher for those between 45 and 64 years and progressively less than expected for patients aged 65 and over. The survivorship of cemented hip arthroplasties (derived from the Swedish Arthroplasty Register 2004) exceeds patients’ life expectancy in those over the age of 60 in our area suggesting that this is the procedure of choice in this population

We have determined the 10 year life expectancy of 5,831 patients who had undergone 6,653 elective primary total hip replacements (THR) at a regional orthopaedic centre between April 1993 and October 2004. Methods: We ascertained dates of deaths for all those who had undergone surgery during this period and constructed Kaplan Meier survivorship curves for these patients. Standardized mortality ratios were calculated by comparing this data with available UK mortality rates for the same age groups over the same time period. Results: The mean age at operation was 73 with a male to female ratio of 2:3. Of those with 10 year follow up 29.5% had died a mean of 5.6 years after surgery. 10-year survivorship was 89% in patients under 65 years at surgery, 75% in patients aged between 65 – 74 years and 51% in patients over 75. The standard mortality rates were significantly higher than expected for patients under 45 years, 20% higher for those between 45 and 64 years and progressively less than expected for patients aged 65 and over. Discussion: By comparing our mortality curves with prosthesis survivorship curves from the most recent Swedish Arthroplasty Register results we were able to demonstrate that the survivorship of cemented hip arthroplasties exceeds that of the patients over the age of 60 in our area. As these prostheses are less expensive than their uncemented equivalents this suggests these are the prosthesis of choice in this age group

Purpose. The aim of this study was to document rate of survival among 288 severely affected pediatric patients with spasticity and neuromuscular scoliosis who underwent spinal fusion and to identify exposure variables that could significantly predict survival times. Methods. Kaplan-Meier survivorship analysis was performed and Cox’s proportional hazards model was used to evaluate predictive efficacy of exposure variables such as gender, age at surgery, level of ambulation, mental ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in the hospital, and days in the intensive care unit (ICU). Results. The statistical analysis demonstrated a mean predicted survival of 134.3 months (11.2 years) after spine surgery for this group of globally involved children with cerebral palsy (Figure 1). The number of days in the ICU after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. ICU stay of greater than five days, which was usually associated with respiratory problems, substantially increased the risk of death. Thoracic hyperkyphosis of greater than 70° caused a considerable increase in the predicted mortality rate. Conclusions. Our study demonstrated a relatively long mean predicted survivorship for children and adolescents with severe spastic cerebral palsy and neuromuscular scoliosis who underwent spine surgery, which is consistent with the current concept of increased life expectancy even for the total-body involved patients. The most accurate determinants for survival rates among this population group were the number of days the patient had to spend postoperatively in the intensive care unit, and the presence of excessive thoracic hyper-kyphosis

Objective: The aim of this study was to document rate of survival among 288 severely affected pediatric patients with spasticity and neuromuscular scoliosis who underwent spinal fusion and to identify exposure variables that could significantly predict survival times. Methods: Kaplan-Meier survivorship analysis was performed and Cox’s proportional hazards model was used to evaluate predictive efficacy of exposure variables such as gender, age at surgery, level of ambulation, mental ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in the hospital, and days in the intensive care unit (ICU). Results: The statistical analysis demonstrated a mean predicted survival of 134.3 months (11.2 years) after surgical correction of spinal deformities for this group of globally involved children with cerebral palsy. The number of days in the ICU after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. ICU stay of greater than five days, which was usually associated with respiratory problems, substantially increasing the risk of death. Thoracic hyperkyphosis of greater than 70o caused a considerable increase in the predicted mortality rate. Conclusions: Our study demonstrated a relatively long mean predicted survivorship for pediatric patients with severe spastic cerebral palsy and neuromuscular scoliosis who underwent spinal surgery, which is consistent with the current concept of increased life expectancy even for the total-body involved patients. The most accurate determinants for survival rates among this population group were the number of days the patient had to spend postoperatively in the intensive care unit, and the presence of excessive preoperative thoracic hyperkyphosis

Background

Metastatic bone patients who require surgery needs to be evaluated in order to maximise quality of life and avoiding functional impairment, minimising the risks connected to the surgical procedures. The best surgical procedure needs to be tailored on survival estimation. There are no current available tool or method to evaluate survival estimation with accuracy in patients with bone metastasis. We recently developed a clinical decision support tool, capable of estimating the likelihood of survival at 3 and 12 months following surgery for patients with operable skeletal metastases. After making it publicly available on www.PATHFx.org, we attempted to externally validate it using independent, international data.

