Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

Aims

It is unclear whether mortality outcomes differ for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery who are readmitted to the index hospital where their surgery was performed, or to another hospital.

Aims. Iliopsoas impingement occurs in 4% to 30% of patients after undergoing total hip arthroplasty (THA). Despite a relatively high incidence, there are few attempts at modelling impingement between the iliopsoas and acetabular component, and no attempts at modelling this in a representative cohort of subjects. The purpose of this study was to develop a novel computational model for quantifying the impingement between the iliopsoas and acetabular component and validate its utility in a case-controlled investigation. Methods. This was a retrospective cohort study of patients who underwent THA surgery that included 23 symptomatic patients diagnosed with iliopsoas tendonitis, and 23 patients not diagnosed with iliopsoas tendonitis. All patients received postoperative CT imaging, postoperative standing radiography, and had minimum six months’ follow-up. 3D models of each patient’s prosthetic and bony anatomy were generated, landmarked, and simulated in a novel iliopsoas impingement detection model in supine and standing pelvic positions. Logistic regression models were implemented to determine if the probability of pain could be significantly predicted. Receiver operating characteristic curves were generated to determine the model’s sensitivity, specificity, and area under the curve (AUC). Results. Highly significant differences between the symptomatic and asymptomatic cohorts were observed for iliopsoas impingement. Logistic regression models determined that the impingement values significantly predicted the probability of groin pain. The simulation had a sensitivity of 74%, specificity of 100%, and an AUC of 0.86. Conclusion. We developed a computational model that can quantify iliopsoas impingement and verified its accuracy in a case-controlled investigation. This tool has the potential to be used preoperatively, to guide decisions about optimal cup placement, and postoperatively, to assist in the diagnosis of iliopsoas tendonitis. Cite this article: Bone Jt Open 2023;4(1):3–12

Aims

Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Objectives. The objective of this study was to investigate the association of four single-nucleotide polymorphisms (SNPs) of the cannabinoid receptor 2 (CNR2) gene, gene-obesity interaction, and haplotype combination with osteoporosis (OP) susceptibility. Methods. Chinese patients with OP were recruited between March 2011 and December 2015 from our hospital. In this study, a total of 1267 post-menopausal female patients (631 OP patients and 636 control patients) were selected. The mean age of all subjects was 69.2 years (sd 15.8). A generalized multifactor dimensionality reduction (GMDR) model and logistic regression model were used to examine the interaction between SNP and obesity on OP. For OP patient-control haplotype analyses, the SHEsis online haplotype analysis software (. http://analysis.bio-x.cn/. ) was employed. Results. The logistic regression model revealed that the C allele of rs2501431 and the G allele of rs3003336 were associated with increased OP risk, compared with those with wild genotype. However, no significant correlations were found when analyzing the association of rs4237 and rs2229579 with OP risk. The GMDR analysis suggested that the interaction model composed of two factors, rs3003336 and abdominal obesity (AO), was the best model with statistical significance (p-value from sign test (P. sign. ) = 0.012), indicating a potential gene-environment interaction between rs3003336 and AO. Overall, the two-locus models had a cross-validation consistency of 10/10 and had a testing accuracy of 0.641. Abdominally obese subjects with the AG or GG genotype have the highest OP risk, compared with subjects with the AA genotype and normal waist circumference (WC) (odds ratio (OR) 2.23, 95% confidence interval (CI) 1.54 to 3.51). Haplotype analysis also indicated that the haplotype containing the rs3003336-G and rs2501431-C alleles was associated with a statistically increased OP risk. Conclusion. Our results suggested that the C allele of rs2501431 and the G allele of rs3003336 of the CNR2 gene, interaction between rs3003336 and AO, and the haplotype containing the rs3003336-G and rs2501431-C alleles were all associated with increased OP risk. Cite this article: Bone Joint Res 2019;8:544–549

