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).

There is limited literature on the effects of socioeconomic factors on outcomes after total ankle arthroplasty (TAA). In the setting of hip or knee arthroplasty, patients of a lower socioeconomic status demonstrate poorer post-operative satisfaction, longer lengths of stay, and larger functional limitations. It is important to ascertain whether this phenomenon is present in ankle arthritis patients. This is the first study to address the weight of potential socioeconomic factors in affecting various socioeconomic classes, in terms of how they benefit from ankle arthroplasty. This is retrospective cohort study of 447 patients who underwent a TAA. Primary outcomes included pre-operative and final follow-up AAOS pain, AAOS disability, and SF-36 scores. We then used postal codes to determine median household income using Canadian 2015 census data. Incomes were divided into five groups based on equal amounts over the range of incomes. This method has been used to study medical conditions such as COPD and cardiac disease. These income groups were then compared for differences in outcome measures. Statistical analysis was done using unpaired t-test. A total of 447 patients were divided into quintiles by income. From lowest income to highest income, the groups had 54, 207, 86, 64, and 36 patients, respectively. The average time from surgery to final follow up was 85.6 months. Interestingly, we found that patients within the middle household income groups had significantly lower AAOS disability scores compared to the lowest income groups at final follow-up (26.41 vs 35.70, p=0.035). Furthermore, there was a trend towards middle income households and lower post-operative AAOS pain scores compared to the lowest income group (19.57 vs 26.65, p=0.063). There was also a trend toward poorer AAOS disability scores when comparing middle income groups to high income groups post-operatively (26.41 vs 32.27, p=0.058). Pre-operatively, patients within the middle-income group had more pain, compared to the lowest and the highest income groups. No significant differences in SF-36 scores were observed. There were no significant differences seen in middle income groups compared to the highest income group for AAOS pain post-operatively. There were no significant differences found in pre-operative AAOS disability score between income groups. Patients from middle income groups who have undergone TAA demonstrate poorer function and possibly more pain, compared to lower and higher income groups. This suggests that TAA is a viable option for lower socioeconomic groups and should not be a source of discouragement for surgeons. In this circumstance there is no real disparity between the rich and the poor. Further investigation is needed to explore reasons for diminished performance in middle class patients

Aims. This study aimed to identify risk factors (patient, healthcare system, and socioeconomic) for mortality after hip fractures and estimate their relative importance. Further, we aimed to elucidate mortality and survival patterns following fractures and the duration of excess mortality. Methods. Data on 37,394 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked to data from the Norwegian Patient Registry, Statistics Norway, and characteristics of acute care hospitals. Cox regression analysis was performed to estimate risk factors associated with mortality. The Wald statistic was used to estimate and illustrate relative importance of risk factors, which were categorized in modifiable (healthcare-related) and non-modifiable (patient-related and socioeconomic). We calculated standardized mortality ratios (SMRs) comparing deaths among hip fracture patients to expected deaths in a standardized reference population. Results. Mean age was 80.2 years (SD 11.4) and 67.5% (n = 25,251) were female. Patient factors (male sex, increasing comorbidity (American Society of Anesthesiologists grade and Charlson Comorbidity Index)), socioeconomic factors (low income, low education level, living in a healthcare facility), and healthcare factors (hip fracture volume, availability of orthogeriatric services) were associated with increased mortality. Non-modifiable risk factors were more strongly associated with mortality than modifiable risk factors. The SMR analysis suggested that cumulative excess mortality among hip fracture patients was 16% in the first year and 41% at six years. SMR was 2.48 for the six-year observation period, most pronounced in the first year, and fell from 10.92 in the first month to 3.53 after 12 months and 2.48 after six years. Substantial differences in median survival time were found, particularly for patient-related factors. Conclusion. Socioeconomic, patient-, and healthcare-related factors all contributed to excess mortality, and non-modifiable factors had stronger association than modifiable ones. Hip fractures contributed to substantial excess mortality. Apparently small survival differences translate into substantial disparity in median survival time in this elderly population. Cite this article: Bone Joint J 2022;104-B(7):884–893

