Aims. The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. Methods. Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups. Results. Data were analyzed from 568 patients, recruited in 38 UK secondary care sites between October 2017 and October 2018 (43.5% male; mean (SD) age 71.86 years (9.93); 305 hips, 263 knees). No significant inclusion differences were identified between the two groups. For hip revision, time to revision > ten years (odds ratio (OR) 3.804, 95% confidence interval (CI) (1.353 to 10.694), p = 0.011), periprosthetic fracture (OR 20.309, 95% CI (4.574 to 90.179), p < 0.001), and dislocation (OR 12.953, 95% CI (4.014 to 41.794), p < 0.001), were associated with unplanned revision. For knee, there were no associations with route to revision. Revision after ten years was more likely for those who were younger at primary surgery, regardless of route to revision. No significant differences in cost outcomes, length of surgery time, and access to a health professional in the year prior to revision were found between the two groups. When periprosthetic fractures, dislocations, and infections were excluded, healthcare use was significantly higher in the unplanned revision group. Conclusion. Differences between characteristics for patients presenting for planned and unplanned revision are minimal. Although there was greater healthcare use in those having unplanned revision, it appears unlikely that routine orthopaedic review would have detected many of these issues. It may be safe to disinvest in standard follow-up provided there is rapid access to orthopaedic review. Cite this article: Bone Joint J 2022;104-B(1):59–67

Aims. The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis. Methods. A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated. Results. The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis. Conclusion. Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases. Level of evidence: II. Cite this article: Bone Jt Open 2021;2(12):1027–1034

Introduction: Fifteen revision knee arthroplasties were navigated (Praxim, Grenoble, France). The purpose was to investigate whether revision procedures would require a dedicated navigation system. Material: Two prostheses were revised for severe instability, two for catastrophic failure due to poly wear, 9 for loosening (1 femoral, 1 tibial and 3 both components in total knee arthroplasties, 3 femoral and 1 tibial in uni), two for late infection in extensively cemented prosthesis. The patients were revised using TC3 postero-stabilised revision implants (Depuy, Warsaw, Indiana) and one with hinge prosthesis. Method: Preoperatively, the rotation of the femoral component was investigated by scanner, and the ideal level of the joint line was determined relative to the fibula head on the healthy contralateral side. Navigation was performed with dependant bone cuts, tibia first. The tibial trackers were implanted distally, while the femoral trackers were implanted medially close to the joint line, to prevent impingement with the stems. Bone morphing was performed on the surface of the ancient prosthesis. The system showed the difference between the level of the ideal joint line and the real bone cut, thus indicating the height that had to be reconstructed. The provisional tibial plateau was assembled with its stem and its metallic augments and the knee was balanced with the new tibial component and the ancient femoral component still in place. Femoral reconstruction was finally performed based on an ideal position that had memorized by the computer. Bone reconstruction was required in 2 tibias (morselized allografts) and in one femur (structural femoral head allografts). Results: With a 6-months minimum follow-up, there was no postoperative complication. The HKA angles ranged from 176 to 185. The patella appeared centered on the Merchant view in 14 cases. The femoral rotation was contained between 0 and 5 degrees of external rotation. The 6 month ranges of flexion were 105° with an average gain of −4°. Conclusion: The navigation was a precious help to guide reconstruction of both extremities tibial and femoral, while maintaining the level of the joint line. The navigation system designed for primary surgery appeared convenient to perform revision surgery

Complex primary total knee replacements have been poorly reported in the literature We review all complex primary total knee replacement procedures at Stepping Hill Hospital. Patients underwent knee examination, knee scores, notes review and pre- and post-operative radiograph review. There were 29 patients with 36 knees that had a complex primary total knee replacement. Most frequent indications for surgery were osteoarthritis, rheumatoid arthritis or following trauma. Mean age at surgery 70 years. The prosthesis used were : 3 Stryker Kinemax; 32 De Puy PFC and one rotating hinge. Complex Primary Oxford knee score; preoperative mean 45 (range 33 to 57); postoperative mean 26 (range 14 to 53). NJR Total Knee Replacement Oxford knee score postoperative mean 30. Mean visual analogue scores; pain in the knee, mean 19; knee function, mean 77; outcome of the operation 76; satisfaction with the surgery 87. Mean length of hospital stay 13 days.