Study design: We conducted a prospective cohort study of 448 patients with a variety of spinal metastases. Objective. To compare the predictive value of the Tokuhashi scoring system (T12) and its revised edition (T15) for life expectancy both in the entire study group as well as in the various primary tumor subgroups. Summary of background data. In 1990 Tokuhashi and coworkers formulated a one point-addition-type prognostic scoring system with a total sum of 12 points for preoperative prediction of life expectancy as an adjunct in selecting appropriate treatment. Because the site of the primary tumor influences ultimate survival, the scoring system was revised in 2005 to a total sum of 15 points based on the origin of the primary tumor. Methods. This study included 448 patients with vertebral metastases, all of whom underwent surgical treatment during November 1992 to November 2009 at the Aarhus University Hospital. Data was retrieved from the Aarhus Spinal Metastases Algorithm. Scores based on the T12- and T15 scoring systems were calculated prospectively for each patient. All the patients were divided into three survival groups with different life expectancies according to their score points in both scoring systems. Furthermore, we divided all the patients into different groups dictated by the site of their primary tumor. The predictive value of each scoring system, both in the entire group and in each subgroup determined by the original tumour site, was evaluated by the Log-rank-test. The McNemar's test was used to compare the differences in accuracy rates between these two scoring systems. Survival curves were estimated using the Kaplan-Meier methods. Probability value less than 0.05 was considered statistically significant. Result. For the 448 patients with vertebral metastases, both the T12 and T15 scoring systems showed statistically significant predictive value (T12 group p<0.0001, T15 group p<0.0001, Log-rank test). The correlation between predicted survival period and real survival was significantly higher in T15 (p<0.0001, McNemar's test) than in T12. The further analyses by type of metastases showed that the predictive value of T12 and T15 was found in the prostate (p=0.0003), breast (p=0.0385), other tumor group (p<0.001) and lymphoma (p<0.05). Only T12 displayed predictive value in the colon group (p=0.0011). The accuracy rate of prognosis in T15 was significantly higher in those groups with spinal metastases originating from prostate (p=0.0032), breast (p<0.0001) and lung (p=0.0076). Conclusion. Both the T12 and T15 scoring systems have significant preoperative predictive value in terms of predicting the survival period for the entire vertebral metastases patient group as well as in the prostate, breast, lymphoma, and colon tumor groups. The accuracy rate was significantly improved in T15 for the total study group and in the subgroups of prostate, breast, and lung tumor

Aims. To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). Methods. A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)’s Perioperative Special Interest Group and clinicians’ personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. Results. A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. Conclusion. This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people. Cite this article: Bone Jt Open 2023;4(10):766–775

Aims. Advances in treatment have extended the life expectancy of patients with metastatic bone disease (MBD). Patients could experience more skeletal-related events (SREs) as a result of this progress. Those who have already experienced a SRE could encounter another local management for a subsequent SRE, which is not part of the treatment for the initial SRE. However, there is a noted gap in research on the rate and characteristics of subsequent SREs requiring further localized treatment, obligating clinicians to extrapolate from experiences with initial SREs when confronting subsequent ones. This study aimed to investigate the proportion of MBD patients developing subsequent SREs requiring local treatment, examine if there are prognostic differences at the initial treatment between those with single versus subsequent SREs, and determine if clinical, oncological, and prognostic features differ between initial and subsequent SRE treatments. Methods. This retrospective study included 3,814 adult patients who received local treatment – surgery and/or radiotherapy – for bone metastasis between 1 January 2010 and 31 December 2019. All included patients had at least one SRE requiring local treatment. A subsequent SRE was defined as a second SRE requiring local treatment. Clinical, oncological, and prognostic features were compared between single SREs and subsequent SREs using Mann-Whitney U test, Fisher’s exact test, and Kaplan–Meier curve. Results. Of the 3,814 patients with SREs, 3,159 (83%) patients had a single SRE and 655 (17%) patients developed a subsequent SRE. Patients who developed subsequent SREs generally had characteristics that favoured longer survival, such as higher BMI, higher albumin levels, fewer comorbidities, or lower neutrophil count. Once the patient got to the point of subsequent SRE, their clinical and oncological characteristics and one-year survival (28%) were not as good as those with only a single SRE (35%; p < 0.001), indicating that clinicians’ experiences when treating the initial SRE are not similar when treating a subsequent SRE. Conclusion. This study found that 17% of patients required treatments for a second, subsequent SRE, and the current clinical guideline did not provide a specific approach to this clinical condition. We observed that referencing the initial treatment, patients in the subsequent SRE group had longer six-week, 90-day, and one-year median survival than patients in the single SRE group. Once patients develop a subsequent SRE, they have a worse one-year survival rate than those who receive treatment for a single SRE. Future research should identify prognostic factors and assess the applicability of existing survival prediction models for better management of subsequent SREs. Cite this article: Bone Joint Res 2024;13(9):497–506