Introduction. The aim of this study was to assess patients and healthcare professionals (HCPs) opinions on the validity of using a biopsychosocial model rather than a biomedical model in alleviating patient symptoms/pain. Method. We constructed a questionnaire to assess beliefs on the effectiveness of using a biopsychosocial or biomedical model to develop a treatment plan to optimise patient symptoms/pain. We distributed the questionnaire to new and follow-up patients and healthcare professional in the orthopaedic department. Results. 246 questionnaires were completed - 183 patients and 63 HCPs. The patient group consisted of 77 males and 106 females, the HCP group of 27 males and 36 females. 77(42%) of patients and 9(14%) of HCPs agree the biomedical model is best suited to treat symptoms. 81(44%) of patients and 62(98%) of HCPs agree the biopsychosocial model is best suited to treat symptoms. 70(38%) of patients and 61 (97%) of HCPs agree stress can increase pain. 87(48%) of patients and 62(98%) of HCPs agree distress can increase pain. 83(45%) of patients and 56(89%) of HCPs agree stress can increase disability. 81(44%) of patients and 56(89%) of HCPs agree distress can increase disability. 39(21%) of patients and 43(68%) of HCPs agree if all investigations show no abnormality in explaining symptoms, the main contributor is stress, distress or psychological/socioeconomic factor. Conclusion. HCPs recognise the biopsychosocial model as a useful tool in managing patients pain/symptoms which not recognised by patients. HCPs believe that stress, distress, psychological/socioeconomic factors have a significant impact on a patients pain and disability when compared to patients. No conflicts of interest. No funding obtained

Aims. Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford. Methods. An observational study was conducted, using data from the Bradford Teaching Hospitals TB database of patients with a formal diagnosis of MSK TB between January 2005 and July 2017. Patient data included demographic data (including nationality/date of entry to the UK), disease focus, microbiology, and management strategies. Disease incidence was calculated using population data from the Office for National Statistics. Poisson confidence intervals were calculated to demonstrate the extent of statistical error. Disease incidence and nationality were also analyzed, and correlation sought, using the chi-squared test. Results. Between January 2005 and July 2017, 109 cases of MSK TB were diagnosed in Bradford. Mean incidence was 1.65 per 100,000 population, per calendar year (SD 0.75). A total of 38 cases required surgical intervention. Low rates of antimicrobial resistance were encountered. A low rate of loss to follow-up was observed (four patients; 3.7%). Overall, 94.5% of patients (n = 103) were successfully treated. 67% of patients (n = 73) reported their country of origin as either India, Pakistan, or Bangladesh. These ethnicities account for around 25% of the local population. Conclusion. Bradford maintains a high prevalence of MSK TB infection relative to national data; the prevalence within the local immigrant population remains grossly disproportionate. Typical associated factors (HIV/hepatitis coinfection, drug resistance), have only modest prevalence in our dataset. However, local socioeconomic factors such as deprivation and poverty appear germane as suggested by global literature. We advocate a high degree of suspicion in treatment of atypical infection in any area with similar population factors to ensure timely diagnosis. Cite this article: Bone Jt Open 2022;3(5):432–440

Aims. The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. Patients and Methods. Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors. Results. The use of short and long intramedullary nails was associated with an increase in 30-day mortality (adjusted odds ratio (OR) 1.125, 95% confidence interval (CI) 1.040 to 1.218; p = 0.004) compared with the use of sliding hip screws (12.5% increase). If this were causative, it would represent 98 excess deaths over the four-year period of the study and one excess death would be caused by treating 112 patients with an intramedullary nail rather than a sliding hip screw. Conclusion. There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of a trochanteric fractures of the hip