Using the Knee Society Radiographic Scoring System, there were no signs that need to be monitored or signify failure. Seven patients were transfused postoperatively, four patients had minor wound problems, three required further surgery, two to washout the knee and exchange the polyethylene liner, one femoral plating to stabilise an osteotomy site. Long term complications : one above knee amputation for infection, one foot drop.

Revision implants can be used in complex primary knee replacements, and pose technical difficulties but address various pathologies. The surgery is associated with an increased risk of complications and transfusion. Clinical scores at least match scores for routine total knee replacements, patient satisfaction is excellent.

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement).

Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair.

A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group.

Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed.

We report a cost-effectiveness analysis of Primary Total Ankle Replacements (TAR). In addition, we looked for factors that could be predictors of increased gain in Quality-Adjusted Life Years (QALYs).

Pre-operative and six-month post-operative data for TAR was obtained over seven-and-a-half-years in NHS Lothian. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and Deprivation category. Continuous variables were assessed with Pearson correlation coefficients, Deprivation and BMI categories with Boxplots and gender with the Mann-Whitney U test.

The 74-patient cohort [Mean age 68.03 (SD 8.61), 60.8% male] had 49% classed as obese or higher. Cost per QALY gained was £3841, rising to £9202 when annual 3.5% reduction in health gains and 1.9% revision rates were included. Lower pre-operative EQ-5D-3L index correlated significantly with increased QALYs gained (p <0.01), all other predictors returned insignificant results (p >0.05).

Primary TAR has proven very cost-effective in treating end-stage ankle arthritis. Pre-operative EQ-5D-3L is the most promising predictor of QALYs gained identified.

Objective of the study is to determine to what extent patients experience more limitations 1–5 years after revision total hip arthroplasty (THA) compared to patients after primary THA, and if this is accompanied by a reduction in physical activity behavior. Five hundred and six patients were included: 372 primary and 134 revision THA. Questionnaires were used to measure limitations and physical activity. Linear regression analysis showed that patients after revision surgery report significantly more, clinically relevant limitations compared with primary THA patients, but did not show a significant difference in mean total minutes of physical activity per week. Physical activity behavior appeared to be similar for primary and revision THA patients. The results stress the importance of determining different aspects of recovery after THA.

Aim. A significant number of patients undergoing shoulder arthroplasty surgery have C acnes contamination at the end of the primary surgery. The objective of this study is to determine whether patients with C acnes contamination at the end of their primary shoulder surgery have a worse prognosis than those who end up without C. acnes contamination. Method. Prospective study including all patients who underwent a reverse shoulder prosthesis from January 2015 to December 2018. In all of them, 5 to 12 cultures were performed during primary surgery. The patients underwent surgery for shoulder arthritis secondary to rotator cuff tears, acute fracture of the proximal humerus, and sequelae of fracture of the proximal humerus. Exclusion criteria included the existence of previous surgeries on the affected shoulder, the presence of signs of infection, having received infiltrations and / or complementary invasive examinations (Arthro-MRI and Arthro-CT). Follow-up from 2 to 5 years. Functional assessment according to the Constant Functional Scale. All complications were also recorded. Results. 162 patients were included. Of these, 25 had positive cultures for C. acnes at the end of primary shoulder surgery. Average age of 74.8 years. 136 women and 26 men. 75.9% Shoulder arthritis secondary to rotator cuff tears, 13.6% acute fractures and 10.5% sequelae of fractures. There were no differences between patients with C. acnes and those without C. acnes regarding age and indication for surgery. Predominance of men in the group with positive C. acnes (p <0.001). No differences at 2 and 5 years in the Constant functional scale between the two groups (2 years, 59.6 vs 59.2 p 0.870) (5 years, 62.4 vs 59.5 p 0.360). Significant differences regarding the number of complications (p 0.001). Patients without C. acnes had 1 aseptic loosening of the metaglene and patients with C. acnes had 2 infections, 1 dislocation, and 1 revision surgery. Patients with contamination by C. acnes had more comorbidities (p 0.035) than patients without contamination. Conclusions. Patients with C acnes contamination at the end of primary surgery do not have functional differences when compared with patients without contamination at 2 and 5 years, but they have a higher number of complications in the medium term