The ‘Best Practice Tariff‘ (BPT) was developed to improve hip fracture care by incentivising hospitals to provide timely multidisciplinary care to patients sustaining these injuries. The current literature examining the association between BPT and patient outcomes is conflicting and underpowered. We aimed to determine if achieving BPT has an impact on 30-day mortality and postoperative length of stay. A retrospective analysis for patients admitted to a major trauma centre (MTC) was performed between 01/01/2013 to 31/12/2020. Data were extracted from the National Hip Fracture Database. The study population was divided into two groups: those who achieved all BPT criteria (BPT-passed) and those who did not (BPT-failed). The primary outcomes of interest included the 30-day mortality rate and postoperative length of stay (LOS). As a secondary objective, we aimed to assess factors that predict perioperative mortality by utilising a logistic regression model. 4397 cases were included for analysis. 3422 (78%) met the BPT criteria, whereas 973 (22%) did not. The mean LOS in the BPT-achieving group was 17.2 days compared with 18.6 in the BPT-failed group, p<0.001. 30-day mortality was significantly lower in the BPT-achieving group i.e., 4.3% in BPT-achieved vs. 12.1% in BPT-failed, p<0.001. Logistic regression modelling demonstrated that attainment of BPT was associated with significantly lower 30-day mortality (OR: 0.32; 95% CI:0.24–0.41; p<0.001). To our knowledge, this is the largest study to investigate the association between BPT attainment and 30-day mortality as well as the length of stay. The present study demonstrates that achieving BPT in hip fracture patients is associated with a significant reduction in the average length of stay and 30-day mortality rates. Our crude calculations revealed that achieving BPT for 3422 patients earned our hospital trust >£4 million over 8 years. Findings from this study suggest that achieving BPT not only improves 30-day survival in patients with hip fractures but also aids cost-effectiveness by reducing LOS and helps generate NHS Trusts a significant amount of financial reward

Aims. The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. Methods. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. Results. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. Conclusion. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions. Cite this article: Bone Jt Open 2023;4(2):110–119

Aims. We aimed to develop a gene signature that predicts the occurrence of postmenopausal osteoporosis (PMOP) by studying its genetic mechanism. Methods. Five datasets were obtained from the Gene Expression Omnibus database. Unsupervised consensus cluster analysis was used to determine new PMOP subtypes. To determine the central genes and the core modules related to PMOP, the weighted gene co-expression network analysis (WCGNA) was applied. Gene Ontology enrichment analysis was used to explore the biological processes underlying key genes. Logistic regression univariate analysis was used to screen for statistically significant variables. Two algorithms were used to select important PMOP-related genes. A logistic regression model was used to construct the PMOP-related gene profile. The receiver operating characteristic area under the curve, Harrell’s concordance index, a calibration chart, and decision curve analysis were used to characterize PMOP-related genes. Then, quantitative real-time polymerase chain reaction (qRT-PCR) was used to verify the expression of the PMOP-related genes in the gene signature. Results. We identified three PMOP-related subtypes and four core modules. The muscle system process, muscle contraction, and actin filament-based movement were more active in the hub genes. We obtained five feature genes related to PMOP. Our analysis verified that the gene signature had good predictive power and applicability. The outcomes of the GSE56815 cohort were found to be consistent with the results of the earlier studies. qRT-PCR results showed that RAB2A and FYCO1 were amplified in clinical samples. Conclusion. The PMOP-related gene signature we developed and verified can accurately predict the risk of PMOP in patients. These results can elucidate the molecular mechanism of RAB2A and FYCO1 underlying PMOP, and yield new and improved treatment strategies, ultimately helping PMOP monitoring. Cite this article: Bone Joint Res 2022;11(8):548–560