To design osteoarthritis (OA) care based on prognosis, we need to identify individuals who are most likely of disease progression. We estimated survival time of the native hip and knee joint and evaluated what patient-related and OA disease-related factors associated with progression to joint replacement surgery. We included 72,069 patients referred to first-line OA intervention (patient education and exercise) during 2008 and 2016 and registered in the Swedish quality register Better Management of Patients with Osteoarthritis (BOA). Kaplan–Meier survival analyses were used to estimate joint survival time. Hazard ratios (HR) with 95% confidence interval [CI] were calculated using multiple Cox regression. The 5-year survival time of the native joint was 56% for hip OA and 80% for knee OA. Disease-related factors were more strongly associated with progression to joint replacement (e.g. willingness for surgery HR; hip 2.9 [95% CI, 2.7–3.1], knee 2.7 [2.6–2.9] and walking difficulties (HR; hip 2.2 [2.0–2.5], knee 1.9 [1.7–2.2]), than patient-related factors such socioeconomic factors (e.g. highest income quartile HR; hip 1.3 [1.2–1.3], knee 1.3 [1.2–1.4]) and comorbidities (e.g. ≥6 conditions HR; hip: 0.7 [0.6–0.7], knee; 1.1 [1.0–1.2]). Patients with hip OA were more likely to undergo surgery and at an earlier time compared with those with knee OA. Progression was strongly influenced by factors associated with the OA disease, but other patient-related factors are important. However, a large proportion of patients with OA do not seem to require surgery, especially among those with knee OA

Background. Patients with Neck and/or Low Back Pain (NLBP) constitute a heterogeneous group with the prognosis and precise mix of factors involved varying substantially between individuals. This means that a one-size-fits-all approach is not recommended, but methods to tailor treatment to the individual needs are still relatively under-developed. Moreover, the fragmentation of disciplines involved in its study hampers achieving sound answers to clinical questions. Data mining techniques open new horizons by combining data from existing datasets, in order to select the best treatment at each moment in time to a patient based on the individual characteristics. Method. Within the Back-UP project (H2020 #777090) a multidisciplinary consortium is creating a prognostic model to support more effective and efficient management of NLBP, based on the digital representation of multidimensional clinical information. Patient-specific models provide a personalized evaluation of the patient case, using multidimensional health data from the following sources: (1) psychological, behavioral, and socioeconomic factors, (2) biological patient characteristics, including musculoskeletal structures and function, and molecular data, (3) workplace and lifestyle risk factors. Conclusion. The Back-UP system leverages shared-decision making, not only by enabling interoperability between all professionals involved in the care trajectory, but also empowering the patient in the decisions related to his/her care path. Furthermore, dynamic intervention models ensure that the patient receives the most beneficial treatment at each moment in time, considering the current position of the patient in the care path (i.e. within clinical rehabilitation, in return-to-work process or through motivational strategies supporting self-management in daily life). No conflicts of interest. Sources of funding: This project has received funding from the European Union Horizon 2020 research and innovation programme under grant agreement No 777090

Radial head fractures are common and mainly require a functional conservative treatment. About 20% of patients will present an unsatisfactory final functional result. There is, however, little data allowing us to predict which patients are at risk of bad evolve. This makes it difficult to optimize our therapeutic strategies in these patients. The aim of this study is to determine the personal and environmental factors that influence the functional prognosis of patients with a radial head fracture. We realized over a 1-year period a prospective observational longitudinal cohort study including 125 consecutive patients referred for a fracture of the radial head in a tertiary trauma center. We originally collected the factors believed to be prognostic indicators: age, sex, socioeconomic status, factors related to trauma or fracture, alcohol, tobacco, detection of depression scale, and financial compensation. A clinical and radiological follow-up took place at 6 weeks, 3 months, 6 months, and 1 year. The main functional measurement tool is the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH). 123 patients were included in the study. 114 patients required nonsurgical management. 102 patients completed the 1-year follow-up for the main outcome (89 for the DASH score). Two patients required an unplanned surgery and were excluded from analyses. At 1 year, the average MEPS was 96.5 (range, 65–100) and 81% of subjects had an excellent result (MEPS ≥90). The most constant factor to predict an unsatisfactory functional outcome (MEPS <90 or DASH >17) is the presence of depressive symptoms at the initial time of the study (P = 0.03 and P = 0.0009, respectively). This factor is present throughout the follow-up. Other observed factors include a higher socioeconomic status (P = 0.009), the presence of financial compensation (P = 0.027), and a high-velocity trauma (P = 0.04). The severity of the fracture, advanced age, female sex, and the nature of the treatment does not influence the result at 1 year. No factor has been associated with a reduction in range of motion. Most of the radial head fractures heal successfully. We identified for the first time, with a valid tool, the presence of depressive symptoms at the time of the fracture as a significant factor for an unsatisfactory functional result. Early detection is simple and fast and would allow patients at risk to adopt complementary strategies to optimize the result