Aim. This retrospective study evaluated the outcome of treatment for unhealed fracture-related infections (FRI). Methods. We identified a consecutive, single-centre cohort of patients having treatment for an FRI Consensus confirmed FRI. All fractures were unhealed at the time of treatment. Patients were followed up for at least one year. Successful outcome was a healed fracture without recurrent infection. Lack of union, persistent infection and/or unplanned reoperation defined failure. Results. Demographics: 183 patients (184 FRIs) with mean age 52.1 years (range 17-96) were treated and followed up for a mean of 2.8 years (range 1-9.4). Mean duration of FRI was 1.1 years with 65 (35.5 %) presenting within 6 months of injury. 118 patients had established infected non-union. FRI was most frequent in the tibia (74), femur (48) and humerus (24). 171 patients were BACH Complex. 75.5% of FRIs were culture positive, with Staph. aureus being the most frequent organism. Polymicrobial infection and Gram negative cultures were common (25.5% and 33.6%). Treatment: 98.3% of surgeries were performed in one stage with just 3 planned 2-stage procedures (2 endoprosthetic replacements and 1 free fibular flap). No bone graft was used in any surgery and all wounds were closed at first operation. 48 cases (26%) required flap coverage (29 free flaps and 19 local flaps). Local antibiotics were used in 124 cases (67.4%) of primary surgeries. All patients had sampling, debridement, systemic antibiotics and wound closure. 40 (21.7%) had DAIR, 31 (16.8%) had new internal fixation and 105 (57.1%) had external fixation (including 79 Ilizarov fixators). Outcomes: After primary surgery, 84.6% of all patients were infection-free and 77.2% had united. After further surgery, 98.8% were infection-free and 98.1% had united. External fixation techniques achieved infection eradication in 89.1% compared to 71.7% with any internal fixation (p=0.005). Primary internal fixation achieved union in 81.7% compared to 74.3% with external fixation (p=0.27). Secondary surgery after external fixation was mainly docking site fixation. Conclusion. Unhealed FRIs present a difficult challenge for treatment. This large series demonstrated that single-stage treatment, without bone grafting, gave acceptable results with few reoperations. Primary external fixation gave more certainty of infection eradication but required more reoperations to secure union. However, this difference in reoperation was not statistically significant. We strongly advocate managing these patients with a multidisciplinary team which can treat all aspects of the condition

Aim. Cutibacterium acnes (C. acnes) is the most cultured organism implicated in periprosthetic shoulder infections. Nevertheless, the clinical significance of its persistence on the skin surface and in the deep layers during shoulder arthroplasty surgery remains still unknown. The purpose of this study was to know if the C. acnes isolate present in deep tissues at the end of a primary shoulder arthroplasty could be responsible for shoulder arthroplasty infection. Method. Prospective study including 156 patients undergoing primary shoulder arthroplasty. In all the patients included 5 to 12 tissue samples were obtained and were specifically cultured to detect C. acnes presence. DNA was extracted from the C. acnes colonies selected with the QIAsymphony DSP Virus/Pathogen Midi Kit (Qiagen, Hilden, Germany). Libraries were prepared using Nextera XT kit (Illumina) and sequenced in an Illumina MiSeq sequencer. Sequencing files were pre-processed using The Microbial Genome Atlas pipeline. Samples that failed on QC analysis were discarded for further analysis. Isolate nucleotide distances were calculated using Genome-based distance matrix calculator from the enveomics collection. Comparative genomic analysis was performed between intra- and inter-patients’ isolates. Data analysis was performed using R 3.6.3. Results. For twenty-seven out of 156 patients (17.31%), C. acnes was present at the end of the primary surgery. Two of these patients (both male) developed a C. acnes periprosthetic shoulder infection after 6 and 4 months from the primary surgery. DNA from the C. acnes responsible for the periprosthetic infection was further analysed by whole genome sequencing (WGS). Average Nucleotide Identity (ANI) value was assessed, measuring the nucleotide-level genomic similarity between genome pairs. We found a clear ANI clustering in two major groups which corresponded, mainly, to the associated phylotype (97%–98% ANI). Moreover, when analysing both isolates that developed a periprosthetic shoulder infection, we found that all the revision-surgery isolates clustered nearer to their corresponding primary-surgery isolates (99.4% of similarity) than to the other independent bacterial isolates, supporting the causal relationship between the initial and the delayed infection. Conclusions. C. acnes present at the end of the primary surgery can be the cause of early- or delayed-periprosthetic joint infections in shoulder arthroplasty, revealing the potential route of infection. Therefore, efforts must be made in terms of antibiotic prophylaxis and skin preparation to limit infections of total shoulder arthroplasties