Patients may be able to return to higher level activities following hip arthroplasty with modern techniques and prostheses, but the Oxford hip score, the standard PROM used by the NJS exhibits severe skew and kurtosis. The commonest score is 48/48. Most patients score above 40 preventing any discrimination between approaches or prostheses. We therefore sought both subjective and objective metrics which were relevant and valid without skew or high kurtosis in postoperative patients. The Metabolic Equivalent of Task (MET) reports energy usage in kcal/min burnt across a range of activities, condensed into a score of 0–25. A MET over 8 is considered ‘conditioning exercise’ tethered to life expectancy. A 2 point difference in average MET is considered a clinically relevant difference. Walking speed is a simple valid metric tethered to life expectancy, with a 0.1m/sec difference in walking speed equates to a clinically important difference. Oxford Hip Score (OHS), and the MET were prospectively recorded in 221 primary hip arthroplasty procedures pre-operatively and at 1-year using a web based application. Pre and postoperative Gait analysis was undertaken on a subgroup of 34 patients, in comparison with age and sex matched controls. Post-operatively, the OHS demonstrated significant skewed distributions with ceiling effects of 41% scoring 48/48. The MET was normally distributed around a mean of 10.3, with a standard deviation of 3.8 and no ceiling effect. Walking speed was normally distributed around a mean of 1.8m/sec, with a standard deviation was 0.15 m/sec. The MET is a simple patient reported score, which is normally distributed in patients following hip arthroplasty, around a mean of 10.3 with a standard deviation of 3.8. This valid activity metric correlates well with fast walking speed. This is also normally distributed with a standard deviation of over 0.1m/sec confirming low kurtosis. These simple measures have face validity: undertaking less active pastimes and being unable to keep up with other walkers are obviously inadvisable. The normal kurtosis of these metrics suggest that they may able to detect clinically relevant differences in outcome which are undetectable with commonly used PROMs. For surgeons developing less invasive approaches or using novel stems, these measures may detect clinically important improvements undetectable by the Oxford Hip Score

Disease modifying approaches are commonly applied in OA patients. An aging society with better life expectancies is increasing in Europe and the globe. Orthobiologics cover intraarticular hyaluronan injections and also cellular therapies. Cellular therapies range from platelet rich plasma (PRP) applications to exosomes. Short term follow-up of limited number of patients revealed favorable results in clinical cellular therapies. Most of these studies evaluated decrease of pain and increase in function. Recent basic science studies focused on the action mechanism of orthobiologic therapies however patient perspective is less studied. Our research team has recently performed a qualitative study on the patient perspective of hyaluronan injection of the knee joint. Findings of that study will be shared and future patient knowledge based options on orthobiologics will be discussed

Abstract. Introduction. In general the life expectancy of population is improving. This is causing to increase case load of peri-prosthesis fractures after joint replacements. We present our results of peri-prosthesis fracture around hip managed by revision arthroplasty. Methods. A retrospective analysis of 24 consecutive patients of periprosthetic hip fracture treated with a revision arthroplasty at Major Trauma Centre between February 2021 and January 2022. Results. 12 male and 12 female patients, average age 78 years. 3 fractures around BHR prosthesis, 2 type A, 15 type B and 3 of type C (Vancouver). The surgery was done in an average 6 days after injury (range 1–14). 6 patients died in follow up, 1 patient contracted infection, 2 developed LLD and 1 patient had multiple dislocations. 6 patients had revision using endo-prosthesis. Advanced age with peri-prosthesis fracture has increased risk of mortality (average age 84.5 years). Conclusion. Endo-prosthesis replacement had higher risk of dislocation, infection and mortality. Overall patients do well after a revision arthroplasty for periprosthetic hip fracture. 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