We report the functional and socioeconomic long-term outcome of patients with pelvic ring injuries. We identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring, with an Injury Severity Score (ISS) of ≥ 16. These patients were invited for clinical review at a minimum of ten years after the initial injury, at which point functional results, general health scores and socioeconomic factors were assessed. In all 33 isolated anterior (group A), 33 isolated posterior (group P) and 43 combined anterior/posterior pelvic ring injuries (group A/P) were included. The mean age of the patients at injury was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44). At review the mean Short-Form 12 physical component score for the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42), being significantly worse compared with the other two groups (p = 0.004 and p = 0.024, respectively). A total of 42 patients (39%) had a limp and 12 (11%) required crutches. Car or public transport usage was restricted in 16 patients (15%). Overall patients in groups P and A/P had a worse outcome. The long-term outcome of patients with posterior or combined anterior/posterior pelvic ring injuries is poorer than of those with an isolated anterior injury. Cite this article: Bone Joint J 2013;95-B:548–53

A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation. We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods

The December 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Clavicle fractures: is the evidence changing practice?; Humeral shaft fractures, and another meta-analysis…let’s wait for the trials now!; Hemiarthroplasty or total elbow arthroplasty for distal humeral fractures…what does the registry say?; What to do with a first-time shoulder dislocation?; Deprivation indices and minimal clinically important difference for patient-reported outcomes after arthroscopic rotator cuff repair; Prospective randomized clinical trial of arthroscopic repair versus debridement for partial subscapularis tears; Long-term follow-up following closed reduction and early movement for simple dislocation of the elbow; Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability.

Introduction: Osteomyelitis remains a rare diagnosis and a difficult one to make. Acute osteomyelitis in the context of sickle cell disease remains the subject of some controversy, particularly with regard to aetiology. It is known that Salmonella species are more commonly the cause of acute bone infection in sickle cell patients than in patients with normal red blood cell morphology, but there has long been an argument as to whether Staphylococcus Aureus is in fact still the most common bacterial cause overall in this patient group, as it is in the population overall. We present a consecutive case series of 12 cases of acute osteomyelitis in paediatric patients in East London over the last twenty years. Materials and Methods: Retrospective review of 12 consecutive cases. Medical Notes along with microbiology records and radiographic results were cross referenced with a paediatric sickle cell data base held by the haematology department. Results: 10 of the 12cases had an organism isolated from either blood or bone culture(s). Salmonella spp in cases, S. Aureus in 2 cases and Pseudomonas in the remaining case. Discussion: The question of causative organism is complicated by the fact that most case series’ have bracketed adults and children together, and that conflicting conclusions have resulted from quite small, usually retrospective studies at different times and from different parts of the world – Nigeria, Saudi Arabia and the United States of America. It appears that endemicity is a result of many factors including age; race and socioeconomic factors all play a role. Conclusion: These results reveal that in our paediatric sickle cell population, Salmonella infection occurs ore commonly than Staphylococcus

The June 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning to identify surgical candidates for hip and knee arthroplasty: a viable option?; Poor outcome after debridement and implant retention; Can you cement polyethylene liners into well-fixed acetabular shells in hip revision?; Revision stem in primary arthroplasties: the Exeter 44/0 125 mm stem; Depression and anxiety: could they be linked to infection?; Does where you live affect your outcomes after hip and knee arthroplasties?; Racial disparities in outcomes after total hip arthroplasty and total knee arthroplasty are substantially mediated by socioeconomic disadvantage both in black and white patients.

Aims

Socioeconomic and racial disparities have been recognized as impacting the care of patients with cancer, however there are a lack of data examining the impact of these disparities on patients with bone sarcoma. The purpose of this study was to examine socioeconomic and racial disparities that impact the oncological outcomes of patients with bone sarcoma.

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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).

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Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, postoperative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA and identify the patient characteristics linked to suboptimal trajectories.

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The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

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The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days.

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Time to treatment initiation (TTI) is generally defined as the time from the histological diagnosis of malignancy to the initiation of first definitive treatment. There is no consensus on the impact of TTI on the overall survival in patients with a soft-tissue sarcoma. The purpose of this study was to determine if an increased TTI is associated with overall survival in patients with a soft-tissue sarcoma, and to identify the factors associated with a prolonged TTI.