While pre-soaking grafts in vancomycin has demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. The primary aim of this study was to determine the cost-effectiveness of vancomycin pre-soaking during primary ACLR to prevent post-operative joint infections. The secondary aims of the study were to establish the breakeven cost-effectiveness threshold of the technique. A Markov model was used to determine cost effectiveness and the incremental cost effectiveness ratio of additional vancomycin pre-soaking compared to intravenous antibiotic prophylaxis alone. A repeated meta-analysis of nine cohort studies (Level III evidence) was completed to determine the odds ratio of infection with vancomycin pre-soaking compared to intravenous antibiotics alone. Estimated costs and transitional probabilities for further surgery were obtained from the literature. Breakeven threshold analysis was performed. The vancomycin soaking technique provides an expected cost saving of $600AUD per patient. There was an improvement in the quality-adjusted life years of 0.007 compared to intravenous antibiotic prophylaxis alone (4.297 versus 4.290). If the infection rate is below 0.023% with intravenous antibiotics alone or the additional intervention cost more than $1000AUD, the vancomycin wrap would no longer be cost-effective. For $30AUD, the vancomycin soaking technique provides a $600AUD cost saving by both reducing the risk of ACLR related infection and economic burden of infection. Treating septic arthritis represents a mean cost per patient of 6 times compared to that of the primary surgery. There has been no previous cost-effectiveness study of the vancomycin wrap technique. The vancomycin pre-soaking technique is a highly cost-effective method to prevent post-operative septic arthritis following primary ACLR

Periprosthetic joint infection is a serious complication of primary total hip replacement (THR) with significant associated morbidity. In acute infection, Debridement, Antibiotics and Implant Retention (DAIR) may be considered. Current national guidelines recommend a DAIR should be performed by “an experienced arthroplasty surgeon┕ but do not specify the need for this to be a revision arthroplasty surgeon. We investigated outcomes in our NHS Trust of DAIR procedures performed by revision and non-revision arthroplasty surgeons. Infection registry data and patient records were analysed for all DAIR procedures of infected primary THRs between 2017 and 2021. Data collected included details of the primary surgery, the presentation with infection, the DAIR procedure and any subsequent complications including return to theatre at any time point. Routinely collected pre- and post-operative patient reported outcome measures (PROMs) were reviewed. 54 periprosthetic joint infections of primary THRs received a DAIR procedure. 41 DAIRs were performed by a revision surgeon and 13 by non-revision surgeons. There was no significant difference in time from primary THR to presentation with infection, time from presentation to DAIR or pre-operative C-reactive protein between the two groups. In 21 (38.9%) patients the DAIR procedure was classed as a treatment failure; 17 patients (31.5%) returned to theatre for further revision surgery, one (2.4%) died related to infection and three (5.6%) had persistent infection but did not receive further surgery. Treatment failure was significantly higher in the non-revision surgeon group (9/13 (69.2%)) than in the revision surgeon group (12/41 (29.3%)) (p = 0.02). Overall, improvement in PROMs after DAIR was seen at both six and 12 months. The overall success rate of DAIR was 61.1% and there was a sustained improvement in PROMs after surgery. However, there was a significant difference in failure rates between revision surgeons and non-revision surgeons