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results

Background. Loss of muscle mass (sarcopenia) and function in ageing are associated with reduced functional ability, quality of life and reduced life expectancy. In cancer patients, age related muscle loss may be exacerbated by cachexia and poor nutritional intake. Individuals with widespread disseminated disease are most prone to increasing functional decline, increased morbidity and accelerated death. However subjective assessments of physical performance have been shown to be poor indicators of life expectancy in these patients. Aims. To develop an objective measure to aid calculation of life expectancy in cancer by investigating the association between objectively measured lean muscle mass and longevity, in 41 patients with known spinal metastases from all cause primaries. Methods. Lean muscle mass was calculated as total psoas area (TPA)/height (m)2. Two blinded doctors independently calculated TPA from CT images at the L3 level, performed routinely within 7 days of diagnosis of spinal metastases. Time to death was recorded from retrospective analysis of hospital notes. Results. Of patients within the highest tertile for muscle mass 85% were alive at one year, compared with 50% in the lowest tertile. Conclusion. Death within one year in individuals with spinal metastases is significantly higher in patients with low lean muscle mass at presentation

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences. Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups. Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either. To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols

Several different algorithms attempt to estimate life expectancy for patients with metastatic spine disease. The Skeletal Oncology Research Group (SORG) has recently developed a nomogram to estimate survival of patients with metastatic spine disease. Whilst the use of the SORG nomogram has been validated in the international context, there has been no study to date that validates the use of the SORG nomogram in New Zealand. This study aimed to validate the use of the SORG nomogram in Aotearoa New Zealand. We collected data on 100 patients who presented to Waikato Hospital with a diagnosis of spinal metastatic disease. The SORG nomogram gave survival probabilities for each patient at each time point. Receiver Operating Characteristic (ROC) Area Under Curve (AUC) analysis was performed to assess the predictive accuracy of the SORG score. A calibration curve was also performed, and Brier scores calculated. A multivariate Cox regression analysis was performed. The SORG score was correlated with 30 day (AUC = 0.72) and 90-day mortality (AUC = 0.71). The correlation between the SORG score and 90-day mortality was weaker (AUC = 0.69). Using this method, the nomogram was correct for 79 (79%) patients at 30-days, 59 patients (59%) at 90-days, and 42 patients (42%) at 365-days. Calibration curves demonstrated poor forecasting of the SORG nomogram at 30 (Brier score = 0.65) and 365 days (Brier score = 0.33). The calibration curve demonstrated borderline forecasting of the SORG nomogram at 90 days (Brier score = 0.28). Several components of the SORG nomogram were not found to be correlated with mortality. In this New Zealand cohort the SORG nomogram demonstrated only acceptable discrimination at best in predicting life 30-, 90- or 356-day mortality in patients with metastatic spinal disease

Introduction. Tendon ruptures represent one of the most common acute tendon injuries in adults worldwide, affecting millions of people anually and becoming more prevalent due to longer life expectancies and sports activities. Current clinical treatments for full tears are unable to completely restore the torn tendons to their native composition, structure and mechanical properties. To address this clinical challenge, tissue-engineered substitutes will be developed to serve as functional replacements for total tendon ruptures that closely resemble the original tissue, restoring functionality. Method. Water borne polyurethanes (WBPU) containing acrylate groups, specifically polyethylene glycol methacrylate (PEGMA) or 2-hydroxyethyl methacrylate (HEMA), were combined with mouse mesenchymal stem cells (MoMSCs) and heparin sodium to formulate bioinks for the fabrication of scaffolds via extrusion-based 3D bioprinting. Result. The biocompatibility of acrylated-WBPUs was confirmed in 2D with MoMSCs using lactate dehydrogenase assay, DNA assay and live/dead assays. Cell-laden scaffolds were 3D-bioprinted by encapsulating MoMSCs at varying cell densities within the acrylated WBPUs. The resulting 3D structures support cell viability and proliferation within the scaffolds, as confirmed by live/dead assay, lactate dehydrogenase assay and DNA assays. Differentiation studies in the 3D-bioprinted scaffolds demonstrated the phenotype transition of MoMSCs toward tenocytes through gene expression and protein deposition analysis. The inclusion of sodium heparin in the bioinks revealed increased synthesis of matrix assembly proteins within the 3D-bioprinted constructs. Conclusion. The developed bioinks were biocompatible and printable, supporting cell viability within the 3D-bioprinted scaffold. The fabricated cell-laden constructs sustained cell proliferation, differentiation, and tissue formation. The addition of heparin sodium enhanced tissue formation and organization, showing promising results for the regeneration of tendon total ruptures. Principio del formularioThis work was supported by the Spanish State Research Agency (AEI) under grant No CPP2021-008754. The authors would like to thank their partners in the project, which are in charge of the synthesis of heparin sodium and acrylated-WBPUs