Introduction. The COVID-19 pandemic led to a swift adoption of telehealth in orthopedic surgery. The purpose of this study was to analyze patient and surgeon satisfaction with a rapid expansion of telehealth use during COVID-19 pandemic within the division of adult reconstructive surgery at a major urban academic hospital. Methods. 334 hip and knee arthroplasty patients who completed a telemedicine visit from March 30th, 2020 through April 30th, 2020 were sent a 14-question survey. Eight adult reconstructive surgeons who used telemedicine were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modeling. Results. 20.4% of patients (68/334) and 100% of surgeons (8/8) completed the surveys. Patients were on average “Satisfied” with their telemedicine visits (4.10/5.00 ± 0.98), 54.4% considered themselves high-risk for COVID-19 complications, and 27.9% reported that they preferred future visits to be conducted using telemedicine for reasons unrelated to COVID-19. Multivariate ordinal logistic regression modeling revealed that patients reported higher satisfaction if their surgeon effectively responded to their questions/concerns (OR 3.977; 95% CI 1.260 to 13.190, p=0.019) and if their visit had higher audiovisual quality (OR 2.46; 95% CI 1.052 to 6.219, p=0.042). Surgeons were “Satisfied” with their telemedicine experience (3.63/5.00 ± 0.92), felt that physical exams conducted via telemedicine were “Slightly Effective” (1.88/5.00 ± 0.99), and believed that 43.5% of visits required an in-person component. Most adult reconstructive surgeons would continue to use telemedicine in the future (87.5%). Conclusion. Telehealth emerged as a valuable tool during the COVID-19 pandemic. Arthroplasty patients and surgeons were generally satisfied with telehealth and see a role for telehealth after the pandemic. Future investigations should explore how to improve telehealth physical examinations and identify which types of visits and patient concerns are reliably addressed using telehealth

Aims. Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. Methods. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. Results. A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Conclusion. Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail. Cite this article: Bone Jt Open 2024;5(6):457–463

Aims. The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Methods. Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Results. Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as ‘black and minority ethnic’ (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. Conclusion. There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training. Cite this article: Bone Jt Open 2024;5(8):697–707

Abstract. Introduction. Previous research has demonstrated no clinically significant benefit of arthroscopic meniscectomy in patients with a meniscal tear, however, patients included in these studies would not meet current treatment recommendations. Prior to further randomised controlled trials (RCTs) research is needed to understand a younger population in more detail. Aim. To describe the baseline characteristics of patients with a meniscal tear and explore any association between baseline characteristics and outcome. Methodology. A prospective, national multicentre cohort study was performed recruiting patients aged 18 to 55 presenting to secondary care. MRI analysis of arthritis was performed using Whole Organ Magnetic Resonance Imaging Score (WORMS) and bone shape analysis. Outcomes included the Western Ontario Meniscal Evaluation Tool (WOMET) and Knee Injury and Osteoarthritis Outcome Score (KOOS4) at 12 months. Results. 150 participants were recruited across eight sites with a mean age of 43.47 (SD 9.63). MRI analysis using WORMS score and bone shape analysis revealed no or early osteoarthritis. At 12 months, 67 (44.67%) of participants were managed non-operatively and 68 (45.33%) were operatively. Participants in the operative group were significantly younger with a lower BMI (p<0.05). A stepwise logistic regression model including 17 characteristics revealed that only baseline score and surgery significantly affected 12-month WOMET and KOOS4. Conclusion. This study in contrast to previous trials demonstrated a benefit of surgery for patients with a meniscal tear. The METRO study demonstrates that it is feasible to recruit younger patients and a future RCT is required using the study population included in this cohort

In-hospital length of stay (LOS) and discharge disposition following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, we wished to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge disposition following robotic-arm assisted (RO THA) versus conventional technique Total Hip Arthroplasty (CO THA). This large-scale, single institution study included patients of any age undergoing primary THA (N = 1,732) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for Post Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. The median LOS in the RO THA group was 54 hours (34, 78) versus 60 (51, 100) in the CO THA group, p<0.001. Discharge disposition was comparable between the two groups. In the multivariate model, age, need for PACU admission, ASA score > 2, female gender, general anaesthesia and utilisation of the conventional technique were significantly associated with LOS > 2 days. Our study showed that robotic-arm assistance was associated with a shorter LOS in patients undergoing primary THA and no difference in discharge destination. Our results suggest that robotic-arm assistance could be advantageous in partly addressing the upsurge of hip arthroplasty procedures and the concomitant health care burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies

The stem design in total hip arthroplasty (THA) is constantly evolving. The impact of the collar on the risk of periprosthetic fracture remains controversial. This study aimed to determine whether adding a collar to the femoral stem impacts the early periprosthetic fracture risk within 90 days of surgery. This retrospective study included 1,623 patients who underwent primary total hip arthroplasty in a single orthopedic department between January 2010 and December 2020. The inclusion criteria were uncemented stem with or without a collar, in a primary intention, without previous hip surgery with a similar “corail like” design. The assessed data were demographic characteristics (age, gender, number of obese (BMI > 30)), single or dual mobility, the surgical approach, the early complication, particularly the periprosthetic femoral fractures. Of the 1,623 patients, 1,380 received a collared stem (85%), and 243 received a collarless stem (15%). A multivariate analysis was performed to determine the collar's effect on the risk of early periprosthetic fracture (<90 days). Nine (0.55%) early periprosthetic fractures were identified in the whole cohort. There were four fractures (1.65%) in the collarless stem group and five fractures (0.36%) in the collared stem group (p=0,005). One patient required revision surgery in the collared stem group, while two patients required revision surgery in the collarless stem group. The multinomial logistic regression model indicated a statistically significant lower (p<0.05) risk of early periprosthetic fracture within 90 days of surgery in the collared stems group. No other risk factor for early periprosthetic fractures has been identified. Using collared stems in cementless THA protects early periprosthetic femoral fractures within 90 days of surgery

Introduction. Debridement, antibiotics irrigation and implant retention (DAIR) is a common management strategy for hip and knee prosthetic joint infections (PJI). However, failure rates remain high, which has led to the development of predictive tools to help determine success. These tools include KLIC and CRIME80 for acute-postoperative (AP) and acute haematogenous (AH) PJI respectively. We investigated whether these tools were applicable to a Waikato cohort. Method. We performed a retrospective cohort study that evaluated patients who underwent DAIR between January 2010 and June 2020 at Waikato Hospital. Pre-operative KLIC and CRIME80 scores were calculated and compared to success of operation. Failure was defined as: (i) need for further surgery, (ii) need for suppressive antibiotics, (iii) death due to the infection. Logistic regression models were used to calculate the area under the curve (AUC). Results. 117 eligible patients underwent DAIR, 53 in the AP cohort and 64 in the AH cohort. Failure rate at 2 years post-op was 43% in the AP cohort and 59% in the AH cohort. In the AP cohort a KLIC score of <4 had a DAIR failure rate of 28.6%, while those who scored ³4 had a failure rate of 72.2% (p=0.002). In the AH cohort a CRIME80 score of <3 had a DAIR failure rate of 48% while those who scored ³3 had a 100% failure rate (p<0.001). Discussion. This study represents the first external validation of the KLIC and CRIME80 scores for predicting DAIR failure in an Australasian population. The results indicate that both KLIC and CRIME80 scoring tools are valuable aids for the clinician seeking to determine the optimal management strategy in patients with AP or AH PJI