The Accolade®TMZF is a taper-wedge cementless metaphyseal coated femoral stem widely utilized from 2002-2012. In recent years, there have been reports of early catastrophic failure of this implant. Establishing a deeper understanding of the rate and causes of revision in patients who developed aseptic failure in stems with documented concerns about high failure rates is critical. Understanding any potential patient or implant factors which are risk factors for failure is important to inform both clinicians and patients. We propose a study to establish the long-term survival of this stem and analyze patients who underwent aseptic revision to understand the causes and risk factors for failure. A retrospective review was undertaken of all patients who received a primary total hip arthroplasty with an Accolade® TMZF stem at a high-volume arthroplasty center. The causes and timing of revision surgery were documented and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to minimize loss to follow-up. Survivorship analysis was performed with use of the Kaplan-Meier curves to determine the overall and aseptic survival rates at final follow-up. Patient and implant factors commonly associated with aseptic failure were extracted and Cox proportional hazards model was used. A consecutive series of 2609 unilateral primary THA patients implanted with an Accolade®TMZF femoral hip stem were included. Mean time from primary surgery was 12.4 years (range 22 days to 19.5 years). Cumulative survival was 96.1% ± 0.2 at final follow-up. One hundred and seven patients underwent revision surgery with aseptic loosening of the femoral component was the most common cause of aseptic failure in this cohort (33/2609, 1.3%). Younger age and larger femoral head offset were independent risk factors for aseptic failure. To our knowledge, this is the largest series representing the longest follow-up of this taper-wedge cementless femoral implant. Despite early concerns, the Accolade® TMZF stem has excellent survivorship in this cohort. Trunnionosis as a recognized cause for revision surgery was rare. Younger age and larger femoral head offset were independent risk factors for aseptic failure

Aims. Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately. Methods. We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately. Results. Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group. Conclusion. In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods. Cite this article: Bone Jt Open 2024;5(2):86–92

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery. Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test. A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point. In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 - 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Aims. Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery. Methods. Retrospective review of osseointegration frequency, pattern, and timing to a specific HA-coated collar on massive endoprostheses used in revision surgery at our tertiary referral centre between 2010 to 2017 was undertaken. Osseointegration was radiologically classified on cases with a minimum follow-up of six months. Results. In all, 39 patients underwent radiological review at mean 43.5 months; 22/39 (56.4%) showed no osseointegration to the collar. Revision endoprostheses for aseptic loosening were less likely to show osseointegration compared with other indications for revision. Oncological cases with previous or current infection were more likely to show osseointegration to ≥ 1 collar side than those without evidence of prior infection. Conclusion. This seven-year review identified osseointegration of HA-coated collars after revision surgery is less likely (43.6%, 17/39) than after primary surgery. Young patients who undergo revision surgery following initial oncological indication may benefit the most from this collar design. Use in revision oncological cases with a history of infection may be beneficial. HA-coated collars showed limited benefit for patients undergoing revision for failed arthroplasty with history of infection. Cite this article: Bone Jt Open 2021;2(6):371–379