Dislocations have impact on quality of life, but it is difficult to quantify this impact for each patient. The Quality-of-Life Time Trade-Off assesses the percentage of a patient's remaining life that the patient would be willing to trade for perfect health [1]. This technique has been used for non-unions [2], but never proposed for dislocation. 154 patients (with 3 recurrent dislocations) undergoing revision were asked to choose between living with their associated dislocation risk or trading a portion of their life expectancy for a period of perfect health without dislocation, thus determining their Quality-of-Life score. This score may range from 0.1 (willing to trade nine years among 10) to 1.0 (unwilling to trade any years). Additionally, patients were assessed on their willingness to trade implant survival time for a reduced risk of dislocation, considering various implant options that might offer lower (but not necessary) survival time before revision than the theoretical best (for the surgeon) “standard” implant, thus determining a “Survival Implant Quality” score. Patients diagnosed with 3 hip dislocations have a low health-related quality of life. The score of our “dislocation” cohort was average 0.77 with patients willing to trade average 23% of remaining lifespan for perfect health (range 48% to 12%). This score is below that (0.88) of illnesses type-I diabetes mellitus [3] and just higher than tibial non-union (0.68) score [2]. The mean “Survival Implant Quality” score of our recurrent dislocation cohort was 0.71 (range 0.59 to 0.78) which means that patients accept to trade average 3 years (range 2 to 4 years) among 10 theoretical years of survival of the implant. Hip dislocation has a devastating impact that can be quantified for each patient when discussing revision and choice of implants for instability. For references, please contact the author directly

Purpose: To identify local and systemic risk factors for the development of pathologic fractures and determine the value of the Tokuhashi Score in patients with known asymptomatic lytic spinal metastases secondary to breast cancer. Method: A prospective cohort study was carried out on 51 patients with lytic spinal metastases secondary to breast cancer identified as having either purely lytic or mixed disease. The Tokuhashi Score, developed to estimate life expectancy for patients with symptomatic spinal metastases being considered for surgery, was calculated for each of the 51 patients. The score consists of six parameters each of which is rated from 0–2. Initial and follow up CT images and pain and function data were obtained every four months for one year. A final review of patient charts was performed two years later to determine if each patient was still alive. Results: Tumour burden was predominantly blastic and mixed rather than lytic. There was no progression of lytic tumour burden over the 12-month period, however there was progression of blastic tumour load. Eleven compression fractures occurred in seven patients; no burst fractures occurred during the study. No correlation between tumour burden (lytic, blastic or both) and risk of fracture was found. A weak correlation between bone mineral density and length of time elapsed from diagnosis of metastatic disease and fracture risk was found. Pain and functional data results were not related to tumour load. Tokuhashi score did correlate with survival, however actual survival in our population was far longer than that found in previous studies. Negative progesterone status was found to be negatively associated with life expectancy. Conclusion: Metastatic vertebral disease in breast cancer patients has a predominantly blastic and mixed appearance with current pharmacologic therapies. Pathologic fracture risk appears to be more related to bone mineral density than tumour burden in this population. Tokuhashi score does correlate with life expectancy in patients with relatively asymptomatic spinal metastases. Having a progesterone receptor negative tumour has a significantly negative impact on life expectancy