Aims. The aim of this study was to screen the entire genome for genetic markers associated with risk for anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injury. Methods. Genome-wide association (GWA) analyses were performed using data from the Kaiser Permanente Research Board (KPRB) and the UK Biobank. ACL and PCL injury cases were identified based on electronic health records from KPRB and the UK Biobank. GWA analyses from both cohorts were tested for ACL and PCL injury using a logistic regression model adjusting for sex, height, weight, age at enrolment, and race/ethnicity using allele counts for single nucleotide polymorphisms (SNPs). The data from the two GWA studies were combined in a meta-analysis. Candidate genes previously reported to show an association with ACL injury in athletes were also tested for association from the meta-analysis data from the KPRB and the UK Biobank GWA studies. Results. There was a total of 2,214 cases of ACL and PCL injury and 519,869 controls within the two cohorts, with three loci demonstrating a genome-wide significant association in the meta-analysis: INHBA, AEBP2, and LOC101927869. Of the eight candidate genes previously studied in the literature, six were present in the current dataset, and only COL3A1 (rs1800255) showed a significant association (p = 0.006). Conclusion. Genetic markers in three novel loci in this study and one previously-studied candidate gene were identified as potential risk factors for ACL and PCL injury and deserve further validation and investigation of molecular mechanisms. Cite this article: Bone Jt Open 2021;2(6):414–421

Iliopsoas tendonitis occurs in up to 30% of patients after hip resurfacing arthroplasty (HRA) and is a common reason for revision. The primary purpose of this study was to validate our novel computational model for quantifying iliopsoas impingement in HRA patients using a case-controlled investigation. Secondary purpose was to compare these results with previously measured THA patients. We conducted a retrospective search in an experienced surgeon's database for HRA patients with iliopsoas tendonitis, confirmed via the active hip flexion test in supine, and control patients without iliopsoas tendonitis, resulting in two cohorts of 12 patients. The CT scans were segmented, landmarked, and used to simulate the iliopsoas impingement in supine and standing pelvic positions. Three discrete impingement values were output for each pelvic position, and the mean and maximum of these values were reported. Cup prominence was measured using a novel, nearest-neighbour algorithm. The mean cup prominence for the symptomatic cohort was 10.7mm and 5.1mm for the asymptomatic cohort (p << 0.01). The average standing mean impingement for the symptomatic cohort was 0.1mm and 0.0mm for the asymptomatic cohort (p << 0.01). The average standing maximum impingement for the symptomatic cohort was 0.2mm and 0.0mm for the asymptomatic cohort (p << 0.01). Impingement significantly predicted the probability of pain in logistic regression models and the simulation had a sensitivity of 92%, specificity of 91%, and an AUC ROC curve of 0.95. Using a case-controlled investigation, we demonstrated that our novel simulation could detect iliopsoas impingement and differentiate between the symptomatic and asymptomatic cohorts. Interestingly, the HRA patients demonstrated less impingement than the THA patients, despite greater cup prominence. In conclusion, this tool has the potential to be used preoperatively, to guide decisions about optimal cup placement, and postoperatively, to assist in the diagnosis of iliopsoas tendonitis

OpenPredictor, a machine learning-enabled clinical decision aid, has been developed to manage backlogs in elective surgeries. It aims to optimise the use of high volume, low complexity surgical pathways by accurately stratifying patient risk, thereby facilitating the allocation of patients to the most suitable surgical sites. The tool augments elective surgical pathways by providing automated secondary opinions for perioperative risk assessments, enhancing decision-making. Its primary application is in elective sites utilising lighter pre-assessment methods, identifying patients with minimal complication risks and those high-risk individuals who may benefit from early pre-assessment. The Phase 1 clinical evaluation of OpenPredictor entailed a prospective analysis of 156 patient records from elective hip and knee joint replacement surgeries. Using a polynomial logistic regression model, patients were categorised into high, moderate, and low-risk groups. This categorisation incorporated data from various sources, including patient demographics, co-morbidities, blood tests, and overall health status. In identifying patients at risk of postoperative complications, OpenPredictor demonstrated parity with consultant-led preoperative assessments. It accurately flagged 70% of patients who later experienced complications as moderate or high risk. The tool's efficiency in risk prediction was evidenced by its balanced accuracy (75.6%), sensitivity (70% with a 95% confidence interval of 62.05% to 76.91%), and a high negative predictive value (96.7%). OpenPredictor presents a scalable and consistent solution for managing elective surgery pathways, comparable in performance to secondary consultant opinions. Its integration into pre-assessment workflows assists in efficient patient categorisation, reduces late surgery cancellations, and optimises resource allocation. The Phase 1 evaluation of OpenPredictor underscores its potential for broader clinical application and highlights the need for ongoing data refinement and system integration to enhance its performance