Introduction. Osseointegration has emerged as a promising alternative to rehabilitating with a traditional socket mounted prosthesis. Advantages have been reported to include improved functional mobility, better osseoperception, improved comfort, reduced pain, better biomechanical alignment and better gait, which all lead to a less restricted lifestyle and significantly improved quality of life. A major concern of the Osseointegrated approach lies in the risk of infections occurring from the permanent transcutaneous opening often referred to as the stoma. Several systematic reviews have indicated that the occurrence of minor infections can be quite common, serious complications are reported to be rare. In addition to commonly anticipated complications including fractures, surgical debridements or revisions, we have identified several significant events in which a patient may require to be readmitted and go through additional surgery. The objective of this study is to examine the rate of occurrence and reports on the best management practices of serious complications across a multi-centre review of more than 1000 osseointegration surgeries. Materials & Methods. A detailed analysis has been performed on all osseointegration surgeries performed by the Osseointegration Group of Australia and it's affiliates between since 2010. The majority of surgeries took place in Australia, the United States, the Middle East as well as in Europe. All events leading to a re-admission and subsequent re-operation have been identified through hospital operation records and pooled together for meta-analysis. Events identified include: revision of implants, periprosthetic fracture fixation, surgical debridement due to infections, neurectomies and soft- tissue refashioning. Results. Over 800 surgeries have been identified with a minimum 12-month follow-up time and included in this study. These included tibial, femoral and humeral, radial-ulnar and transpelvic osseointegration cases. The majority of these were performed using a single stage protocol. While general complications such as infection and soft tissue refashioning are common, serious events such as revision and fracture are rare. Interestingly, the rate of debridements and soft-tissue refashions were found to be higher among patients who were operated using a two-stage surgery. Among all cases, there were a total of 399 re-operation events recorded which occurred among 163 patients, indicating a high recurrence rate among the same patients. We recorded a total of 112 washouts, 93 neurectomies, 117 soft tissue refashions, 53 implant revisions and 24 periprosthetic fracture fixations. Conclusions. Many events leading to readmission after the primary surgery may not necessarily be graded as a complication of the osseointegration technique. This study has identified several addition possible reasons in which an osseointegration patient may need to be re-admitted into hospital for additional surgery. It was identified that through the implementation of improved surgical techniques and rehabilitation protocols, the rate of several of these re-operation events can be largely reduced, thus improving the overall outcomes of patients undergoing osseointegration surgery

External validation of machine learning predictive models is achieved through evaluation of model performance on different groups of patients than were used for algorithm development. This important step is uncommonly performed, inhibiting clinical translation of newly developed models. Recently, machine learning was used to develop a tool that can quantify revision risk for a patient undergoing primary anterior cruciate ligament (ACL) reconstruction (https://swastvedt.shinyapps.io/calculator_rev/). The source of data included nearly 25,000 patients with primary ACL reconstruction recorded in the Norwegian Knee Ligament Register (NKLR). The result was a well-calibrated tool capable of predicting revision risk one, two, and five years after primary ACL reconstruction with moderate accuracy. The purpose of this study was to determine the external validity of the NKLR model by assessing algorithm performance when applied to patients from the Danish Knee Ligament Registry (DKLR). The primary outcome measure of the NKLR model was probability of revision ACL reconstruction within 1, 2, and/or 5 years. For the index study, 24 total predictor variables in the NKLR were included and the models eliminated variables which did not significantly improve prediction ability - without sacrificing accuracy. The result was a well calibrated algorithm developed using the Cox Lasso model that only required five variables (out of the original 24) for outcome prediction. For this external validation study, all DKLR patients with complete data for the five variables required for NKLR prediction were included. The five variables were: graft choice, femur fixation device, Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life subscale score at surgery, years from injury to surgery, and age at surgery. Predicted revision probabilities were calculated for all DKLR patients. The model performance was assessed using the same metrics as the NKLR study: concordance and calibration. In total, 10,922 DKLR patients were included for analysis. Average follow-up time or time-to-revision was 8.4 (±4.3) years and overall revision rate was 6.9%. Surgical technique trends (i.e., graft choice and fixation devices) and injury characteristics (i.e., concomitant meniscus and cartilage pathology) were dissimilar between registries. The model produced similar concordance when applied to the DKLR population compared to the original NKLR test data (DKLR: 0.68; NKLR: 0.68-0.69). Calibration was poorer for the DKLR population at one and five years post primary surgery but similar to the NKLR at two years. The NKLR machine learning algorithm demonstrated similar performance when applied to patients from the DKLR, suggesting that it is valid for application outside of the initial patient population. This represents the first machine learning model for predicting revision ACL reconstruction that has been externally validated. Clinicians can use this in-clinic calculator to estimate revision risk at a patient specific level when discussing outcome expectations pre-operatively. While encouraging, it should be noted that the performance of the model on patients undergoing ACL reconstruction outside of Scandinavia remains unknown