One out of nine Canadian males would suffer prostate cancer (PC) during his lifetime. Life expectancy of males with PC has increased with modern therapy and 90% live >10 years. However, 20% of PC-affected males would develop incurable metastatic diseases. Bone metastases (BM) are present in ~80% of metastatic PC patients, and are the most severe complication of PC, generating severe pain, fractures, spinal cord compression, and death. Interestingly, PC-BMs are mostly osteoblastic. However, the structure of this newly formed bone and how it relates to pain and fracture are unknown. Due to androgen antagonist treatment, different PC phenotypes develop with differential dependency on androgen receptor (AR) signaling: androgen-dependent (AR+), double negative (AR-) and neuroendocrine. How these phenotypes are related to changes in bone structure has not been studied. Here we show a state-of-the-art structural characterization of PCBM and how PC phenotypes are associated to abnormal bone formation in PCBM. Cadaveric samples (n=14) obtained from metastases of PC in thoracic or lumbar vertebrae (mean age 74yo) were used to analyze bone structure. We used micro-computed tomography (mCT) to analyze the three-dimensional structure of the bone samples. After imaging, the samples were sectioned and one 3mm thick section was embedded in epoxy-resin, ground and polished. Scanning electron microscopy (SEM)/energy-dispersive X-ray spectroscopy (EDS) and quantitative backscattering electron (qBSE) imaging were used to determine mineral morphology and composition. Another section was used for histological analysis of the PC-affected bone. Collagen structure, fibril orientation and extracellular matrix composition were characterized using histochemistry. Additionally, we obtained biopsies of 3 PCBM patients undergoing emergency decompression surgery following vertebral fracture and used them for immunohistological characterization. By using mCT, we observed three dysmorphic bone patterns: osteolytic pattern with thinned trabecula of otherwise well-organized structures, osteoblastic pattern defined as accumulation of disorganized matrix deposited on pre-existing trabecula, and osteoblastic pattern with minimum residual trabecula and bone space dominated by accumulation of disorganized mineralized matrix. Comparing mCT data with patho/clinical parameters revealed a trend for higher bone density in males with larger PSA increase. Through histological sections, we observed that PC-affected bone, lacks collagen alignment structure, have a higher number of lacunae and increased amount of proteoglycans as decorin. Immunohistochemistry of biopsies revealed that PC-cells inside bone organize into two manners: i) glandular-like structures where cells maintain their polarization in the expression of prostate markers, ii) diffuse infiltrate that spreads along bone surfaces, with loss of cell polarity. These cells take direct contact with osteoblasts in the surface of trabecula. We define that PCBM are mostly composed by AR+ with some double negative cells. We did not observe neuroendocrine phenotype cells. PCBMs generate predominantly osteoblastic lesions that are characterized by high lacunar density, lack of collagen organization and elevated proteoglycan content. These structural changes are associated with the infiltration of PC cells that are mostly androgen-dependent but have lost their polarization and contact directly with osteoblasts, perhaps altering their function. These changes could be associated with lower mechanical properties that led to fracture and weakness of the PCBM affected bone

Nationally, experimental estimated Indigenous life expectancy was 59 years for Indigenous males (compared with 77 for all males) and 65 years for Indigenous females (compared with 82 years for all females). This is a difference of around 17 years for both males and females (ABS 2004). The Australian Government has embarked on numerous educational and health campaigns addressing the disease processes that lead to such a stark difference in life expectancy. The results of these campaigns are evident, as the population of Indigenous Australians over 60 years of age has risen from 9968 (Census 1986) to 25604 (Census 2008). As a result, we are now beginning to see orthopaedic degenerative disease states such as osteoarthritis. This increase in the number of Iindigenous Australians suffering from osteoarthritis will result in a greater number of hip and knee joint arthroplasty for osteoarthritis. Although the largest populations of Indigenous patients reside in urban areas, notably Sydney (census count 41,800), Brisbane (41,400) and Perth (21,300), the Torres Strait region of Queensland has 83% of the Indigenous population in remote Australia (Census 2008). This is reflected in the number of hip and knee joint arthroplasties performed through the orthopaedic department at the Cairns Base Hospital on indigenous patients, from a total of seven in 2001 to a total of 22 in 2008. Retrospective analysis was conducted of those patients failing to attend their full complement of post-operative follow-up in the first year post total hip and knee joint arthroplasty for the eight year period from 2001 to 2008 at the Cairns Base Hospital. Within this period a total of 99 hip and knee arthroplasties were performed on indigenous patients. Over 30% of indigenous patients failed to attend their full complement of post-operative follow up in the first year post hip and knee joint arthroplasty. Due to the increasing life expectancy of the indigenous population, more are presenting with orthopaedic degenerative disease states that require joint arthroplasty. The higher number of co-morbidities such as type II diabetes mellitus and peripheral vascular disease makes post operative follow up of the indigenous patient essential to avoid complications. The lack of follow up will undoubtedly lead to an inability to appropriately monitor the indigenous patient's recovery and/or decrease in morbidity post total hip and knee joint arthroplasty. Patient centered follow-up must be given greater consideration in relation to the Australian indigenous population such as an increase in outreach services, the provision of orthopaedic follow up by the local health practitioners in the rural and remote setting, maintaining up to date contact details along with affording the indigenous patient greater access to transport so as to improve follow up