Aims. To analyze the potential role of synovial fluid peptidase activity as a measure of disease burden and predictive biomarker of progression in knee osteoarthritis (KOA). Methods. A cross-sectional study of 39 patients (women 71.8%, men 28.2%; mean age of 72.03 years (SD 1.15) with advanced KOA (Ahlbäck grade ≥ 3 and clinical indications for arthrocentesis) recruited through the (Orthopaedic Department at the Complejo Asistencial Universitario de León, Spain (CAULE)), measuring synovial fluid levels of puromycin-sensitive aminopeptidase (PSA), neutral aminopeptidase (NAP), aminopeptidase B (APB), prolyl endopeptidase (PEP), aspartate aminopeptidase (ASP), glutamyl aminopeptidase (GLU) and pyroglutamyl aminopeptidase (PGAP). Results. Synovial fluid peptidase activity varied significantly as a function of clinical signs, with differences in levels of PEP (p = 0.020), ASP (p < 0.001), and PGAP (p = 0. 003) associated with knee locking, PEP (p = 0.006), ASP (p = 0.001), GLU (p = 0.037), and PGAP (p = 0.000) with knee failure, and PEP (p = 0.006), ASP (p = 0.001), GLU (p = 0.037), and PGAP (p < 0.001) with knee effusion. Further, patients with the greatest functional impairment had significantly higher levels of APB (p = 0.005), PEP (p = 0.005), ASP (p = 0.006), GLU (p = 0.020), and PGAP (p < 0.001) activity, though not of NAP or PSA, indicating local alterations in the renin-angiotensin system. A binary logistic regression model showed that PSA was protective (p = 0.005; Exp (B) 0.949), whereas PEP (p = 0.005) and GLU were risk factors (p = 0.012). Conclusion. These results suggest synovial fluid peptidase activity could play a role as a measure of disease burden and predictive biomarker of progression in KOA. Cite this article: Bone Joint Res 2020;9(11):789–797

There is very limited literature describing the outcomes of management for proximal humerus fractures with more than 100% displacement of the head and shaft fragments as a separate entity. This study aimed to compare operative and non-operative management of the translated proximal humerus fracture. A prospective cohort study was performed including patients managed at a Level 1 trauma centre between January 2010 to December 2018. Patients with 2, 3 and 4-part fractures were included based on the degree of translation of the shaft fragment (≥100%), resulting in no cortical contact between the head and shaft fragments. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Linear and logistic regression models were used to compare management options. There were 108 patients with a proximal humerus fracture with ≥100% translation; 76 underwent operative management and 32 were managed non-operatively with sling immobilisation. The mean (SD) age in the operative group was 54.3 (±20.2) and in the non-operative group was 73.3 (±15.3) (p<0.001). There was no association between OSS and management options (mean 38.5(±9.5) operative vs mean 41.3 (±8.5) non-operative, p=0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference 0.16 (95%CI 0.04-0.27, p=0.008); EQ-5D VAS adjusted mean difference 19.2 (95%CI 5.2-33.2, p=0.008). Operative management was further associated with a lower odds of non-union (adjusted OR 0.30, 95%CI 0.09-0.97, p=0.04), malunion (adjusted OR 0.14, 95%CI 0.04-0.51, p=0.003) and complications (adjusted OR 0.07, 95%CI 0.02-0.32, p=0.001). Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes following surgical fixation. Patients with this injury should be considered for operative intervention